title: Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study.
abstract: 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.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors: J.M. Beneciuk, PT, PhD, MPH, Department of Physical Therapy, University of Florida, PO Box 100154, Gainesville, FL 32610 (USA), and Brooks Rehabilitation-College of Public Health and Health Professions Research Collaboration, Jacksonville, Florida. beneciuk@phhp.ufl.edu.
authors: Jason M
authors: JM
authors: Beneciuk
authors: S.Z. George, PT, PhD, Department of Physical Therapy, University of Florida, and Brooks Rehabilitation-College of Public Health and Health Professions Research Collaboration.
authors: Steven Z
authors: SZ
authors: George
mesh_terms: D000553:Ambulatory Care / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000534:rehabilitation*; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010147:Pain Measurement; D026741:Physical Therapy Modalities; D011320:Primary Health Care / Q000379:methods*; D016730:Program Development; D018570:Risk Assessment