GLA:D® Back: group-based patient education integrated with exercises to support self-management of persistent back pain - feasibility of implementing standardised care by a course for clinicians

Alice Kongsted, Jan Hartvigsen, Eleanor Boyle, Inge Ris, Per Kjaer, Line Thomassen, Werner Vach, Alice Kongsted, Jan Hartvigsen, Eleanor Boyle, Inge Ris, Per Kjaer, Line Thomassen, Werner Vach

Abstract

Background: Clinical guidelines for management of low back pain (LBP) are not routinely implemented in practice, and guidelines rarely offer tools for implementation. Therefore, we developed GLA:D® Back, a standardised intervention of patient education and supervised exercises. This pilot study tested the feasibility of implementing GLA:D Back in clinical practice in Denmark by delivering a course for physiotherapists and chiropractors. It should further inform the planning of an implementation-effectiveness study using a pre-post group design alongside nation-wide implementation.

Methods: Thirty-one clinicians from nine clinics participated. Feasibility of implementation was evaluated in terms of adoption and through focus group interviews and a feedback meeting. Patient-level data, including pain, disability, and pain enablement, were collected from (1) LBP patients visiting the clinics during a pre-specified 2-week period 2 months prior to clinicians attending the GLA:D Back course (n = 84), (2) LBP patients consulting during a 2-week period 2 months after the course (n = 77), and (3) those enrolled in GLA:D Back during 4 months after implementation (n = 89). Patient data were collected at baseline and at 4 months.

Results: Clinicians' evaluations of the course were positive and resulted in several modifications. The clinical intervention was adopted by all test sites. Most patient characteristics were similar across groups. Patients mainly had persistent LBP (73% > 3 months) and most had been treated for more than 4 weeks at inclusion. Patients in GLA:D Back were more often retired (30% vs. 16% before implementation) and at high risk of poor prognosis (25% vs. 13%). Procedures for data collection were feasible, and outcomes after implementation, especially with GLA:D Back, were as good as or better than before implementation. Recruiting patients and achieving comparable pre- and post-groups was difficult.

Conclusions: Implementation of the GLA:D Back clinical intervention in Danish primary care physiotherapy and chiropractic clinics was feasible through a 2-day clinician course. Both clinicians and patients were satisfied with the programme, and patient-reported outcomes were slightly better than outcomes in patients registered before implementation. It was not deemed possible to conduct an implementation-effectiveness trial as part of a nation-wide implementation.

Keywords: Back pain; Exercise; Feasibility; Implementation; Patient education; Pilot study; Self-management.

Conflict of interest statement

The data collection has obtained authorisation from the Danish Data Protection Agency (DPA) as part of the University of Southern Denmark’s institutional authorisation (DPA no. 2015-57-0008 SDU no. 17/30591). When registered by the clinician, the patient receives an email with a link to a patient-reported survey. Written information about the study, data protection, and participants’ rights are in the survey with a request to confirm consent for using data for research purposes. The Regional Committees on Health Research Ethics for Southern Denmark decided that the study did not need ethical approval (file number S-20172000-93) (Additional file 1). According to Danish regulations, an observational study implementing a non-experimental treatment that was offered to patients on the decision of the clinicians does not undergo research ethics evaluation [37].NAAK’s position at the University of Southern Denmark is financially supported by the Foundation for Chiropractic Research and Postgraduate Education, and IR’s position is supported by income from the GLA:D Back clinician courses. GLA:D® is a non-profit initiative hosted at the University of Southern Denmark, and the GLA:D® trademark is a property of the University of Southern Denmark. The GLA:D initiative is developed in close collaboration with the SDU Research & Innovation Organisation, including legal reviews. The researchers do not have any personal financial benefits from working with the project.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Study flow. Rough overview of activities and data collections at the level of clinicians and patients. Please refer to the text for exact time periods
Fig. 2
Fig. 2
Clinicians’ scores on two subscales of the Pain Attitudes and Beliefs Scale before course participation and 4 months later
Fig. 3
Fig. 3
Patient flow chart. Before-group = participants recruited prior to implementation of GLA:D Back; after-group = participants recruited after the implementation

