Effectiveness and Quality of Implementing a Best Practice Model of Care for Low Back Pain (BetterBack) Compared with Routine Care in Physiotherapy: A Hybrid Type 2 Trial

Abstract

Low back pain (LBP) occurs in all ages and first-line treatment by physiotherapists is common. The main aim of the current study was to evaluate the effectiveness of implementing a best practice model of care for LBP (intervention group—BetterBack☺ MoC) compared to routine physiotherapy care (control group) regarding longitudinal patient reported outcomes. The BetterBack☺ MoC contains clinical guideline recommendations and support tools to facilitate clinician adherence to guidelines. A secondary exploratory aim was to compare patient outcomes based on the fidelity of fulfilling a clinical practice quality index regarding physiotherapist care. A stepped cluster randomized design nested patients with LBP in the three clusters which were allocated to control (n = 203) or intervention (n = 264). Patient reported measures were collected at baseline, 3, 6 and 12 months and analyzed with mixed model regression. The primary outcome was between-group changes from baseline to 3 months for pain intensity and disability. Implementation of the BetterBack☺ MoC did not show any between-group differences in the primary outcomes compared with routine care. However, the intervention group showed significantly higher satisfaction at 3 months and clinically meaningful greater improvement in LBP illness perception at 3 months and quality of life at 3 and 6 months but not in patient enablement and global impression of change compared with the control group. Physiotherapists’ care that adhered to all clinical practice quality indices resulted in an improvement of most patient reported outcomes with a clinically meaningful greater improved LBP illness perception at 3 month and quality of life at 3 and 6 months, significantly greater improvement in LBP illness perception, pain and satisfaction at 3 and 6 months and significantly better enablement at all time points as well as better global improvement outcomes at 3 months compared with non-adherent care. This highlights the importance of clinical guideline based primary care for improving patient reported LBP outcomes.

The prevalence of diagnosed specific back pain in primary health care in Region Västra Götaland: a register study of 1.7 million inhabitants

“…Physiotherapy and patient education are in clinical guidelines recommended to be first-line treatments for back pain including specific benign spinal pathologies. Improving direct access to health care practitioners such as physiotherapists is therefore of importance (Schroder et al, 2021).…”

Does the implementation of clinical practice guidelines for low back and neck pain by physical therapists improve patient outcomes? A systematic review

“…All twenty-one studies were published between 2005 and 2021. Of the twenty-one studies retained for final review, seven were retrospective cohort studies [ 16 – 22 ], seven were randomized controlled trials [ 23 – 29 ], six were prospective, longitudinal cohort studies [ 30 – 35 ], and one was a case report [ 36 ].…”

“…Seven studies were conducted in the USA [ 16 – 20 , 34 , 36 ], six studies were conducted in the Netherlands [ 21 , 24 , 25 , 29 , 31 , 35 ], and two studies were conducted in Canada [ 28 , 30 ]. The remainder of the studies were conducted in Nepal [ 26 ], Denmark [ 32 ], Sweden [ 23 ], and Australia [ 27 ]. Two did not report a country as they were conducted in global military health systems [ 16 , 33 ].…”

The association between patients' illness perceptions and longitudinal clinical outcome in patients with low back pain

“…The main results from the cluster randomized controlled trial investigating implementation of a physiotherapy model of care (BetterBack) for patients with LBP showed no statistically significant difference in ODI, NRS-LBP, EQ-5D, PEI, and the total score for the BIPQ between patients receiving care before and after the implementation of the model of care. 46 Thus, no adjustments for treatment according to group allocation were made.…”

“…The results, however, rejected the a priori hypothesis based on no statistically significant difference in patient-reported outcomes. 46 …”