Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study
Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study
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DOI：
10.2522/ptj.20140418
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发表时间：
2015-08-01
期刊：
影响因子：
3.2
通讯作者：
George, Steven Z.
中科院分区：
文献类型：
--
作者：
Beneciuk, Jason M.;George, Steven Z.
背景风险分层对腰痛（LBP）管理的有效性尚未在门诊物理治疗环境中得到证实。目的。本研究的目的是：（1）通过评估短期治疗效果来评估LBP管理分层护理方法的实施情况;（2）确定进行大规模研究的可行性。这是一个2阶段的初步研究。在第1阶段，临床医生被随机分配接受标准（n=6）或分层护理（n=6）培训。分层护理培训包括8个小时的内容，重点是心理知情的做法。LBP的态度和信念的变化进行了评估，使用疼痛态度和信念量表的物理治疗师（PABS-PT）和医疗保健提供者疼痛和损害关系量表（HC-PAIRS）。在第2阶段，指导接受分层护理培训的临床医生将这些策略纳入他们的实践中，并使用数字疼痛评定量表（NPRS）和奥斯韦斯特里残疾指数（ODI）收集4周患者结局。研究的可行性进行了评估，以确定潜在的障碍，完成一个更大规模的研究。在第1阶段，观察到标准治疗临床医生的PABS-PT和HC-PAIRS评分变化极小（Cohen d= 0. 00 - 0. 28）。在分层护理临床医生中观察到生物医学（-4.5 +/- 2.5分，d=1.08）和生物心理社会（+5.5 +/- 2.0分，d=2.86）治疗取向下降，这些变化在PABS-PT上持续6个月。在第2阶段，与接受标准物理治疗的患者（n=33）相比，接受分层治疗的患者（n=67）在NPRS（0.8分; 95%置信区间=0.1，1.5; d=0.40）和ODI（8.9%分; 95%置信区间=4.1，13.6; d=0.76）评分方面的组间改善更大。在第2阶段，治疗不是随机分配的，治疗师对治疗建议的依从性也没有监测。这项研究没有足够的把握度进行亚组分析。在物理治疗环境中，可以修改生物医学方向，并可以有效地实施LBP的风险分层护理。这项研究的结果可用于规划更大的研究。
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.