References

    1. Oliveira Crystian B., Maher Chris G., Pinto Rafael Z., Traeger Adrian C., Lin Chung-Wei Christine, Chenot Jean-François, van Tulder Maurits, Koes Bart W. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European Spine Journal. 2018;27(11):2791–2803. doi: 10.1007/s00586-018-5673-2.
    1. Liang L, Abi Safi J, Gagliardi AR. Number and type of guideline implementation tools varies by guideline, clinical condition, country of origin, and type of developer organization: content analysis of guidelines. Implement Sci. 2017;12:136. doi: 10.1186/s13012-017-0668-7.
    1. Foster Nadine E, Anema Johannes R, Cherkin Dan, Chou Roger, Cohen Steven P, Gross Douglas P, Ferreira Paulo H, Fritz Julie M, Koes Bart W, Peul Wilco, Turner Judith A, Maher Chris G, Buchbinder Rachelle, Hartvigsen Jan, Cherkin Dan, Foster Nadine E, Maher Chris G, Underwood Martin, van Tulder Maurits, Anema Johannes R, Chou Roger, Cohen Stephen P, Menezes Costa Lucíola, Croft Peter, Ferreira Manuela, Ferreira Paulo H, Fritz Julie M, Genevay Stéphane, Gross Douglas P, Hancock Mark J, Hoy Damian, Karppinen Jaro, Koes Bart W, Kongsted Alice, Louw Quinette, Öberg Birgitta, Peul Wilco C, Pransky Glenn, Schoene Mark, Sieper Joachim, Smeets Rob J, Turner Judith A, Woolf Anthony. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368–2383. doi: 10.1016/S0140-6736(18)30489-6.
    1. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and metasynthesis of qualitative studies. Clin J Pain. 2016;32:800–816. doi: 10.1097/ajp.0000000000000324.
    1. Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA:D): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC Musculoskelet Disord. 2017;18:72. doi: 10.1186/s12891-017-1439-y.
    1. Foster NE, Mullis R, Hill JC, Lewis M, Whitehurst DG, Doyle C, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;12:102–111. doi: 10.1370/afm.1625.
    1. Grønne DT, Roos E, Skou ST. Annual report 2017 GLA:D. Odense: University of Southern Denmark; 2017.
    1. Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, et al. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet. 2010;375:916–923. doi: 10.1016/s0140-6736(09)62164-4.
    1. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560–1571. doi: 10.1016/S0140-6736(11)60937-9.
    1. Kjaer P, Kongsted A, Ris I, Abbott A, Rasmussen CDN, Skou ST, et al. GLA:D® Back: group-based patient education and exercises to support self-management of back pain. Development, theories and scientific evidence. 2018.
    1. Mesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskelet Disord. 2016;17:258. doi: 10.1186/s12891-016-1110-z.
    1. Suman A, Dikkers MF, Schaafsma FG, van Tulder MW, Anema JR. Effectiveness of multifaceted implementation strategies for the implementation of back and neck pain guidelines in health care: a systematic review. Implement Sci. 2016;11:126. doi: 10.1186/s13012-016-0482-7.
    1. Kongsted A, Ris I, Kjaer P, Vach W, Morsø L, Hartvigsen J. GLA:D® Back: implementation of group-based patient education integrated with exercises to support self-management of back pain - protocol for a hybrid effectiveness-implementation study. BMC Musculoskelet Disord. 2019;20(1):85. 10.1186/s12891-019-2443-1.
    1. Bush T, Cherkin D, Barlow W. The impact of physician attitudes on patient satisfaction with care for low back pain. Arch Fam Med. 1993;2:301–305. doi: 10.1001/archfami.2.3.301.
    1. Ostelo RW, Stomp-van den Berg SG, Vlaeyen JW, Wolters PM, de Vet HC. Health care provider’s attitudes and beliefs towards chronic low back pain: the development of a questionnaire. Man Ther. 2003;8:214–222. doi: 10.1016/S1356-689X(03)00013-4.
    1. Houben RM, Ostelo RW, Vlaeyen JW, Wolters PM, Peters M, Stomp-van den Berg SG. Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Eur J Pain. 2005;9:173–183. doi: 10.1016/j.ejpain.2004.05.002.
    1. Eland Nicolaas D., Kvåle Alice, Ostelo Raymond W.J.G., Strand Liv Inger. The Pain Attitudes and Beliefs Scale for Physiotherapists: Dimensionality and Internal Consistency of the Norwegian Version. Physiotherapy Research International. 2016;22(4):e1670. doi: 10.1002/pri.1670.
