Patients’ and physiotherapists’ perspectives on implementing a tailored stratified treatment approach for low back pain in Nigeria: a qualitative study
Abstract:BackgroundStratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation.MethodsA qualitative design with semistructured individual telephone interviews for physiotherapists and patients with… Show more
“…These subgrouping based on multiple fear avoidance measures related to work or physical activity can be seen as potentially beneficial for assessment and intervention [49]. The relationship between FAB and disability is consistent with literature reporting increased disability with elevated FAB and showing that early interventions are not only feasible but can potentially improve or prevent chronic LBP problems [50,51].…”
BACKGROUND: Specific stabilisation exercises (SSE) can combat the debilitating effects of chronic non-specific low back pain (CLBP), improve disability, pain and fear-avoidance beliefs (FAB). OBJECTIVE: To elicit the determinants of outcome in patients with CLBP with associated FABs after treatment with SSE. METHOD: Twenty-nine patients (20 females) with CLBP were classified using FAB questionnaire into high or low Work and Physical Activity (PA) subscales. After 4-week treatment, evaluations were done for pain, disability and lumbar spine active range of motion (AROM). Data was analysed exploratory-descriptively with a significance level set at p< 0.05. RESULTS: Participants were aged 55.24 ± 11.91 years. They scored 19 (65.5%) and 5 (17.2%) respectively on Work and PA subscales. The post-intervention evaluation showed significant differences in all outcomes, but no significant difference between patients with high or low FAB scores for both subscales. PA scores correlated significantly with pain while work scores correlated significantly with disability. Participants’ gender predicted disability, pain and AROM with moderate to large effect sizes. CONCLUSION: SSE can potentially improve disability, pain and range of motion for patients with chronic low back pain regardless of FABQ status. Gender and baseline patient status are potential determinants of outcome of treatment using SSE.
“…These subgrouping based on multiple fear avoidance measures related to work or physical activity can be seen as potentially beneficial for assessment and intervention [49]. The relationship between FAB and disability is consistent with literature reporting increased disability with elevated FAB and showing that early interventions are not only feasible but can potentially improve or prevent chronic LBP problems [50,51].…”
BACKGROUND: Specific stabilisation exercises (SSE) can combat the debilitating effects of chronic non-specific low back pain (CLBP), improve disability, pain and fear-avoidance beliefs (FAB). OBJECTIVE: To elicit the determinants of outcome in patients with CLBP with associated FABs after treatment with SSE. METHOD: Twenty-nine patients (20 females) with CLBP were classified using FAB questionnaire into high or low Work and Physical Activity (PA) subscales. After 4-week treatment, evaluations were done for pain, disability and lumbar spine active range of motion (AROM). Data was analysed exploratory-descriptively with a significance level set at p< 0.05. RESULTS: Participants were aged 55.24 ± 11.91 years. They scored 19 (65.5%) and 5 (17.2%) respectively on Work and PA subscales. The post-intervention evaluation showed significant differences in all outcomes, but no significant difference between patients with high or low FAB scores for both subscales. PA scores correlated significantly with pain while work scores correlated significantly with disability. Participants’ gender predicted disability, pain and AROM with moderate to large effect sizes. CONCLUSION: SSE can potentially improve disability, pain and range of motion for patients with chronic low back pain regardless of FABQ status. Gender and baseline patient status are potential determinants of outcome of treatment using SSE.
