Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

The smallest worthwhile effect of surgery versus non-surgical treatments for sciatica: a benefit-harm trade-off study

QUESTION

What is the smallest worthwhile (SWE) effect of discectomy compared with non-surgical treatments amongst people with sciatica?

DESIGN

Benefit-harm trade-off study.

PARTICIPANTS

People with sciatica of any duration living in Australia and recruited through social media.

OUTCOME

The outcome of interest was leg pain intensity. Participants were asked to nominate the additional percentage reduction in leg pain from discectomy--above the reduction anticipated from non-surgical treatments--that would make discectomy worthwhile for them. The SWE was estimated as the median (IQR) of the smallest percentage reduction in leg pain with discectomy (compared with non-surgical treatment) that participants considered worthwhile. The SWE was estimated for the overall sample and those with acute (≤ 6 weeks), subacute (> 6 to 12 weeks) and chronic (> 12 weeks) sciatica, and investigated factors associated with the SWE.

RESULTS

Two hundred participants with a mean age of 59 years (SD 12) were included. The SWE was estimated to be an additional 15% (IQR 10 to 40) reduction in leg pain with discectomy, beyond any reduction in leg pain achieved by non-surgical treatments. Dissatisfaction with previous non-surgical treatments and low pain self-efficacy were associated with smaller SWE estimates.

CONCLUSION

People with sciatica would require discectomy to provide an additional 15% reduction in their leg pain beyond the expected 50% improvement in leg pain from non-surgical treatments in the short term to consider discectomy worthwhile. These results can inform the interpretation of the effects of discectomy in randomised trials and meta-analysis from the perspective of consumers.

Models of care for managing non-specific low back pain

BACKGROUND

Alternative care models seek to improve the quality or efficiency of care, or both, and thus optimise patient health outcomes. They provide the same health care but change how, when, where, or by whom health care is delivered and co-ordinated. Examples include care delivered via telemedicine versus in-person care or care delivered to groups versus individual patients.

OBJECTIVES

To assess the effects of alternative models of evidenced-based care for people with non-specific low back pain on the quality of care and patient self-reported outcomes and to summarise the availability and principal findings of economic evaluations of these alternative models.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries up to 14 June 2024, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials comparing alternative care models to usual care or other care models. Eligible trials had to investigate care models that changed at least one domain of the Cochrane EPOC delivery arrangement taxonomy and provide the same care as the comparator arm. Participants were individuals with non-specific low back pain, regardless of symptom duration. Main outcomes were quality of care (referral for/receipt of lumbar spine imaging, prescription/use of opioids, referral to a surgeon/lumbar spine surgery, admission to hospital for back pain), patient health outcomes (pain, back-related function), and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was alternative models of care versus usual care at closest follow-up to 12 months.

