Improving Function and Reducing Opioid Use for Patients with Chronic Low Back Pain in Rural Communities through Improved Access to Physical Therapy using Telerehabilitation

项目摘要 慢性腰痛（LBP）给受影响的个人、医疗保健系统和患者带来了巨大的负担。 社会LBP已被确定为全球和美国（US）最常见的残疾原因。 LBP也是美国医疗保健支出的最大驱动力（2016年为1350亿美元）和最常见的诊断 与阿片类药物处方和消费有关。对于慢性LBP患者，物理治疗一直是 这是一种具有成本效益的改善疼痛和残疾的方法。此外，物理治疗一直是 显示可降低慢性LBP患者的高级成像，注射，手术和阿片类药物使用的风险。 尽管有证据支持，但只有7-13%的LBP患者，包括慢性LBP患者， 接受物理治疗服务，患者报告在接受物理治疗方面存在障碍，例如 交通、供应商的可用性和错过的工作时间。在农村社区， 与大都市地区相比，人均可用的物理治疗师大约少40%。在 此外，生活在农村社区的患者可能需要长途跋涉才能接受物理治疗， 需要额外的误工时间和运输成本。农村地区缺乏物理治疗， 社区可能会导致与LBP相关的残疾和阿片类药物消费率更高， 与大城市相比，农村社区的情况更糟。改善获得服务的创新方法 迫切需要物理治疗来解决慢性LBP患者生活结果的差异 在美国的农村社区。远程医疗在COVID-19大流行期间迅速扩张。这包括 允许物理治疗师开始远程提供护理的政策变化，也称为 远程康复远程康复站，以改善获得物理治疗的慢性LBP患者 生活在农村社区，可以作为改善这些患者的结果的一种手段。 我们将进行一项单盲前瞻性随机临床试验，以解决理解 风险分层远程康复对减少阿片类药物使用和LBP相关残疾的有效性， 改善慢性LBP患者身体功能和健康相关生活质量（HRQoL）。此外，本发明还 我们将采用混合方法探索实施成果，包括电子调查， 与患者、物理治疗师、实践管理者和门诊服务的半结构化访谈 行政管理侧重于感知质量和对护理障碍的影响。我们将入组434例LBP患者 向服务于农村社区的初级保健诊所（TidalHealth，Salisbury，MD）进行介绍。合格患者将 提供知情同意书，并随机分配至教育对照组或风险分层远程康复组 （低风险，远程治疗监测;中等风险，物理治疗远程保健访问;或高风险， 提供心理信息的物理治疗远程保健访问）。主要有效性结局是以下方面的差异 治疗8周后LBP相关残疾（奥斯韦斯特里残疾指数）和阿片类药物使用的变化。

Project Summary Chronic low back pain (LBP) imposes tremendous burden on affected individuals, healthcare systems, and society. LBP has been identified as the most common cause of disability globally and in the United States (US). LBP is also the largest driver of US healthcare spending ($135 billion in 2016) and the most common diagnoses associated with opioid prescription and consumption. For patients with chronic LBP, physical therapy has been shown to be a cost-effective method for improving pain and disability. In addition, physical therapy has been shown to decrease the risk of advanced imaging, injections, surgery, and opioid use in patients with chronic LBP. Despite available evidence in support, only 7-13% of patients with LBP, including those with chronic LBP, go on to receive physical therapy services, with patients reporting barriers accessing physical therapy, such as transportation, provider availability and missed work time. Access is especially limited in rural communities where there are approximately 40% fewer physical therapists available per capita compared to metropolitan regions. In addition, patients living in rural communities likely need to travel longer distances to receive physical therapy, requiring additional missed work time and transportation costs. This lack of access to physical therapy in rural communities likely contributes to the greater rates of LBP-related disability and opioid consumption that have been observed in rural communities compared to metropolitan areas. Innovative methods for improving access to physical therapy are urgently needed to address disparities in outcomes for patients with chronic LBP living in rural communities in the US. Telehealth has rapidly expanded during the COVID-19 pandemic. This includes policy changes that have allowed physical therapists to begin providing care remotely, also referred to as telerehabilitation. Telerehabilitation stands to improve access to physical therapy for patients with chronic LBP living in rural communities and may serve as a means of improving outcomes of these patients. We will conduct a single-blind prospective randomized clinical trial addressing key questions to understanding the effectiveness of a risk-stratified telerehabilitation to reduce opioid use and LBP-related disability and to improve physical function and health-related quality of life (HRQoL) in patients with chronic LBP. Additionally, we will explore implementation outcomes using a mixed methods approach consisting of electronic surveys and semi-structured interviews with patients, physical therapists, practice managers, and outpatient services administration focusing on perceived quality and impact on barriers to care. We will enroll 434 patients with LBP presenting to primary care clinics serving rural communities (TidalHealth, Salisbury, MD). Eligible patients will provide informed consent and be randomized to either an educational control or risk-stratified telerehabilitation (low-risk, remote therapeutic monitoring; medium-risk, physical therapy telehealth visits; or high-risk, psychologically informed physical therapy telehealth visits). Primary effectiveness outcome is difference in change in LBP-related disability (Oswestry Disability Index) and in opioid use after 8 weeks of treatment.