Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study

Background. The effectiveness of risk stratification for low back pain (LBP) management has not been demonstrated in outpatient physical therapy settings. Objective. The purposes of this study were: (1) to assess implementation of a stratified care approach for LBP management by evaluating short-term treatment effects and (2) to determine feasibility of conducting a larger-scale study. Design. This was a 2-phase, preliminary study. Methods. In phase 1, clinicians were randomly assigned to receive standard (n=6) or stratified care (n=6) training. Stratified care training included 8 hours of content focusing on psychologically informed practice. Changes in LBP attitudes and beliefs were assessed using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). In phase 2, clinicians receiving the stratified care training were instructed to incorporate those strategies in their practice and 4-week patient outcomes were collected using a numerical pain rating scale (NPRS), and the Oswestry Disability Index (ODI). Study feasibility was assessed to identify potential barriers for completion of a larger-scale study. Results. In phase 1, minimal changes were observed for PABS-PT and HC-PAIRS scores for standard care clinicians (Cohen d=0.00 - 0.28). Decreased biomedical (-4.5 +/- 2.5 points, d=1.08) and increased biopsychosocial (+5.5 +/- 2.0 points, d=2.86) treatment orientations were observed for stratified care clinicians, with these changes sustained 6 months later on the PABS-PT. In phase 2, patients receiving stratified care (n=67) had greater between-group improvements in NPRS (0.8 points; 95% confidence interval=0.1, 1.5; d=0.40) and ODI (8.9% points; 95% confidence interval=4.1, 13.6; d=0.76) scores compared with patients receiving standard physical therapy care (n=33). Limitations. In phase 2, treatment was not randomly assigned, and therapist adherence to treatment recommendations was not monitored. This study was not adequately powered to conduct subgroup analyses. Conclusions. In physical therapy settings, biomedical orientation can be modified, and risk-stratified care for LBP can be effectively implemented. Findings from this study can be used for planning of larger studies.