MAIN RESULTS

Fifty-seven trials (29,578 participants) met our inclusion criteria. Trials were primarily set within primary care (18 trials) or physiotherapy practices (15 trials) in high-income countries (51 trials). Forty-eight trials compared alternative models of care to usual care. There was substantial clinical diversity across alternative care models. Alternative care models most commonly differed from usual care by altering the co-ordination/management of care processes (18 trials), or by utilising information and communication technology (10 trials). Moderate-certainty evidence indicates that alternative care models probably result in little difference in referral for or receipt of any lumbar spine imaging at follow-up closest to 12 months compared to usual care (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.86 to 0.98; I2 = 2%; 18 trials, 16,157 participants). In usual care, 232/1000 people received lumbar spine imaging compared to 213/1000 people who received alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement). Moderate-certainty evidence suggests that alternative care models probably result in little or no difference in the prescription or use of opioid medication at follow-up closest to 12 months compared to usual care (RR 0.95, 95% CI 0.89 to 1.03; I2 = 0%; 15 trials, 13,185 participants). In usual care, 349 out of 1000 people used opioid medication compared to 332 out of 1000 people in alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement). We are uncertain if alternative care models alter referral for or use of lumbar spine surgery at follow-up closest to 12 months compared to usual care as the certainty of the evidence was very low (odds ratio (OR) 1.04, 95% CI 0.79 to 1.37; I2 = 0%; 10 trials, 4189 participants). We downgraded the certainty of the evidence by three levels due to very serious imprecision (wide CIs) and serious indirectness (diversity in outcome measurement). We are uncertain if alternative care models alter hospital admissions for non-specific low back pain at follow-up closest to 12 months compared to usual care as the certainty of evidence was very low (OR 0.86, 95% CI 0.67 to 1.11; I2 = 8%; 12 trials, 10,485 participants). We downgraded the certainty of the evidence by three levels due to serious indirectness (diversity in outcome measurement), serious publication bias (asymmetry of results), minor imprecision (wide CIs), and minor risk of bias (blinding of participants/personnel). High-certainty evidence indicates that alternative care models result in a small but clinically unimportant improvement in pain on a 0 to 10 scale (mean difference -0.24, 95% CI -0.43 to -0.05; I2 = 68%; 36 trials, 9403 participants). Mean pain at follow-up closest to 12 months was 2.4 points on a 0 to 10 rating scale (lower score indicates less pain) with usual care compared to 2.2 points with alternative care models, a difference of 0.2 points better (95% CI 0.4 better to 0.0 better; minimal clinically important difference (MCID) 0.5 to 1.5 points). High-certainty evidence indicates that alternative care models result in a small, clinically unimportant improvement in back-related function compared with usual care (standardised mean difference -0.12, 95% CI -0.20 to -0.04; I2 = 66%; 44 trials, 13,688 participants). Mean back-related function at follow-up closest to 12 months was 6.4 points on a 0 to 24 rating scale (lower score indicates less disability) with usual care compared to 5.7 points with alternative care models, a difference of 0.7 points better (95% CI 1.2 better to 0.2 better; MCID 1.5 to 2.5 points). We are uncertain of the effect of alternative care models on adverse events compared to usual care as the certainty of the evidence was very low (OR 0.81, 95% CI 0.45 to 1.45; I2 = 43%; 10 trials, 2880 participants). We downgraded the certainty of the evidence by three levels due to serious risk of bias (blinding of participants/personnel), serious indirectness (variation in assumed risk), and serious inconsistency (substantial between-study heterogeneity).

AUTHORS' CONCLUSIONS

Compared to usual care, alternative care models for non-specific low back pain probably lead to little or no difference in the quality of care and result in small but clinically unimportant improvements in pain and back-related function. Whether alternative care models result in a difference in total adverse events compared to usual care remains unresolved.

Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial

CONTEXT

The biopsychosocial approach to managing low back pain (LBP) has the potential to improve the quality of care for patients. However, LBP trials that have utilized the biopsychosocial approach to treatment have largely neglected sexual activity, which is an important social component of individuals with LBP.

OBJECTIVES

The objectives of the study are to determine the effects of manual therapy plus sexual advice (MT+SA) compared with manual therapy (MT) or exercise therapy (ET) alone in the management of individuals with lumbar disc herniation with radiculopathy (DHR) and to determine the best sexual positions for these individuals.

METHODS

This was a single-blind randomized controlled trial. Fifty-four participants diagnosed as having chronic DHR (>3 months) were randomly allocated into three groups with 18 participants each in the MT+SA, MT and ET groups. The participants in the MT+SA group received manual therapy (including Dowling's progressive inhibition of neuromuscular structures and Mulligan's spinal mobilization with leg movement) plus sexual advice, those in the MT group received manual therapy only and those in the ET group received exercise therapy only. Each group received treatment for 12 weeks and then followed up for additional 40 weeks. The primary outcomes were pain, activity limitation, sexual disability and kinesiophobia at 12 weeks post-randomization.

RESULTS

The MT+SA group improved significantly better than the MT or ET group in all outcomes (except for nerve function), and at all timelines (6, 12, 26, and 52 weeks post-randomization). These improvements were also clinically meaningful for back pain, leg pain, medication intake, and functional mobility at 6 and 12 weeks post-randomization and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at 6, 12, 26, and 52 weeks post-randomization (p<0.05). On the other hand, many preferred sexual positions for individuals with DHR emerged, with "side-lying" being the most practiced sexual position and "standing" being the least practiced sexual position by females. While "lying supine" was the most practiced sexual position and "sitting on a chair" was the least practiced sexual position by males.

CONCLUSIONS

This study found that individuals with DHR demonstrated better improvements in all outcomes when treated with MT+SA than when treated with MT or ET alone. These improvements were also clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up. There is also no one-size-fits-all to sexual positioning for individuals with DHR.

The intangible costs of living with low back pain from a patient perspective: a scoping review

PURPOSE

Health-related low back pain costs can be direct monetary, indirect monetary, or intangible, non-monetary. The purpose of this review was to identify the intangible, non-monetary costs of low back pain from the perspective of the individual.

MATERIALS AND METHODS

A scoping review of literature was undertaken. Four databases were searched up to 6th August 2024. Data were charted and coded using deductively derived categories in line with our purpose; additional categories were developed for text that did not fit these categories. Data were analysed using directed content analysis.

RESULTS

Forty-six studies met the inclusion criteria. Six categories were derived from the data, which express the experience of the person with low back pain: Perceptions of pain, Experience of healthcare, Becoming defined by low back pain, Life on hold, My social self, and Disrupted work life. Each category explored an aspect of life affected by low back pain.

CONCLUSION

This review highlights that low back pain profoundly affects many areas, with implications for peoples' personal, social, and work lives. Our findings suggest that suffering can be reduced when healthcare practitioners show empathy and legitimise the lived experience of low back pain, acknowledging the restrictions it imposes on peoples' lives.

A scoping review on implementation processes and outcomes of models of care for low back pain in primary healthcare

BACKGROUND

To address the societal burden of low back pain (LBP), several health systems have adopted Models of Care (MoCs). These evidence-informed models aim for consistent care and outcomes. However, real-world applications vary, with each setting presenting unique challenges and nuances in the primary healthcare landscape. This scoping review aims to synthesize the available evidence regarding the use of implementation theories, models or frameworks, context-specific factors, implementation strategies and outcomes reported in MoCs targeting LBP in primary healthcare.

METHODS

MEDLINE(Pubmed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were searched. Eligible records included MoCs for adults with LBP in primary healthcare. Two reviewers independently extracted data concerning patient-related, system-related and implementation-related outcomes. The implementation processes, including guiding theories, models or frameworks, barriers and facilitators to implementation and implementation strategies were also extracted. The data were analysed through a descriptive qualitative content analysis and synthesized via both quantitative and qualitative approaches.

RESULTS

Eleven MoCs (n = 29 studies) were included. Implementation outcomes were assessed in 6 MoCs through quantitative, qualitative, and mixed methods approaches. Acceptability and appropriateness were the most reported outcomes. Only 5 MoCs reported underlying theories, models, or frameworks. Context-specific factors influencing implementation were identified in 3 MoCs. Common strategies included training providers, developing educational materials, and changing record systems. Notably, only one MoC included a structured multifaceted implementation strategy aligned with the evaluation of patient, organizational and implementation outcomes.

CONCLUSIONS

The implementation processes and outcomes of the MoCs were not adequately reported and lacked sufficient theoretical support. As a result, conclusions about the success of implementation cannot be drawn, as the strategies employed were not aligned with the outcomes. This study highlights the need for theoretical guidance in the development and implementation of MoCs for the management of LBP in primary healthcare.

REGISTRATION

Open Science Framework Registries ( https://osf.io/rsd8x ).

Perceived factors influencing the success of pain neuroscience education in chronic musculoskeletal pain: a meta-synthesis of qualitative studies

PURPOSE

We aimed to identify the factors influencing the success of Pain Neuroscience Education (PNE) in chronic musculoskeletal (MSK) pain from the perspective of those experiencing PNE first-hand.

MATERIALS AND METHODS

We conducted a meta-synthesis of qualitative studies. Articles were found on MEDLINE via Pubmed, EMBASE, Cochrane Library, CINHAL, and PsycINFO up to April 2023. Eligible qualitative studies focussed on adults (>16 years old) with a diagnosis of chronic primary or secondary MSK pain who performed PNE. Thematic synthesis by Thomas and Harden was followed. The Critical Appraisal Skills Programme (CASP) tool ensured the quality of the studies, while the Confidence in Evidence from the Reviews of Qualitative Research (CERQual) approach facilitated data confidence assessment.

RESULTS

Nine studies were included (188 participants). Three analytical themes were developed: (i) "Efficient Communication of Information", emphasising the importance of accurate content transmission; (ii) "Emotional Support and Well-being", recognising emotional aspects as integral to treatment; and (iii) "Empowerment Promotion", focusing on information retention and personal transformation. The studies showed good quality, with moderate confidence in the evidence.

CONCLUSIONS

The perceived factors influencing the success of PNE are intricately related to the domain of communication, the emotional dimension of personal experience, and the capacity to be empowered.

Using normalisation process theory for intervention development, implementation and refinement in musculoskeletal and orthopaedic interventions: a qualitative systematic review

BACKGROUND

Normalisation process theory (NPT) provides researchers with a set of tools to support the understanding of the implementation, normalisation and sustainment of an intervention in practice. Previous reviews of published research have explored NPT's use in the implementation processes of healthcare interventions. However, its utility in intervention research, specifically in orthopaedic and musculoskeletal interventions, remains unclear. The aim of this review is to explore how NPT (including extended NPT, ENPT) has been used in orthopaedic/musculoskeletal intervention research.

METHODS

A qualitative systematic review was conducted. Two bibliographic databases (Scopus and Web of Science) and a search engine (Google Scholar) were searched for peer-reviewed journal articles citing key papers outlining the development of NPT, related methods, tools or the web-based toolkit. We included studies of any method, including protocols, and did not exclude based on published language. A data extraction tool was developed, and data were analysed using a framework approach.

RESULTS

Citation searches, of the 12 key studies, revealed 10,420 citations. Following duplicate removal, title, abstract and full-text screening, 14 papers from 12 studies were included. There were 8 key findings assessed against GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research). Five were of high confidence supporting NPT/ENPT's use in the implementation process for interventions targeting a range of MSK/orthopaedic conditions. NPT/ENPT offers a useful analytical lens to focus attention and consider implementation factors robustly. There is limited evidence for the selection of NPT/ENPT and for the use of the Normalisation Measure Development instrument. Three findings of moderate confidence suggest that coherence is seen as a fundamental initial step in implementation, there is limited evidence that study population limits NPT's utility and the application of ENPT may pose a challenge to researchers.

CONCLUSION

This review demonstrates NPT's utility in supporting intervention implementation for orthopaedic and musculoskeletal conditions. We have theorised the benefits ENPT offers to intervention development and refinement and recommend future researchers consider its use. We also encourage future researchers to offer clear justification for NPT's use in their methodology.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (CRD42022358558).

Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group

ABSTRACT

Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

BACKGROUND

A stratified approach to exercise therapy may yield superior clinical and economic outcomes, given the large heterogeneity of individuals with knee osteoarthritis (OA).

OBJECTIVE

To evaluate the cost-effectiveness during a 12-month follow-up of a model of stratified exercise therapy compared to usual exercise therapy in patients with knee OA, from a societal and healthcare perspective.

METHODS

An economic evaluation was conducted alongside a cluster-randomized controlled trial in patients with knee OA (n = 335), comparing subgroup-specific exercise therapy for a 'high muscle strength subgroup', 'low muscle strength subgroup', and 'obesity subgroup' supplemented by a dietary intervention for the 'obesity subgroup' (experimental group), with usual ('non-stratified') exercise therapy (control group). Clinical outcomes included quality-adjusted life years - QALYs (EuroQol-5D-5 L), knee pain (Numerical Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score in daily living). Costs were measured by self-reported questionnaires at 3, 6, 9 and 12-month follow-up. Missing data were imputed using multiple imputation. Data were analyzed through linear regression. Bootstrapping techniques were applied to estimate statistical uncertainty.

RESULTS

During 12-month follow-up, there were no significant between-group differences in clinical outcomes. The total societal costs of the experimental group were on average lower compared to the control group (mean [95% confidence interval]: € 405 [-1728, 918]), albeit with a high level of uncertainty. We found a negligible difference in QALYs between groups (mean [95% confidence interval]: 0.006 [-0.011, 0.023]). The probability of stratified exercise therapy being cost-effective compared to usual exercise therapy from the societal perspective was around 73%, regardless of the willingness-to-pay threshold. However, this probability decreased substantially to 50% (willingness-to-pay threshold of €20.000/QALY) when using the healthcare perspective. Similar results were found for knee pain and physical functioning.

CONCLUSIONS

We found no clear evidence that stratified exercise therapy is likely to be cost-effective compared to usual exercise therapy in patients with knee OA. However, results should be interpreted with caution as the study power was lower than intended, due to the Coronavirus disease (COVID-19) pandemic.

Exploring visual pain trajectories in neck pain patients, using clinical course, SMS-based patterns, and patient characteristics: a cohort study

Background

The dynamic nature of neck pain has so far been identified through longitudinal studies with frequent measures, a method which is time-consuming and impractical. Pictures illustrating different courses of pain may be an alternative solution, usable in both clinical work and research, but it is unknown how well they capture the clinical course. The aim of this study was to explore and describe self-reported visual trajectories in terms of details of patients’ prospectively reported clinical course, their SMS-based pattern classification of neck pain, and patient’s characteristics.

Methods

Prospective cohort study including 888 neck pain patients from chiropractic practice, responding to weekly SMS-questions about pain intensity for 1 year from 2015 to 2017. Patients were classified into one of three clinical course patterns using definitions based on previously published descriptors. At 1-year follow-up, patients selected a visual trajectory that best represented their retrospective 1-year course of pain: single episode, episodic, mild ongoing, fluctuating and severe ongoing.

Results

The visual trajectories generally resembled the 1-year clinical course characteristics on group level, but there were large individual variations. Patients selecting Episodic and Mild ongoing visual trajectories were similar on most parameters. The visual trajectories generally resembled more the clinical course of the last quarter.

Discussion

The visual trajectories reflected the descriptors of the clinical course of pain captured by weekly SMS measures on a group level and formed groups of patients that differed on symptoms and characteristics. However, there were large variations in symptoms and characteristics within, as well as overlap between, each visual trajectory. In particular, patients with mild pain seemed predisposed to recall bias. Although the visual trajectories and SMS-based classifications appear related, visual trajectories likely capture more elements of the pain experience than just the course of pain. Therefore, they cannot be seen as a proxy for SMS-tracking of pain over 1 year.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00443-3.

A Scoping Review of Item-Level Missing Data in Within-Trial Cost-Effectiveness Analysis

OBJECTIVES

Cost-effectiveness analysis (CEA) alongside randomized controlled trials often relies on self-reported multi-item questionnaires that are invariably prone to missing item-level data. The purpose of this study is to review how missing multi-item questionnaire data are handled in trial-based CEAs.

METHODS

We searched the National Institute for Health Research journals to identify within-trial CEAs published between January 2016 and April 2021 using multi-item instruments to collect costs and quality of life (QOL) data. Information on missing data handling and methods, with a focus on the level and type of imputation, was extracted.

RESULTS

A total of 87 trial-based CEAs were included in the review. Complete case analysis or available case analysis and multiple imputation (MI) were the most popular methods, selected by similar numbers of studies, to handle missing costs and QOL in base-case analysis. Nevertheless, complete case analysis or available case analysis dominated sensitivity analysis. Once imputation was chosen, missing costs were widely imputed at item-level via MI, whereas missing QOL was usually imputed at the more aggregated time point level during the follow-up via MI.

CONCLUSIONS

Missing costs and QOL tend to be imputed at different levels of missingness in current CEAs alongside randomized controlled trials. Given the limited information provided by included studies, the impact of applying different imputation methods at different levels of aggregation on CEA decision making remains unclear.

Application of the Stratified Nursing Mode of the Prediction Model Constructed Based on Case System Data in the Nursing of Patients with Acute Renal Failure

Objective

To explore the application of the stratified nursing mode of the prediction model constructed based on case system data in the nursing of patients with acute renal failure (ARF).

Methods

A total of 84 patients with ARF confirmed in the hospital were enrolled between February 2020 and February 2022. According to the simple random grouping method, they were divided into an observation group and a control group, 42 cases in each group. The control group was given routine nursing while the observation group was given stratified nursing of the prediction model constructed based on case system data. All were nursed for 2 months.

Results

There was no significant difference in general data such as gender, age, body mass index (BMI), serum creatinine (Scr), hemoglobin (Hb), and albumin between the two groups (P > 0.05). Age >60 years, weight fluctuation >2 kg during dialysis, vascular blockage or infection, coronary heart disease, diabetes mellitus, chronic hepatopathy and stroke, bleeding tendency, and neuromuscular abnormalities were high-risk factors for ARF patients, hypertension, thyroid abnormalities, hyperlipidemia, persistent or repeated blood volume overload, and usage of antihypertensive drugs were moderate-risk factors for ARF patients, and nonpermeability dehydration was a low-risk factor of ARF patients. The scores of nursing satisfaction and treatment compliance in the observation group were significantly higher than those in the control group (P < 0.05). After 2 months of nursing, scores of SAS, SDS, and SPBS in both the groups were significantly decreased (P < 0.05), which were significantly lower in the observation group than those in the control group (P < 0.05).