“…In the global implementation of stratified care, a research work by Sowden et al suggests that stakeholder engagement can be done through various mechanisms including quality improvement meetings and mentorship [ 67 ]. This has a bearing not only on hierarchal implementation, where the seniors physiotherapists instigate these appraisals and systematically monitor the progress, it also involves their full participation and cooperation in convincing junior physiotherapy practitioners [ 34 ].…”
Section: Discussionmentioning
confidence: 99%
“…Interviews were audio recorded, transcribed and analysed using Grounded theory [ 48 ] generating categories and sub-categories used in the Delphi rounds (Additional file 1 ). This preliminary round was described in detail in a published manuscript [ 34 ]. Fig.…”
Section: Methodsmentioning
confidence: 99%
“…It also reveals contextual concerns that might serve as barriers to implementation such as time constraints, treatment expectations held by patients regarding the method and success of approach and the incentivised tradition of practice. These studies reveal potential facilitators like communication, patients’ trust and socio-cultural factors with the potential to accentuate implementation [ 17 , 34 ].…”
Background
Stratified care approach involving use of the STarT-Back tool to optimise care for patients with low back pain is gaining widespread attention in western countries. However, adoption and implementation of this approach in low-and-middle-income countries will be restricted by context-specific factors that need to be addressed. This study aimed to develop with physiotherapists, tailored intervention strategies for the implementation of stratified care for patients with low back pain.
Methods
A two-round web-based Delphi survey was conducted among purposively sampled physiotherapists with a minimum of three years of clinical experience, with post-graduation certification or specialists. Thirty statements on barriers and enablers for implementation were extracted from the qualitative phase. Statements were rated by a Delphi panel with additional open-ended feedback. After each Delphi round, participants received feedback which informed their subsequent responses. Additional qualitative feedback were analysed using qualitative content analysis. The criteria for consensus and stability were pre-determined using percentage agreement (≥ 75%), median value (≥ 4), Inter-quartile range (≤ 1), and Wilcoxon matched-pairs test respectively.
Results
Participants in the first round were 139 and 125 of them completed the study, yielding a response rate of 90%. Participants were aged 35.2 (SD6.6) years, and 55 (39.6%) were female. Consensus was achieved in 25/30 statements. Wilcoxon’s test showed stability in responses after the 5 statements failed to reach consensus: ‘translate the STarT-Back Tool to pidgin language’ 71% (p = 0.76), ‘begin implementation with government hospitals’ 63% (p = 0.11), ‘share knowledge with traditional bone setters’ 35% (p = 0.67), ‘get second opinion on clinician’s advice’ 63% (p = 0.24) and ‘carry out online consultations’ 65% (p = 0.41). Four statements strengthened by additional qualitative data achieved the highest consensus: ‘patient education’ (96%), ‘quality improvement appraisals’ (96%), ‘undergraduate training on psychosocial care’ (96%) and ‘patient-clinician communication’ (95%).
Conclusion
There was concordance of opinion that patients should be educated to correct misplaced expectations and proper time for communication is vital to implementation. This communication should be learned at undergraduate level, and for already qualified clinicians, quality improvement appraisals are key to sustained and effective care. These recommendations provide a framework for future research on monitored implementation of stratified care in middle-income countries.
“…Castellvi discovered that those with Type II transitional vertebrae had a higher prevalence of herniations just above the transition, whereas those with a complete bony union had a similar distribution of herniations to the normal population. An unbalanced motion induced by a unilateral articulation may provide increased stresses on the articulation or the contralateral facet 17 .…”
Background: The lumbar spine's lumbrosacral transitional vertebrae (LSTV), a structural defect, have been variously linked to low back pain (LBP). Their presence can also lead to an incorrect pre-operative level identification. Objective: To examine the relationship between lumbosacral transitional vertebrae detected on plain radiographs and low back pain in patients. Study Setting: Department of orthopedics, Shifa international hospital, Islamabad Methods: The study design was prospective and descriptive. The study was conducted between July 2021 to December 2021. The radiographs of 100 patients with low back pain who met the inclusion/exclusion criteria were evaluated. The frequency of patients with low back pain and lumbosacral transitional vertebra (LSTV) was calculated using SPSS version 26. For the quantitative data presentation mean and standard deviation was utilized and for qualitative data frequencies were used. P value less than 0.05 was considered significant. Results: In a sample of 100 patients, 40 were men and 60 were women. 45 patients were diagnosed with axial type of lower back pain. The prevalence of LSTV was 27%, with males constituting the majority. No significant difference in the LSTV and Normal spine age distribution intervals was observed except, in the age interval of 51-60 years with a P-Value of <0.001. Conclusion: There is substantial evidence linking lumbosacral transitional vertebrae and low back pain.
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