Implementation of a Best Practice Primary Health Care Model for Low Back Pain (BetterBack)

August 12, 2019 updated by: Allan Abbott, Linkoeping University

Implementation of a Best Practice Primary Health Care Model for Low Back Pain in Sweden (BetterBack): A Cluster Randomised Trial

POPULATION: Low back pain (LBP) is a major health problem commonly requiring health care. In Sweden, primary care professionals require an evidenced based model of care for LBP.

INTERVENTION: The multi-faceted implementation of a best practice BetterBack model of care for LBP.

CONTROL: Current routine practice for LBP care before implementation of the BetterBack model of care.

OUTCOME: Patient reported measures (function, activity, health), therapist reported measures (diagnosis, intervention, specialist referral, best practice self-confidence, determinants of implementation) and cost-effectiveness.

AIM: To deliver best practice recommendations for LBP and study their most effective implementation through the BetterBack model of care.

METHOD: A cluster randomised trial with dog leg design. The hypothesis is that the BetterBack model of care will result in significantly better patient and therapist outcomes as well as cost-effectiveness compared to current routine care.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Low back pain (LBP) is a major health and socioeconomic burden. LBP is usually a result of benign dysfunction and context that affects the patient's perception of pain and limits their activity and participation. At present there are no national clinical guidelines or best practice models of care in Sweden focused on the primary care of low back pain. Implementation of a model of LBP primary care based on international evidence-based guidelines is needed to improve care and patient outcomes in Sweden. This project aims to investigate the effectiveness of a best practice model of care (BetterBack) for the primary care management of LBP. A cluster randomised trial with dog leg design will be conducted in the Östergötland Health care region. The hypothesis is that the BetterBack model of care will result in significantly better patient and therapist reported outcomes as well as cost-effectiveness compared to current routine care. This by improved patient outcomes in terms of physical function, low back pain intensity, activity level, work and quality of life. Furthermore, improved care processes and knowledge support for physiotherapists can lead to a smaller proportion of patients requiring specialist care.

Study Type

Interventional

Enrollment (Actual)

467

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Sweden
      • Linköping, Sweden, 58191
        • Östergötland health care region

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 65 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Health care practictioner sample

Inclusion Criteria:

  • Registered physiotherapists practicing in the allocated clinics and regularly working with patients with LBP

Patient sample

Inclusion Criteria:

  • Males and females 18-65 years; Fluent in Swedish; Accessing public primary care due to a current episode of a first-time or recurrent debut of benign low back pain with or without radiculopathy

Exclusion Criteria:

  • Current diagnosis of malignancy, spinal fracture, infection, cauda equine syndrome, ankylosing spondylitis or systemic rheumatic disease, previous malignancy during the past 5 years; Current pregnancy or previous pregnancy up to 3 months before consideration of inclusion; Patients that fulfill criteria for multimodal/multi-professional rehabilitation for complex longstanding pain; Severe psychiatric diagnosis

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Sequential Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Östergötland region - Control group
Behavioral: Current routine practice
Current routine practice for the primary care management of LBP
Experimental: Östergötland region - Intervention group
Behavioral: Multifaceted implementation of the BetterBack

The multifaceted intervention is composed of the following:

  1. Forming an implementation forum including head of departments/managers of the rehabilitation units and the clinical researchers.
  2. Forming a support team comprised of experience clinicians as local supervisors and faculty researchers as knowledge facilitators.
  3. Developing the Betterback model of care through a collaboration of the implementation forum, support team and international experts.
  4. Forming and delivering a 2-day package of education and training that the support team can utilize to assist the use of the BetterBack model of care by clinicians.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Numeric rating scale (NRS) for lower back related pain intensity during the latest week
Time Frame: Change between baseline and 3 months post baseline
Patient rated 11-point scale consisting of integers from 0 through 10; 0 representing ''No pain'' and 10 representing ''Worst imaginable pain''
Change between baseline and 3 months post baseline
Oswestry disability index (ODI) version 2.1
Time Frame: Change between baseline and 3 months post baseline
Patient rating of LBP disability analysed as a 0 to100 scale variable where lower scores represent lower levels of low back pain disability.
Change between baseline and 3 months post baseline
Practitioner Confidence Scale (PCS)
Time Frame: Change between baseline and 3 months post baseline
A total of 4 items are reported by the practitioner and a total score is collated where 4 represents greatest self-confidence and 20 represents lowest self-confidence
Change between baseline and 3 months post baseline
Incidence of participating patients recieving specialist care
Time Frame: 12 months after baseline
Data on the number of participants accessing specialist care for LBP will be extracted from the Östergötland public health care region registry.
12 months after baseline

