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- Schröder, Karin, 1966-
(författare)
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Implementing BetterBack – a Best Practice Physiotherapy Healthcare Model for Low Back Pain : Clinician and Patient Evaluation
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Low back pain (LBP) occurs in all ages, and first-line treatment by physiotherapists (PTs) is common. However, national evidence-based LBP clinical guidelines are still lacking in Sweden. To facilitate guideline uptake, we developed and with a multifaceted strategy implemented a best practice physiotherapy healthcare model (BetterBack☺ MoC) with the aim of supporting management of LBP in primary care. The overall aim of this thesis was to evaluate a multifaceted implementation strategy and a best practice physiotherapy healthcare model for LBP.Methods: This thesis is based on one methodological study and three experimental trials with PTs and patients with LBP. In Paper I a mixed method design was used to translate, tailor, validate and feasibility-test the Determinants of Implementation Behaviour Questionnaire (DIBQ). This tailored DIBQ Questionnaire (DIBQ-t) was used to evaluate potential barriers/facilitators during the implementation process together with evaluation of PTs’ confidence, attitudes and beliefs in managing LBP. In a stepped cluster randomised controlled trial, PTs and their patients in three clusters were allocated to intervention group (after implementation of BetterBack☺ MoC) or control group (routine physiotherapy care). The proportions of guideline-adherent care were compared between groups (Paper III). This evaluation was based on PTs’ adherence to eight clinical practice recommendations and three clinical practice quality indices (CPQI). The overall CPQI containing the five most prioritised recommendations are: no referral to specialist care; no referral to medical imaging for benign LBP; use of educational interventions; use of exercise interventions; and no use of non-evidence-based physiotherapy. Finally, in Paper IV patient-reported outcome measures (PROMs) were compared between intervention (after the implementation of BetterBack☺ MoC) and routine care. In Paper IV an additional secondary analysis was performed, comparing PROMs based on whether or not PTs had delivered care that met all five criteria of the overall CPQI or not.Results: A tailored, feasible and valid questionnaire was developed, DIBQ-t to be used for evaluation of the implementation of LBP primary care programmes. After implementation workshop, PTs’ (n = 116) confidence increased, and PTs’ attitudes and beliefs shifted towards a more biopsychosocial orientation. PTs had high expectations of the BetterBack☺ MoC, which decreased after using the MoC. When evaluating received treatment for 500 patients with LBP, a more frequent delivery of guideline-adherent care was seen after implementation (n = 278) compared to routine care (n = 222). The overall CPQI containing the five prioritised recommendations was fulfilled in 59% of all patients in intervention versus 26% in routine care group. Analysis of adherence to specific recommendations showed a significantly improved use of stratification of number of PT visits and patient educational interventions, frequent use of exercise was maintained, and use of non-evidence-based treatment and medical imaging decreased after implementation. The primary outcome, i.e. referral to specialist consultation, was low in both groups, with no between-group differences. After implementation of the BetterBack☺ MoC, no between-group differences in PROMs were seen except for greater satisfaction with LBP care, greater improvement in illness perception and better health-related quality of life, compared with routine care. However, when PTs’ care adhered to all five CPQI criteria, a greater improvement of most patient-reported outcomes was seen compared to patient care that did not adhere to all five CPQI criteria. Conclusions: The implementation of a best practice physiotherapy healthcare model (BetterBack☺ MoC) for LBP improved both clinician and patient outcomes. PTs increased use of guideline-adherent care, confidence and biopsychosocial orientation in managing LBP. Patients reported improved satisfaction, illness perception and health-related quality of life. The implementation did not decrease referral to specialist consultation from an initial low level; nor did it improve patients’ disability and pain more than routine care. However, when guideline-adherent care was fulfilled, most PROMs improved. It is therefore important to highlight the importance of guideline-based primary care for improving patient-reported LBP outcomes.
