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Shashua A1,2, Levran I1, Srulovici E3,4, Friger MD2
1Clalit Health Services, Physiotherapy, Tel Aviv, Israel, 2Ben-Gurion University of the Negev, Department of Public Health, Faculty of Health Sciences, Beer-Sheva, Israel, 3University of Haifa, School of Nursing, Haifa, Israel, 4Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
Background: Physical therapy (PT) is a common therapeutic approach, which includes a variety of modalities, to treat patients with low back pain. However, PT combinations of modalities that are associated with better outcomes have not been examined yet. A new technological development allows early and accessible assessment, using online patient reported outcomes (PROMs). Identifying the appropriate treatment modalities combinations, based on real-world data analyses, along with early information from PROMs, may assist the physiotherapist tailoring the appropriate intervention to each patient.
Purpose: Developing a decision support system empirically based on treatment modalities combinations associated with improvement in PROMs among patients with LBP.
Methods: This is a secondary data analysis of a retrospective cohort study, based on electronic medical records of Clalit Health Services, among patients (age≥25) with LBP who participated in a course of PT treatment with complete PROMs during 2013-2014. Patients were excluded if they had active cancer during the five years prior to treatment, or if they attended only one PT session.
Disability and pain level, measured at beginning and end of treatment, were the primary outcome measures. Improvement in both outcomes was considered an integrated outcome defined as PROMs.
Decision tree analyses and multivariable regression models were performed to examine the associations between different doses (none/low/high per course of treatment) of eight treatment modalities and their combinations, and the outcomes, adjusted to sociodemographic characteristics, clinical and health-related factors, and health care utilization factors.
Results: The sample included 4,624 patients with a mean age of 56.3(±16.4). Clinical improvement in pain or disability was observed in 69% and 49% of patients, respectively, and improvement in PROMs was observed in 40%.
In the multivariable analysis, low-dosage of manual therapy was associated with improvement in disability, and high-dosage of manual therapy was associated with improvement in disability and pain. Low-dosage of individual exercise was associated with improvement in disability and PROMs.
Three significant treatment modalities combinations were found: the combination of high-dosage of individual exercise with low-dosage of group exercise was associated with improvement in pain and PROMs; the combination of high-dosage of individual exercise with high-dosage of electrotherapy was associated with pain improvement; the combination of low-dosage of manual therapy with low-dosage of group exercise was associated with improvement in PROMs.
Conclusion(s): Manual therapy and individual exercise modalities were significantly associated with improvement in disability and pain among patients with LBP. Furthermore, combining the appropriate modalities improved the outcomes. Clinicians should direct the appropriate modality and combination considering the patient´s condition and treatment goals. For example, group exercise should be considered as a part of comprehensive treatment program combined with manual therapy or individual exercise rather than in isolation.
Implications: This real-world data allows creating a novel decision support system based on online PROMs data and treatment modalities combinations associated with them. The PROMs data will be available in the medical record prior to patients´ PT consultation session, and may assist the physiotherapist, along with the clinical examination, to plan the treatment program.
Keywords: Treatment modalities combinations, patient reported outcomes, decision support system
Funding acknowledgements: There were no sources of support or financial involvement in any organization or entity.
Purpose: Developing a decision support system empirically based on treatment modalities combinations associated with improvement in PROMs among patients with LBP.
Methods: This is a secondary data analysis of a retrospective cohort study, based on electronic medical records of Clalit Health Services, among patients (age≥25) with LBP who participated in a course of PT treatment with complete PROMs during 2013-2014. Patients were excluded if they had active cancer during the five years prior to treatment, or if they attended only one PT session.
Disability and pain level, measured at beginning and end of treatment, were the primary outcome measures. Improvement in both outcomes was considered an integrated outcome defined as PROMs.
Decision tree analyses and multivariable regression models were performed to examine the associations between different doses (none/low/high per course of treatment) of eight treatment modalities and their combinations, and the outcomes, adjusted to sociodemographic characteristics, clinical and health-related factors, and health care utilization factors.
Results: The sample included 4,624 patients with a mean age of 56.3(±16.4). Clinical improvement in pain or disability was observed in 69% and 49% of patients, respectively, and improvement in PROMs was observed in 40%.
In the multivariable analysis, low-dosage of manual therapy was associated with improvement in disability, and high-dosage of manual therapy was associated with improvement in disability and pain. Low-dosage of individual exercise was associated with improvement in disability and PROMs.
Three significant treatment modalities combinations were found: the combination of high-dosage of individual exercise with low-dosage of group exercise was associated with improvement in pain and PROMs; the combination of high-dosage of individual exercise with high-dosage of electrotherapy was associated with pain improvement; the combination of low-dosage of manual therapy with low-dosage of group exercise was associated with improvement in PROMs.
Conclusion(s): Manual therapy and individual exercise modalities were significantly associated with improvement in disability and pain among patients with LBP. Furthermore, combining the appropriate modalities improved the outcomes. Clinicians should direct the appropriate modality and combination considering the patient´s condition and treatment goals. For example, group exercise should be considered as a part of comprehensive treatment program combined with manual therapy or individual exercise rather than in isolation.
Implications: This real-world data allows creating a novel decision support system based on online PROMs data and treatment modalities combinations associated with them. The PROMs data will be available in the medical record prior to patients´ PT consultation session, and may assist the physiotherapist, along with the clinical examination, to plan the treatment program.
Keywords: Treatment modalities combinations, patient reported outcomes, decision support system
Funding acknowledgements: There were no sources of support or financial involvement in any organization or entity.
Topic: Musculoskeletal: spine; Musculoskeletal: spine
Ethics approval required: Yes
Institution: Clalit Health Services
Ethics committee: Clalit ethical review board
Ethics number: 0036-15-COM
All authors, affiliations and abstracts have been published as submitted.
