Determining the Impact of a New Physiotherapist Led Primary Care Model for Back Pain

Experimental: Physiotherapist-led primary care model for back pain

The PT-led primary care model for back pain will involve incorporating a PT within the primary care team at the first point of contact for people with back pain at no cost to the patient. Patients in this model will be given the choice of seeing the PT or family doctor. They will be encouraged to book with the PT except when the primary reason for visit is for medication renewals or when the patient has additional health concerns that need attention from their physician in the same visit. There will be 4 key components of the PT led primary care intervention: 1) Initial assessment and screening; 2) Brief individualized intervention at the first visit; 3) Health services navigation; 4) Providing additional PT care for people with an unmet need.

Behavioral: Physiotherapist-led primary care model for back pain

1. Assessment and screening: taking a history; screening for red flags, comorbidities, and risk factors of ongoing pain and disability; physical examination
2. Brief individualized intervention at the first visit: effective communication, cognitive reassurance, a few exercises, and advice/strategies to stay active.
3. Health services navigation: PT assistance with navigating healthcare services based on the assessment findings. First, red-flags requiring emergency or urgent referrals. Next, comorbid conditions that would benefit from care from other healthcare providers. Finally, referral to PT (if appropriate).
4. Providing additional physiotherapy care to people with an unmet need: Additional physiotherapy care will be provided to patients who have an identified need for physiotherapy but no physiotherapy coverage through private or government health insurance plans.

Active Comparator: Usual care

The physician led primary care intervention will be unstandardized to best reflect standard clinical practice in Canada. This usually includes a visit to a primary care physician, who would perform a history and physical examination, provide LBP education, and prescribe medications and/or refer based on their assessment findings and patient preferences.

Other: Usual care

The physician led primary care intervention will be unstandardized to best reflect standard clinical practice in Canada.

Recruitment of primary care teams

Ability to recruit four primary care teams (Family Health Teams or Community Health Centres) to paricipate

Recruitment of patient participants

Recruitment rate (participants/week) or total number of participants recruited in 14 weeks

Assessment completion

Percentage of all assessment items completed by participants completing each assessment

Retention of patient participants

Attrition rate

Physiotherapist confidence in carrying out the interventions

The PT will rate his/her confidence in each component of the intervention after the training on a scale from 0-10 with higher scores indicating greater confidence in carrying out that component of the intervention.

Treatment fidelity

Treatment fidelity will be measured by consistency with the intervention described in the protocol measured through an intervention checklist completed by the physiotherapist and an audit of the EMR notes.

Self-reported disability

measured using the Roland Morris Disability Questionnaire (0 to 24 with higher scores indicating greater disability)

Self-reported pain intensity

measured using a numeric pain rating scale from 0 to 10 with higher scores indicating greater pain intensity (measured at rest, during walking, and during a lifting task)

Health Related Quality of Life

measured using the EuroQoL-5D-5L (0 to 100 with greater scores indicating greater self-reported health related quality of life)

Global rating of change

measured using an 11-point scale (-5 to +5 with negative scores indicating a worsening of physical functioning related to back pain and positive scores indicating an improvement of physical functioning related to back pain)

Satisfaction with health care

measured using an 11-point scale(-5 to +5 with negative scores indicating a dissatisfaction with health care received and positive scores indicating satisfaction with health care received)

Catastrophic Thinking

measured using the Pain Catastrophizing Scale (0 to 52 with higher scores indicating greater catastrophic thinking)

Depressive symptoms

measured using the 9-item Patient Health Questionnaire (PHQ-9) (0 to 27 with greater scores indicating increased depressive symptoms)

Adverse events

measured using an adverse events questionnaire that asks 1) if the patient has experienced any adverse events as a result of the treatments received (yes/no); 2) how long the event lasted (hours or days); 3) how severe the adverse event was (0-10 scale); 4) what adverse events were experienced.

Health care accessibility

Percentage of patients receiving care within 48 hours.

Health care accessibility

Percentage of patients who score medium or high risk on the STarT Back tool who receive physiotherapy care.

Health care utilization

All health care visits (aggregated and dis-aggregated) including: primary care visits, emergency department visits, hospitalizations, surgeries, consultations with other health care providers, diagnostic imaging, medications, and other care received by the patient

Costs (piloted for a cost utility analysis in a future trial)

Includes all health care costs plus societal costs using a human capital approach for loss of productivity

Medications prescribed

Measured as a process outcome

Diagnostic imaging ordered

Measured as a process outcome

referrals to other health care providers made

Measured as a process outcome

notes made by primary care provider to employers or insurers

Measured as a process outcome