Improving adherence to acute low back pain guideline recommendations with chiropractors and physiotherapists: the ALIGN cluster randomised controlled trial

Abstract

Background Acute low back pain is a common condition, has high burden, and there are evidence-to-practice gaps in the chiropractic and physiotherapy setting for imaging and giving advice to stay active. The aim of this cluster randomised trial was to estimate the effects of a theory- and evidence-based implementation intervention to increase chiropractors’ and physiotherapists’ adherence to a guideline for acute low back pain compared with the comparator (passive dissemination of the guideline). In particular, the primary aim of the intervention was to reduce inappropriate imaging referral and improve patient low back pain outcomes, and to determine whether this intervention was cost-effective. Methods Physiotherapy and chiropractic practices in the state of Victoria, Australia, comprising at least one practising clinician who provided care to patients with acute low back pain, were invited to participate. Patients attending these practices were included if they had acute non-specific low back pain (duration less than 3 months), were 18 years of age or older, and were able to understand and read English. Practices were randomly assigned either to a tailored, multi-faceted intervention based on the guideline (interactive educational symposium plus academic detailing) or passive dissemination of the guideline (comparator). A statistician independent of the study team undertook stratified randomisation using computer-generated random numbers; four strata were defined by professional group and the rural or metropolitan location of the practice. Investigators not involved in intervention delivery were blinded to allocation. Primary outcomes were X-ray referral self-reported by clinicians using a checklist and patient low back pain-specific disability (at 3 months). Results A total of 104 practices (43 chiropractors, 85 physiotherapists; 755 patients) were assigned to the intervention and 106 practices (45 chiropractors, 97 physiotherapists; 603 patients) to the comparator; 449 patients were available for the patient-level primary outcome. There was no important difference in the odds of patients being referred for X-ray (adjusted (Adj) OR: 1.40; 95% CI 0.51, 3.87; Adj risk difference (RD): 0.01; 95% CI − 0.02, 0.04) or patient low back pain-specific disability (Adj mean difference: 0.37; 95% CI − 0.48, 1.21, scale 0–24). The intervention did lead to improvement for some key secondary outcomes, including giving advice to stay active (Adj OR: 1.96; 95% CI 1.20, 3.22; Adj RD: 0.10; 95% CI 0.01, 0.19) and intending to adhere to the guideline recommendations (e.g. intention to refer for X-ray: Adj OR: 0.27; 95% CI 0.17, 0.44; intention to give advice to stay active: Adj OR: 2.37; 95% CI 1.51, 3.74). Conclusions Intervention group clinicians were more likely to give advice to stay active and to intend to adhere to the guideline recommendations about X-ray referral. The intervention did not change the primary study outcomes, with no important differences in X-ray referral and patient disability between groups, implying that hypothesised reductions in health service utilisation and/or productivity gains are unlikely to offset the direct costs of the intervention. We report these results with the caveat that we enrolled less patients into the trial than our determined sample size. We cannot recommend this intervention as a cost-effective use of resources. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12609001022257. Retrospectively registered on 25 November 2009

Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study

“…We found a 3.4% utilization rate for referral for imaging, which is lower than the previously reported 12% utilization at the same teaching institution [8] and the reported range between 8 and 33% for lumbar imaging utilization in other chiropractic teaching clinics [8,16,26]. Our utilization rate is also considerably lower than the 40% utilization rate reported in Canadian and American field chiropractors referring patients for radiographs with non-specific LBP [17], but similar to the 3% reported by French et al in 2022 in a clinical trial aimed to reduce inappropriate imaging in primary care [19]. Possible explanations for the lower rate at our chiropractic institution include organizational emphasis and implementation of guidelines [6,8,19,27,28], teaching an evidence-based curriculum, discouraging routine and repeat radiographic examinations in the absence of red flags [6,16,28,29], and potential under-use [4].…”

“…All patients who were imaged had at least one red flag, although only 4% of patients with any red flags were referred for imaging. This later proportion may suggest underutilization; however, current literature suggests red flags should not be considered in isolation but used in consideration of the entire clinical context of the patient [6,8,19,23]. Instead, application of criteria considering sensitivity and specificity of red flags would be more appropriate [4], which was considered by Bussieres et al when they grouped specific red flags by condition, as typically encountered in a clinical context [11].…”

“…Guidelines have been developed to address this variation and potential inappropriate use of imaging; however, they too face variation in adherence to components of their recommendations [19]. For example, a 2014 best evidence synthesis suggests chiropractors demonstrated the highest level of overall adherence to acute and subacute LBP guidelines, but the lowest when assessing appropriate use of imaging in comparison to physiotherapists and medical practitioners [20].…”

Low‐value care in musculoskeletal health care: Is there a way forward?

“…66,67 In the ALIGN cluster randomized trial, French et al compared the effectiveness of a tailored, multi-faceted intervention based on guideline recommendations aiming at reducing inappropriate imaging referral and improve outcomes to passive dissemination of the guideline in people seeking care for acute back pain from physiotherapists and chiropractors in Victoria, Australia. 68 They found that clinicians in the intervention group were more likely to provide advice about staying active, but there were no important differences in X-ray referral and no difference in patient outcomes. Finally, Taylor et al compared the effectiveness of a participative group intervention that introduced cognitive behavioral approaches designed to promote self-management to usual care and relaxation music.…”

“…Outcomes from people receiving GLA:D are systematically followed in clinical registries and data are made public 66,67 . In the ALIGN cluster randomized trial, French et al compared the effectiveness of a tailored, multi‐faceted intervention based on guideline recommendations aiming at reducing inappropriate imaging referral and improve outcomes to passive dissemination of the guideline in people seeking care for acute back pain from physiotherapists and chiropractors in Victoria, Australia 68 . They found that clinicians in the intervention group were more likely to provide advice about staying active, but there were no important differences in X‐ray referral and no difference in patient outcomes.…”