Effectiveness of a classification-based approach to low back pain in primary care – a benchmarking controlled trial
Trust your back
DOI:
https://doi.org/10.2340/jrm.v56.28321Keywords:
low back pain, classification, patient education, primary care, benchmarkingAbstract
Objective: The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care.
Design: A benchmarking controlled trial design was used.
Subjects/patients: Three primary healthcare areas and 654 low back pain patients with or without sciatica.
Methods: Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months.
Results: No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval –2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference –1.3, confidence interval –2.1 to –0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval –0.2 to 1.5, treatment*time p = 0.003).
Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.
Downloads
References
Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet 2018; 9: 2356–2357.
https://doi.org/10.1016/S0140-6736(18)30480-X DOI: https://doi.org/10.1016/S0140-6736(18)30480-X
Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthri-tis Rheum 2012; 64: 2028–2037.
https://doi.org/10.1002/art.34347 DOI: https://doi.org/10.1002/art.34347
Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018; 9: 2368–2383.
https://doi.org/10.1016/S0140-6736(18)30489-6 DOI: https://doi.org/10.1016/S0140-6736(18)30489-6
Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med 2010; 8: 271–277.
https://doi.org/10.1001/archinternmed.2009.507 DOI: https://doi.org/10.1001/archinternmed.2009.507
Fullen BM, Maher T, Bury G, Tynan A, Daly LE, Hurley DA. Adherence of Irish general practitioners to European guidelines for acute low back pain: a prospective pilot study. Eur J Pain 2007; 11: 614–623.
https://doi.org/10.1016/j.ejpain.2006.09.007 DOI: https://doi.org/10.1016/j.ejpain.2006.09.007
Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22: 62–68.
https://doi.org/10.3122/jabfm.2009.01.080102 DOI: https://doi.org/10.3122/jabfm.2009.01.080102
Buchbinder R, Underwood M, Hartvigsen J, Maher CG. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain 2020; 161: 57–64.
https://doi.org/10.1097/j.pain.0000000000001869 DOI: https://doi.org/10.1097/j.pain.0000000000001869
Webster BS, Choi Y, Bauer AZ, Cifuentes M, Pransky G. The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine (Phila Pa 1976) 2014; 1: 1433–1440.
https://doi.org/10.1097/BRS.0000000000000408 DOI: https://doi.org/10.1097/BRS.0000000000000408
Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res 2014; 49: 645–665.
https://doi.org/10.1111/1475-6773.12098. DOI: https://doi.org/10.1111/1475-6773.12098
Simula AS, Jenkins HJ, Hancock MJ, Malmivaara A, Booth N, Karppinen J. Patient education booklet to support evidence-based low back pain care in primary care: a cluster randomized controlled trial. BMC Fam Pract 2021; 7: 178. DOI: https://doi.org/10.21203/rs.3.rs-428276/v1
https://doi.org/10.1186/s12875-021-01529-2 DOI: https://doi.org/10.1186/s12875-021-01529-2
Simula AS, Jenkins HJ, Holopainen R, Oura P, Korniloff K, Häkkinen A, et al. Transcultural adaption and preliminary evaluation of “understanding low back pain” patient education booklet. BMC Health Serv Res 2019; 19: 1.
https://doi.org/10.1186/S12913-019-4854-Y DOI: https://doi.org/10.1186/s12913-019-4854-y
Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008; 59: 632–641.
https://doi.org/10.1002/art.23563 DOI: https://doi.org/10.1002/art.23563
Foster NE, Mullis R, Hill JC, Lewis M, Whitehurst GDT, Doyle C, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med 2014; 12: 102–111.
https://doi.org/10.1370/afm.1625 DOI: https://doi.org/10.1370/afm.1625
Simula AS, Malmivaara A, Booth N, Karppinen J. A classification-based approach to low back pain in primary care: protocol for a benchmarking controlled trial. BMC Fam Pract 2020; 6: 61.
https://doi.org/10.1186/s12875-020-01135-8 DOI: https://doi.org/10.1186/s12875-020-01135-8
Malmivaara A. Benchmarking Controlled Trial: a novel concept covering all observational effectiveness studies. Ann Med 2015; 47: 332–340.
https://doi.org/10.3109/07853890.2015.1027255 DOI: https://doi.org/10.3109/07853890.2015.1027255
Malmivaara A. Clinical Impact Research: how to choose experimental or observational intervention study? Ann Med 2016; 48: 492–495.
https://doi.org/10.1080/07853890.2016.1186828 DOI: https://doi.org/10.1080/07853890.2016.1186828
Hill JC, Whitehurst DGT, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560–1571.
