Back and neck pain: in support of routine delivery of non-pharmacologic treatments as a way to improve individual and population health

George, Steven Z.; Lentz, Trevor A.; Goertz, Christine

doi:10.1016/j.trsl.2021.04.006

Cited by 19 publications

(30 citation statements)

References 70 publications

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“…Initial contact with a DC has been shown to be associated with lower cost than most HCPs, while early access to physical therapy has had mixed total episode cost outcomes [25,27,46,47]. Our study also substantiated the findings of a recent narrative review that suggested that access to non-pharmacologic providers is associated with improved guideline concordance for treatment of spinal pain [48]. Reordering the sequencing of services in the early management of LBP has been proposed to systematically align clinical practice with the evidence-based CPGs [26,46,47,49].…”

Section: Discussionsupporting

confidence: 78%

“…CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is associated with improved guideline concordance for treatment of spinal pain [48]. Reordering the sequencing of services in the early management of LBP has been proposed to systematically align clinical practice with the evidence-based CPGs [26,46,47,49].…”

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

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Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

Elton

Kosloff

Zhang

et al. 2022

Preprint

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BackgroundLow back pain (LBP) is prevalent, management benefits from high-quality clinical practice guidelines, and yet LBP is a common source of low value care. The purpose of this retrospective cohort study was to examine the association between the type of initial contact health care provider (HCP), service utilization, and total episode cost for the management of LBP.MethodsEpisode of care was used to analyze a US national sample of LBP episodes completed in 2017-2019. A combined surgical and non-surgical (pooled) sample and a non-surgical sample were separately analyzed. The primary independent variable was the type of the initial contact HCP. Dependent measures included rate and timing of use of 14 types of health care services and total episode cost. The association between initial contact HCP, total episode cost and rate of prescription opioid and NSAID use was tested using a mixed effects model.ResultsThe study included 616,766 continuously insured individuals aged 18 years and older with 756,631 episodes of LBP involving 386,795 HCPs and incurring $1,010,495,291 in expenditures. A primary care or specialist HCP was initially contacted in 62.0% of episodes, with these episodes associated with early use of low-value services such as imaging, pharmacologic, and interventional services. A non-prescribing HCP was initially contacted in 32.5% of episodes with these episodes associated with early use of guideline recommended first line services. Each type of HCP emphasized different initial services with little indication of a stepped approach to managing LBP. Following adjustment for covariates chiropractors were associated with the lowest total episode cost. As an observational study of associations, numerous confounders may have impacted results.ConclusionsAn individual with LBP has different experiences based on the type of HCP initially contacted. Initial contact with primary care or specialist HCPs is associated with second- and third-line services provided before first line services, with little indication of a guideline recommended stepped approach to managing LBP. Increasing the likelihood of guideline-concordant, high-value care for LBP may require systemic changes to the health care delivery system. In the absence of red flags these changes may include increasing the proportion of individuals receiving early non-pharmacological treatment, either through improving direct access to non-prescribing HCPs or increasing timely referrals from primary care and specialist health care providers.

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Section: Discussionsupporting

confidence: 78%

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

Elton

Kosloff

Zhang

et al. 2022

Preprint

View full text Add to dashboard Cite

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“… 51 , 52 For non-pharmacologic approaches like PIPT, part of the contextual considerations that have impacted its uptake include provider beliefs. 1 On the positive side, physical therapists are known for their patient-centered approaches to care through the use of tools like shared-decision making and patient-centered communication. 53 , 54 However, physical therapy training is still heavily focused on biomedical approaches for treating musculoskeletal pain which could make adoption of PIPT more difficult.…”

Section: Moving Towards Wide-scale Implementationmentioning

confidence: 99%

“…There has been substantial growth in interest in biopsychosocial treatments for patients with musculoskeletal pain. 1 One reason for this increased interest is the American College of Physicians Clinical Practice Guidelines and the Centers for Disease Control and Prevention Guidelines for treatment of chronic pain. 2 , 3 Additionally, the revised International Association for the Study of Pain (IASP) definition for pain focuses on the influence of biological, psychological, and social factors on a person’s pain experience.…”

Section: Introductionmentioning

confidence: 99%

“…One challenge limiting uptake of PIPT in care settings is that, in general, non-pharmacological interventions can be challenging for health systems to deliver, when compared to medications or surgery. 1 , 22 Clinician attitudes and beliefs about using behavioral and psychological interventions can also influence their willingness to use PiP approaches since they are still not commonly taught in pre-professional training for many provider types (eg, physical therapists). 23 , 24 Other challenges to PIPT implementation include physical therapists feeling unprepared to treat patients with complex pain conditions and a fear of not meeting patient’s expectations for carrying out traditional physical therapy care.…”

Section: Introductionmentioning

confidence: 99%

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Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?

Ballengee¹,

Zullig²,

George³

2021

JPR

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Low back pain continues to be a leading cause of disability and cost throughout the world. Evidence-based guidelines recommend use of non-pharmacological interventions to address decreases in physical function due to low back pain. Psychologically informed physical therapy (PIPT) is one way to effectively and efficiently address the need for nonpharmacological approaches. However, adoption of psychologically informed practice (PiP) by physical therapists has shown mixed results due to implementation challenges. In this perspective, we discuss the current state of PIPT training and implementation. We also propose a conceptual roadmap for future implementation needs related to increasing delivery of PIPT-informed approaches.

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Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

et al. 2023

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ImportanceTailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems.ObjectiveTo assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP.Design, Setting, and ParticipantsThis parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022.InterventionsRisk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants’ general practitioners and may have included a referral to physiotherapy.Main Outcomes and MeasuresThe primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group.ResultsAnalysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, −0.75 points; 95% CI −2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, −1.66 to 1.76 points).Conclusions and RelevanceIn this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care.Trial RegistrationClinicalTrials.gov Identifier: NCT03127826

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Back and neck pain: in support of routine delivery of non-pharmacologic treatments as a way to improve individual and population health

Abstract: Back and neck pain: in support of routine delivery of nonpharmacologic treatments as a way to improve individual and population health,

Cited by 19 publications

References 70 publications

Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?

Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

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