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| 2. |
- Fors, Maria, 1987-
(författare)
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Best Practice Physiotherapy for Patients with Low Back Pain in Primary Care : Clinical Outcomes and Explanatory Factors
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Clinical practice guidelines provide general recommendations informing best practice physiotherapy for low back pain (LBP). Despite increased research on LBP, the recommendations have barely changed over the last few decades and the burden of LBP remains. New research strategies have been suggested to further understand the complexity of factors influencing recovery of LBP. Several mechanisms are expected to underpin the benefits of physiotherapy care. How different factors influence and explain treatment outcome in patients in different phases of primary care pathway needs to be better understood for the development of better targeted LBP interventions.The overall aim of this thesis was to investigate if and how best practice physiotherapy primary care for patients with LBP can improve clinical outcome.Methods: The four papers in the thesis are based on two randomised controlled trials (RCT) evaluating best practice physiotherapy for patients with LBP in different phases of the primary care pathway reflecting the variation of patients’ needs. Two papers investigated pre-surgery physiotherapy compared to being on a waiting-list in patients with degenerative lumbar spine disorders who are surgical candidates (n = 197). Effects on walking ability and quadriceps femoris strength were evaluated. Associations between the pre-surgery physical factors with 1-year post-surgery physical activity (PA) level were analysed using multiple linear regression. The dose-response relationship was investigated comparing the effects of attending ≤11 treatment sessions with ≥12 treatment sessions. Multiple mediation analyses and conditional process analyses were used to explore physical and psychosocial factors as mediators and patients’ treatment expectations as a moderator of the treatment’s effects on disability, back pain intensity, health-related quality of life (HRQoL), and self-rated health.Two papers were based on a stepped cluster RCT, where a physiotherapy primary healthcare model for LBP (the BetterBack MoC) was regionally implemented. Patients seeking care for LBP were allocated to either the BetterBack MoC (after implementation) or to routine care (before implementation) (n = 467). In a prospective cohort study within the RCT, the associations between patients’ initial illness perceptions and outcomes in disability, back pain intensity, HRQoL, and self-care enablement (i.e., perceived ability to understand and cope with LBP) after 3 and 12 months were explored using stepwise linear regression. Single mediation analyses were used to test whether a priori hypothesised patients’ illness perceptions and self-care enablement at 3 months mediated effects in disability and pain at 6 months of care according to the BetterBack MoC compared to routine care. Exploratory mediation analyses were also used to compare guideline-adherent care with non-adherent care. Guideline-adherent care was defined as care that included education and exercise interventions and did not include non-evidence-based interventions, referral to specialist care, or imaging.Results: Small positive effects from pre-surgery physiotherapy were seen in walking ability and quadriceps femoris strength. No clear dose-response relationship could be demonstrated when comparing the effects of ≤11 treatment sessions with ≥12. Pre-surgery physical outcome measures together explained 27.5% of the variation in PA level 1-year post-surgery, mainly explained by the pre-surgery PA level. The effect of the pre-surgery physiotherapy on patients’ PA level partly explained the treatment’s effect on self-rated health. Furthermore, among biopsychosocial factors, self-efficacy related to activities of daily living (ADL) partly explained the effect on all outcomes. PA related fear avoidance beliefs partly explained the effects on pain and self-rated health. Patients’ treatment expectations moderated the effect in all outcomes. High expectations had a positive moderating effect, while expectation of full recovery had a suppressive effect. In patients seeking physiotherapy for LBP, negative initial prognosis and treatment expectations were associated with worse scores in several outcomes at 3- and 12-month follow-ups. Patients’ illness perceptions and self-care enablement did not explain the effects of care after implementing the BetterBack MoC. This was mainly due to the BetterBack MoC not having superior effects over routine care on the hypothesised mediators. Illness perceptions and self-care enablement at 3 months were associated with disability and pain at 6 months. Further, these factors partly explained the effects of guideline-adherent care in disability and pain.Conclusions: Patients’ illness perceptions, self-care enablement, ADL self-efficacy, and PA related fear-avoidance beliefs were supported to be potential factors explaining the effect on clinical outcomes of best practice physiotherapy for LBP in primary care. Patients’ initial expectations regarding the prognosis and treatment may influence prospective outcomes including patients’ self-care enablement. More specifically, pain and disability outcomes of best practice physiotherapy for patients seeking care for LBP may improve by targeting patients’ illness perceptions and self-care enablement. Patients who are surgical candidates can increase their physical capacity and walking related performance through best practice physiotherapy. In this pre-surgery phase, the treatment should include targeting patients’ ADL self-efficacy, PA related fear-avoidance beliefs, and PA level for improved disability, pain, and HRQoL.
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