https://doi.org/10.1016/S0140-6736(11)60937-9
Piironen S, Paananen M, Haapea M, Hupli M, Zitting P, Ryynänen K, et al. Transcultural adaption and psychometric properties of the STarT Back screening tool among Finnish low back pain patients. Eur Spine J 2016; 2: 287–295.
https://doi.org/10.1007/s00586-015-3804-6 DOI: https://doi.org/10.1007/s00586-015-3804-6
Rose M, Bjorner JB, Becker J, Fries JF, Ware JE. Evaluation of a preliminary physical function item bank supported the expected advantages of the Patient-Reported Outcomes Measurement Information System (PROMIS). J Clin Epidemiol 2008; 61: 17–33.
https://doi.org/10.1016/j.jclinepi.2006.06.025 DOI: https://doi.org/10.1016/j.jclinepi.2006.06.025
Rose M, Bjorner JB, Gandek B, Bruce B, Fries JF, Ware JE Jr. The PROMIS Physical Function item bank was calibrated to a standard-ized metric and shown to improve measurement efficiency. J Clin Epidemiol 2014; 67: 516–526.
https://doi.org/10.1016/j.jclinepi.2013.10.024 DOI: https://doi.org/10.1016/j.jclinepi.2013.10.024
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976) 2000; 25: 2940–2952.
https://doi.org/10.1097/00007632-200011150-00017 DOI: https://doi.org/10.1097/00007632-200011150-00017
Rabin R, Gudex C, Selai C, Herdman M. From translation to version management: a history and review of methods for the cultural adaptation of the EuroQol five-dimensional questionnaire. Value Health 2014; 17: 70–6.
https://doi.org/10.1016/j.jval.2013.10.006 DOI: https://doi.org/10.1016/j.jval.2013.10.006
Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52: 157–168.
https://doi.org/10.1016/0304-3959(93)90127-B DOI: https://doi.org/10.1016/0304-3959(93)90127-B
Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J 2014; 14: 816–836.
https://doi.org/10.1016/j.spinee.2013.09.036 DOI: https://doi.org/10.1016/j.spinee.2013.09.036
Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain 2007; 11: 153–163.
https://doi.org/10.1016/j.ejpain.2005.12.008 DOI: https://doi.org/10.1016/j.ejpain.2005.12.008
Linton SJ, Nicholas M, MacDonald S. Development of a short form of the Örebro Musculoskeletal Pain Screening Questionnaire. Spine (Phila Pa 1976) 2011; 15: 1891–1895.
https://doi.org/10.1097/BRS.0b013e3181f8f775 DOI: https://doi.org/10.1097/BRS.0b013e3181f8f775
Hill JC, Dunn KM, Main CJ, Hay EM. Subgrouping low back pain: a comparison of the STarT Back Tool with the Orebro Musculoskeletal Pain Screening Questionnaire. Eur J Pain 2010; 14: 83–89.
https://doi.org/10.1016/j.ejpain.2009.01.003. DOI: https://doi.org/10.1016/j.ejpain.2009.01.003
Simula AS, Ruokolainen O, Oura P, Lausmaa M, Holopainen R, Paukkunen M, et al. Association of STarT Back Tool and the short form of the Örebro Musculoskeletal Pain Screening Questionnaire with multidimensional risk factors. Sci Rep 2020; 14: 290.
https://doi.org/10.1038/s41598-019-57105-3 DOI: https://doi.org/10.1038/s41598-019-57105-3
Hays RD, Spritzer KL, Fries JF, Krishnan E. Responsiveness and minimally important difference for the patient-reported outcomes measurement and information system (PROMIS®) 20-item physical functioning short-form in a prospective observational study of rheumatoid arthritis. Ann Rheum Dis 2015; 74: 104–107.
https://doi.org/10.1136/annrheumdis-2013-204053 DOI: https://doi.org/10.1136/annrheumdis-2013-204053
Ogbeivor C, Elsabbagh L. Management approach combining prognostic screening and targeted treatment for patients with low back pain compared with standard physiotherapy: a systematic review & meta-analysis. Musculoskeletal Care 2021; 19: 436–456.
https://doi.org/10.1002/msc.1541 DOI: https://doi.org/10.1002/msc.1541
Gaspar FW, Thiese MS, Wizner K, Hegmann K. Guideline adherence and lost workdays for acute low back pain in the California work-ers’ compensation system. PLoS One 2021; 17: 16.
https://doi.org/10.1371/journal.pone.0253268 DOI: https://doi.org/10.1371/journal.pone.0253268
Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 29: 1560–1571.
https://doi.org/10.1016/S0140-6736(11)60937-9 DOI: https://doi.org/10.1016/S0140-6736(11)60937-9
Cherkin D, Balderson B, Wellman R, Hsu C, Sherman KJ, Evers SC, et al. Effect of low back pain risk-stratification strategy on pa-tient outcomes and care processes: the MATCH randomized trial in primary care. J Gen Intern Med 2018; 33: 1324–1336.
https://doi.org/10.1007/s11606-018-4468-9 DOI: https://doi.org/10.1007/s11606-018-4468-9
Choudhry NK, Fifer S, Fontanet CP, Archer KR, Sears E, Bhatkhande G, et al. Effect of a biopsychosocial intervention or postural therapy on disability and health care spending among patients with acute and subacute spine pain: the SPINE CARE randomized clinical trial. JAMA 2022; 20: 2334–2344.
https://doi.org/10.1001/jama.2022.22625 DOI: https://doi.org/10.1001/jama.2022.22625
Ramsay CR, Eccles M, Grimshaw JM, Steen N. Assessing the long-term effect of educational reminder messages on primary care radiology referrals. Clin Radiol 2003; 58: 319–321.
https://doi.org/10.1016/s0009-9260(02)00524-x DOI: https://doi.org/10.1016/S0009-9260(02)00524-X
Becker A, Leonhardt C, Kochen MM, Keller S, Wegscheider K, Baum E, et al. Effects of two guideline implementation strategies on patient outcomes in primary care: a cluster randomized controlled trial. Spine (Phila Pa 1976) 2008; 1: 473–480.
https://doi.org/10.1097/BRS.0b013e3181657e0d DOI: https://doi.org/10.1097/BRS.0b013e3181657e0d
Holopainen R, Simpson P, Piirainen A, Karppinen J, Schütze R, Smith A, et al. Physiotherapists’ perceptions of learning and imple-menting a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain 2020; 161: 1150–1168.
https://doi.org/10.1097/j.pain.0000000000001809. PMID: 31977935 DOI: https://doi.org/10.1097/j.pain.0000000000001809
Simpson P, Holopainen R, Schütze R, O’Sullivan P, Smith A, Linton SJ, et al. Training of physical therapists to deliver individualized biopsychosocial interventions to treat musculoskeletal pain conditions: a scoping review. Phys Ther 2021; 1: 101.
https://doi.org/10.1093/ptj/pzab188. PMID: 34331758 DOI: https://doi.org/10.1093/ptj/pzab188
Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: a review of health care systems and key registries. Clin Epidemiol 2021; 19: 533–554.
https://doi.org/10.2147/CLEP.S314959 DOI: https://doi.org/10.2147/CLEP.S314959
Karabukayeva A, Hearld LR, Kelly R, Hall A, Singh J. Association between the number of adopted implementation strategies and contextual determinants: a mixed-methods study. BMC Health Serv Res 2022; 13: 22: 1518.
https://doi.org/10.1186/s12913-022-08736-2 DOI: https://doi.org/10.1186/s12913-022-08736-2
Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, et al. Tailored interventions to overcome identified barri-ers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010; 17: CD005470. DOI: https://doi.org/10.1002/14651858.CD005470.pub2
https://doi.org/10.1002/14651858.CD005470.pub2. Update in: Cochrane Database Syst Rev. 2015;4:CD005470.
Giguère A, Zomahoun HTV, Carmichael PH, Uwizeye CB, Légaré F, Grimshaw JM, et al. Printed educational materials: effects on professional practice and healthcare out-comes. Cochrane Database Syst Rev 2020; 31: CD004398.
https://doi.org/10.1002/14651858.CD004398.pub4 DOI: https://doi.org/10.1002/14651858.CD004398.pub4
Downloads
Additional Files
Published
How to Cite
License
Copyright (c) 2024 Anna Sofia Simula, Antti Malmivaara, Neill Booth, Jaro Karppinen
This work is licensed under a Creative Commons Attribution 4.0 International License.
All digitalized JRM contents is available freely online. The Foundation for Rehabilitation Medicine owns the copyright for all material published until volume 40 (2008), as from volume 41 (2009) authors retain copyright to their work and as from volume 49 (2017) the journal has been published Open Access, under CC-BY-NC licences (unless otherwise specified). The CC-BY-NC licenses allow third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
From 2024, articles are published under the CC-BY licence. This license permits sharing, adapting, and using the material for any purpose, including commercial use, with the condition of providing full attribution to the original publication.