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Numeric rating scale (NRS) for lower back related pain intensity during the latest week
Time Frame: Baseline, 3, 6 and 12 months
Patient rated 11-point scale consisting of integers from 0 through 10; 0 representing ''No pain'' and 10 representing ''Worst imaginable pain''
Baseline, 3, 6 and 12 months
Oswestry disability index (ODI) version 2.1
Time Frame: Baseline, 3, 6 and 12 months
Patient rating of LBP disability analysed as a 0 to100 scale variable where lower scores represent lower levels of low back pain disability.
Baseline, 3, 6 and 12 months
The European Quality of Life Questionnaire (EQ-5D)
Time Frame: Baseline, 3, 6 and 12 months
Patient rating of health-related quality of life and is computed into a 0 to 1.00 scale from worst to best possible health state by using UK index tariffs.
Baseline, 3, 6 and 12 months
The Brief Illness Perception Questionnaire (BIPQ)
Time Frame: Baseline, 3, 6 and 12 months
Patient rating of cognitive illness representations (consequences, outcome expectancy, personal control, treatment control, and knowledge), emotional representations (concern and emotions) as well as illness comprehensibility. An overall score 0-80 represents the degree to which the LBP is perceived as threatening or benign where a higher score reflects a more threatening view of the illness
Baseline, 3, 6 and 12 months
Patient Enablement Index (PEI)
Time Frame: 3, 6 and 12 months
Patient rating of enablement with a score range between 0 and 12 with a higher score intended to reflect higher patient self-care enablement
3, 6 and 12 months
Patient satisfaction
Time Frame: 3, 6 and 12 months
Patient rating of satisfaction asking "Over the course of treatment for this episode of low back pain or leg pain, how satisfied were you with the care provided by your health-care provider?" Were you very satisfied (1), somewhat satisfied (2), neither satisfied nor dissatisfied (3), somewhat dissatisfied (4), or very dissatisfied (5)?''
3, 6 and 12 months
Patient global rating of change (PGIC)
Time Frame: 3, 6 and 12 months
Patient rating of the degree of change in LBP related problems from the beginning of treatment to the present. This is measured with a balanced 11 point numerical scale.
3, 6 and 12 months
Practitioner Confidence Scale (PCS)
Time Frame: Baseline, directly after commencement of implementation strategy and at 3 and 12 months afterwards
A total of 4 items are reported by the practitioner and a total score is collated where 4 represents greatest self-confidence and 20 represents lowest self-confidence
Baseline, directly after commencement of implementation strategy and at 3 and 12 months afterwards
Clinician rated health care process measures
Time Frame: Baseline and final clinical contact (Up to 3 months where the time point is variable depending upon the amount of clinical contact required for each patient)
Grade of patient functional impairment and activity limitation according to the ICF brief core set for LBP is assesses by the physiotherapist where light, moderate, severe and very severe impairment/limitation is coded 0-4 respectively. A total score for baseline and an additional total score for follow-up measures at the final clinical contact (up to 3 months after baseline) is calculated from the sum of the functional impairments divided by the number of functional impairments and a similar total score is calculated for activity limitations. At the final clinical contact the therapists also report the ICD-10 diagnosis codes as well as type and number of patient treatment interventions.
Baseline and final clinical contact (Up to 3 months where the time point is variable depending upon the amount of clinical contact required for each patient)
Pain Attitudes and Beliefs Scale for physical therapists (PABS-PT)
Time Frame: Baseline, directly after education and at 3 and 12 months afterwards
The PABS-PT consists of two factors where higher scores represent more treatment orientation regarding that factor, one measuring the biomedical treatment orientation (Score 0-60) and one regarding the biopsychosocial treatment orientation (Score 0-54)
Baseline, directly after education and at 3 and 12 months afterwards

Other Outcome Measures

Outcome Measure
Measure Description
Time Frame
Determinants of implementation behavour questionnaire (DIBQ)
Time Frame: directly after commencement of implementation strategies and at 3 and 12 months after
Clinician reported determinants of BetterBack implementation designed according to the Theoretical Domains Framework
directly after commencement of implementation strategies and at 3 and 12 months after

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Linkoeping University

Investigators

  • Principal Investigator: Allan Abbott, Msc Physio, PhD, Linkoeping University
  • Principal Investigator: Birgitta Abbott, MSc Physio, PhD, Linkoeping University
  • Study Chair: Paul Enthoven, MSc Physio, PhD, Linkoeping University
  • Study Chair: Karin Schröder, MSc Physio, Linkoeping University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

April 1, 2017

Primary Completion (Actual)

March 31, 2019

Study Completion (Actual)

March 31, 2019

Study Registration Dates

First Submitted

May 3, 2017

First Submitted That Met QC Criteria

May 6, 2017

First Posted (Actual)

May 10, 2017

Study Record Updates

Last Update Posted (Actual)

August 14, 2019

Last Update Submitted That Met QC Criteria

August 12, 2019

Last Verified

August 1, 2019

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • BetterBack

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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