    1. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, et al. Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework. Implement Sci. 2014;9:33. doi: 10.1186/1748-5908-9-33.
    1. Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59:632–641. doi: 10.1002/art.23563.
    1. Lauridsen HH, Hartvigsen J, Manniche C, Korsholm L, Grunnet-Nilsson N. Danish version of the Oswestry disability index for patients with low back pain. Part 2: Sensitivity, specificity and clinically significant improvement in two low back pain populations. Eur Spine J. 2006;15:1717–1728. doi: 10.1007/s00586-006-0128-6.
    1. Lauridsen HH, Hartvigsen J, Manniche C, Korsholm L, Grunnet-Nilsson N. Danish version of the Oswestry Disability Index for patients with low back pain. Part 1: Cross-cultural adaptation, reliability and validity in two different populations. Eur Spine J. 2006;15:1705–1716. doi: 10.1007/s00586-006-0117-9.
    1. Strong J, Ashton R, Chant D. Pain intensity measurement in chronic low back pain. Clin J Pain. 1991;7:209–218. doi: 10.1097/00002508-199109000-00007.
    1. Leysen M, Nijs J, Meeus M, Paul van Wilgen C, Struyf F, Vermandel A, et al. Clinimetric properties of illness perception questionnaire revised (IPQ-R) and brief illness perception questionnaire (Brief IPQ) in patients with musculoskeletal disorders: a systematic review. Man Ther. 2015;20:10–17. doi: 10.1016/j.math.2014.05.001.
    1. Broadbent E, Wilkes C, Koschwanez H, Weinman J, Norton S, Petrie KJ. A systematic review and meta-analysis of the Brief Illness Perception Questionnaire. Psychol Health. 2015;30:1361–1385. doi: 10.1080/08870446.2015.1070851.
    1. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–168. doi: 10.1016/0304-3959(93)90127-B.
    1. Grotle M, Brox JI, Vollestad NK. Reliability, validity and responsiveness of the fear-avoidance beliefs questionnaire: methodological aspects of the Norwegian version. J Rehabil Med. 2006;38:346–353. doi: 10.1080/16501970600722403.
    1. Howie JG, Heaney DJ, Maxwell M, Walker JJ. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract. 1998;15:165–171. doi: 10.1093/fampra/15.2.165.
    1. Roost M, Zielinski A, Petersson C, Strandberg EL. Reliability and applicability of the Patient Enablement Instrument (PEI) in a Swedish general practice setting. BMC Fam Pract. 2015;16:31. doi: 10.1186/s12875-015-0242-9.
    1. Stroyer J, Essendrop M, Jensen LD, Warming S, Avlund K, Schibye B. Validity and reliability of self-assessed physical fitness using visual analogue scales. Percept Mot Skills. 2007;104:519–533. doi: 10.2466/pms.104.2.519-533.
    1. Gauvin MG, Riddle DL, Rothstein JM. Reliability of clinical measurements of forward bending using the modified fingertip-to-floor method. Phys Ther. 1990;70:443–447. doi: 10.1093/ptj/70.7.443.
    1. Arab AM, Salavati M, Ebrahimi I, Ebrahim Mousavi M. Sensitivity, specificity and predictive value of the clinical trunk muscle endurance tests in low back pain. Clin Rehabil. 2007;21:640–647. doi: 10.1177/0269215507076353.
    1. Moreland J, Finch E, Stratford P, Balsor B, Gill C. Interrater reliability of six tests of trunk muscle function and endurance. J Orthop Sports Phys Ther. 1997;26:200–208. doi: 10.2519/jospt.1997.26.4.200.
    1. Ito T, Shirado O, Suzuki H, Takahashi M, Kaneda K, Strax TE. Lumbar trunk muscle endurance testing: an inexpensive alternative to a machine for evaluation. Arch Phys Med Rehabil. 1996;77:75–79. doi: 10.1016/S0003-9993(96)90224-5.
    1. Liebenson C, Karpowicz AM, Brown SH, Howarth SJ, McGill SM. The active straight leg raise test and lumbar spine stability. PM R. 2009;1:530–535. doi: 10.1016/j.pmrj.2009.03.007.
    1. Matyas TA, Bach TM. The reliability of selected techniques in clinical arthrometrics. Aust J Physiother. 1985;31:175–199. doi: 10.1016/S0004-9514(14)60633-4.
    1. Newton M, Waddell G. Reliability and validity of clinical measurement of the lumbar spine in patients with chronic low back pain. Physiotherapy. 1991;77:796–800. doi: 10.1016/S0031-9406(10)61906-2.
    1. The National Committee on Health Research Ethics. Act on Research Ethics Review of Health Research Projects 2019 [updated 2019-02-21; cited 14 Mar 2019]. Available from: .

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner