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Simula AS, Malmivaara A, Booth N, Karppinen J. Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial. J Rehabil Med 2024; 56:jrm28321. [PMID: 38643363 DOI: 10.2340/jrm.v56.28321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/03/2024] [Indexed: 04/22/2024] Open
Abstract
OBJECTIVE The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care. DESIGN A benchmarking controlled trial design was used. SUBJECTS/PATIENTS Three primary healthcare areas and 654 low back pain patients with or without sciatica. METHODS Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months. RESULTS No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003). Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.
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Affiliation(s)
- Anna Sofia Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of General
Medicine, Wellbeing services county of South Savo (ELOISA), Mikkeli, Finland.
| | - Antti Malmivaara
- Finnish Institute for Health and Welfare, Helsinki, Finland; Orton Orthopaedic Hospital, Helsinki, Finland
| | - Neill Booth
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Karppinen J, Simula AS, Holopainen R, Lausmaa M, Remes J, Paukkunen M, Ussing K, Booth N, Ryynänen K, Koski T, Abbott A, Öberg B, Linton SJ, Smith A, O'Sullivan P, Malmivaara A. Evaluation of training in guideline-oriented biopsychosocial management of low back pain in occupational health services: Protocol of a cluster randomized trial. Health Sci Rep 2021; 4:e251. [PMID: 33728382 PMCID: PMC7933561 DOI: 10.1002/hsr2.251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To prevent low back pain (LBP) from developing into a prolonged disabling condition, clinical guidelines advocate early stage assessment, risk-screening, and tailored interventions. Occupational health services recommend guideline-oriented biopsychosocial screening and individualized assessment and management. However, it is not known whether training a limited number of health care professionals improves the management process. The primary objective of this study is to investigate whether training in the biopsychosocial practice model is effective in reducing disability. Furthermore, we aim to evaluate health-economic impacts of the training intervention in comparison to usual medical care. METHODS The occupational health service units will be allocated into a training or control arm in a two-arm cluster randomized controlled design. The training of occupational physiotherapists and physicians will include the assessment of pain-related psychosocial factors using the STarT Back Tool and the short version of the Örebro Musculoskeletal Pain Screening Questionnaire, the use of an evidence-based patient education booklet as part of the management of LBP, and tailored individualized management of LBP according to risk stratification. The control units will receive no training. The study population will include patients aged 18-65 with nonspecific LBP. The primary outcome is a patient-reported Oswestry Disability Index from baseline to 12 months. By estimating group differences over time, we aim to evaluate the effectiveness of the training intervention in comparison to usual medical care, and to undertake an economic evaluation using individual patients' health care records (participant-level data) and the participating units' registries (cluster-level data). In addition, through interviews and questionnaires, we will explore the health care professionals' conceptions of the adoption of, the barriers to, and the facilitators of the implementation of the practice model. DISCUSSION The evaluation of training in the guideline-oriented biopsychosocial management of LBP in occupational health services is justified because LBP represents an enormous burden in terms of work disability.
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Affiliation(s)
- Jaro Karppinen
- Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
- Finnish Institute of Occupational HealthOuluFinland
| | - Anna Sofia Simula
- Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
- Department of General MedicineThe South Savo Social and Health Care AuthorityMikkeliFinland
| | - Riikka Holopainen
- Faculty of Sport and Health SciencesUniversity of JyväskyläJyväskyläFinland
| | - Mikko Lausmaa
- Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
| | - Jouko Remes
- Finnish Institute of Occupational HealthOuluFinland
| | - Maija Paukkunen
- Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of PhysiotherapyLinköping UniversityLinköpingSweden
| | - Kasper Ussing
- Spine and Mind FysioOdenseDenmark
- Spine Center of Southern DenmarkLillebaelt HospitalMiddelfartDenmark
| | - Neill Booth
- Faculty of Social Sciences (Health Sciences)Tampere UniversityTampereFinland
| | - Katja Ryynänen
- Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
- Mehiläinen CorporationOuluFinland
| | - Tomi Koski
- Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
- Työterveys Virta OyOuluFinland
| | - Allan Abbott
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of PhysiotherapyLinköping UniversityLinköpingSweden
| | - Birgitta Öberg
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of PhysiotherapyLinköping UniversityLinköpingSweden
| | - Steven J. Linton
- Department of Law, Psychology, and Social Work, Center for Health and Medical PsychologyÖrebro UniversityÖrebroSweden
| | - Anne Smith
- School of Physiotherapy and Exercise ScienceCurtin UniversityPerthWestern AustraliaAustralia
| | - Peter O'Sullivan
- School of Physiotherapy and Exercise ScienceCurtin UniversityPerthWestern AustraliaAustralia
- Body Logic PhysiotherapyPerthWestern AustraliaAustralia
| | - Antti Malmivaara
- Centre for Health and Social EconomicsFinnish Institute for Health and WelfareHelsinkiFinland
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Simula AS, Malmivaara A, Booth N, Karppinen J. A classification-based approach to low back pain in primary care - protocol for a benchmarking controlled trial. BMC Fam Pract 2020; 21:61. [PMID: 32252643 PMCID: PMC7137427 DOI: 10.1186/s12875-020-01135-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/29/2020] [Indexed: 12/03/2022]
Abstract
Background Guidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care. Methods We will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up. Discussion The implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway. Trial registration ISRCTN,ISRCTN13273552, retrospectively registered 13/05/2019.
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Affiliation(s)
- A S Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. .,Department of General Medicine, The South Savo Social and Health Care Authority, Mikkeli, Finland.
| | - A Malmivaara
- Centre for Health and Social Economics, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - N Booth
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
| | - J Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Finnish Institute of Occupational Health, Oulu, Finland
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Simula AS, Jenkins HJ, Holopainen R, Oura P, Korniloff K, Häkkinen A, Takala EP, Hancock MJ, Karppinen J. Transcultural adaption and preliminary evaluation of "understanding low back pain" patient education booklet. BMC Health Serv Res 2019; 19:1010. [PMID: 31888605 PMCID: PMC6936060 DOI: 10.1186/s12913-019-4854-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 12/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Low back pain (LBP) is the number one cause of disability globally. LBP is a symptom associated with biological, psychological and social factors, and serious causes for pain are very rare. Unhelpful beliefs about LBP and inappropriate imaging are common. Practitioners report pressure from patients to provide inappropriate imaging. A recently developed patient education and management booklet, ‘Understanding low back pain’, was designed to target previously identified barriers for reducing inappropriate imaging. The booklet includes evidence-based information on LBP and supports communication between patients and practitioners. Our aim was to 1) describe the translation process into Finnish and 2) study patients’ and practitioners’ attitudes to the booklet and to evaluate if it improved patients’ understanding of LBP and practitioners’ ability to follow imaging guidelines. Methods We translated the booklet from English to Finnish. Preliminary evaluation of the booklet was obtained from LBP patients (n = 136) and practitioners (n = 32) using web-based questionnaires. Open-ended questions were analysed using thematic analysis. Results Approximately half of the patients reported that reading the booklet helped them to understand LBP, while a third thought it encouraged them to perform physical activity and decreased LBP-related fear. Eighty percent of practitioners reported that the booklet helped them to follow imaging guidelines. In addition, practitioners reported that they found the booklet helpful and that it decreased the need for imaging. Conclusions The booklet seemed to be helpful in LBP management and in decreasing the need for LBP imaging according to patients and practitioners. Further research on the clinical effectiveness of the booklet in controlled study settings is needed. Trial registration ISRCTN, ISRCTN14389368, Registered 4 April 2019 - Retrospectively registered; ISRCTN11875357, Registered 22 April 2019 - Retrospectively registered.
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Affiliation(s)
- Anna Sofia Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. .,Faculty of Medicine, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland. .,Department of General Medicine Mikkeli Central Hospital (Essote), Mikkeli, Finland.
| | - Hazel J Jenkins
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Balaclava Road, North Ryde, NSW, 2109, Australia.,Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Riikka Holopainen
- Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, FI-40014, Jyväskylä, Finland
| | - Petteri Oura
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Faculty of Medicine, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland
| | - Katariina Korniloff
- School of Health and Social Studies, JAMK University of Applied Sciences, PO BOX 207, FI-40101, Jyväskylä, Finland
| | - Arja Häkkinen
- Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, FI-40014, Jyväskylä, Finland.,Department of Physical Medicine and Rehabilitation, Jyväskylä Central Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland
| | - Esa-Pekka Takala
- Finnish Institute of Occupational Health, P.O. Box 40, FI-00032, Helsinki and Oulu, Työterveyslaitos, Finland
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Balaclava Road, North Ryde, NSW, 2109, Australia
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Faculty of Medicine, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland.,Finnish Institute of Occupational Health, P.O. Box 40, FI-00032, Helsinki and Oulu, Työterveyslaitos, Finland
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