Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial

Abstract

Background: Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes.

Methods: This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites.

Discussion: If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas.

Trial registration: ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.

Keywords: Cluster randomized trial; Low back pain; Physiotherapy; Primary care.

Fig. 1

Overview of the PT in primary care screening and navigation process. The physiotherapist (PT) will help the patient navigate the healthcare system in three stages. First, any red flags identified will lead to emergency, urgent, or soon referrals to the emergency department, physician, and/or imaging. Second, the patient history, examination findings, and validated questionnaires, when appropriate, will be used to determine if other healthcare providers are needed for this patient’s care. Third, the PT will use the STarT back risk stratification tool (individuals screened as low, medium, or high risk of ongoing pain and disability [27]) to guide referral pathways for physiotherapy. The matched low-risk pathway is a brief primary care intervention (reassurance, advice, and exercise) with no referral. The medium-risk pathway involves a referral for usual physiotherapy care in addition to the brief intervention. The high-risk matched pathway includes referral for a combined physical and psychologically informed treatment approach which aims to address barriers to recovery, facilitate increases in activity, and address unhelpful back pain beliefs and behaviors. This treatment approach has been described in more detail elsewhere [56]. GAD-7 General Anxiety Disorder-7, NSAIDS nonsteroidal anti-inflammatory drugs, OT occupational therapy, PC primary care, PHQ-9 Patient Health Questionnaire-9, PTSD post-traumatic stress disorder

Fig. 2

Schedule of enrolment, interventions, and assessments