Conclusion

The stratified nursing mode of the prediction model constructed based on case system data is conducive to timely and targeted nursing, with high patient satisfaction and cooperation, and a better psychological state.

Stratified exercise therapy does not improve outcomes compared with usual exercise therapy in people with knee osteoarthritis (OCTOPuS study): a cluster randomised trial

QUESTION

In people with knee osteoarthritis, how much more effective is stratified exercise therapy that distinguishes three subgroups (high muscle strength subgroup, low muscle strength subgroup, obesity subgroup) in reducing knee pain and improving physical function than usual exercise therapy?

DESIGN

Pragmatic cluster randomised controlled trial in a primary care setting.

PARTICIPANTS

A total of 335 people with knee osteoarthritis: 153 in an experimental arm and 182 in a control arm.

INTERVENTION

Physiotherapy practices were randomised into an experimental arm providing stratified exercise therapy (supplemented by a dietary intervention from a dietician for the obesity subgroup) or a control arm providing usual, non-stratified exercise therapy.

OUTCOME MEASURES

Primary outcomes were knee pain severity (numerical rating scale for pain, 0 to 10) and physical function (Knee Injury and Osteoarthritis Outcome Score subscale activities of daily living, 0 to 100). Measurements were performed at baseline, 3 months (primary endpoint) and 6 and 12 months (follow-up). Intention-to-treat, multilevel, regression analysis was performed.

RESULTS

Negligible differences were found between the experimental and control groups in knee pain (mean adjusted difference 0.2, 95% CI -0.4 to 0.7) and physical function (-0.8, 95% CI -4.3 to 2.6) at 3 months. Similar effects between groups were also found for each subgroup separately, as well as at other time points and for nearly all secondary outcome measures.

CONCLUSION

This pragmatic trial demonstrated no added value regarding clinical outcomes of the model of stratified exercise therapy compared with usual exercise therapy. This could be attributed to the experimental arm therapists facing difficulty in effectively applying the model (especially in the obesity subgroup) and to elements of stratified exercise therapy possibly being applied in the control arm.

REGISTRATION

Netherlands National Trial Register NL7463.

Patients' and clinicians' experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

BACKGROUND

We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups ('high muscle strength subgroup', 'low muscle strength subgroup', 'obesity subgroup'), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the 'obesity subgroup'). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements.

METHODS

Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed.

RESULTS

We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the 'obesity subgroup'. In this 'obesity subgroup', physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the 'high muscle strength subgroup', the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these.

CONCLUSION

Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the 'obesity subgroup'. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy.

TRIAL REGISTRATION

The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).

Clinical pathways for the management of low back pain from primary to specialised care: a systematic review

PURPOSE

Clinical pathways for low back pain (LBP) have potential to improve clinical outcomes and health service efficiency. This systematic review aimed to synthesise the evidence for clinical pathways for LBP and/or radicular leg pain from primary to specialised care and to describe key pathway components.

METHODS

Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) from 2006 onwards were conducted with further manual and citation searching. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. A narrative synthesis of findings is presented.

RESULTS

From 18,443 identified studies, 28 papers met inclusion criteria. Pathways were developed primarily to address over-burdened secondary care services in high-income countries and almost universally used interface services with a triage remit at the primary-secondary care boundary. Accordingly, evaluation of healthcare resource use and patient flow predominated, with interface services associated with enhanced service efficiency through decreased wait times and appropriate use of consultant appointments. Low quality study designs, heterogeneous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical- and cost-effectiveness. Pathways demonstrated basic levels of care integration across the primary-secondary care boundary.

CONCLUSIONS

The limited volume of research evaluating clinical pathways for LBP/radicular leg pain and spanning primary and specialised care predominantly used interface services to ensure appropriate specialised care referrals with associated increased efficiency of care delivery. Pathways demonstrated basic levels of care integration across healthcare boundaries. Well-designed randomised controlled trials to explore the potential of clinical pathways to improve clinical outcomes, deliver cost-effective, guideline-concordant care and enhance care integration are required.