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Kongsted A1,2, Hartvigsen J1,2, Ris I1, Kjær P1,3, Boyle E1, Thomasen L1, Vach W2,4
1University of Southern Denmark, Sports Science and Clinical Biomechanics, Odense M, Denmark, 2Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M, Denmark, 3University College Lillebaelt, Applied Health Science, Odense, Denmark, 4University Hospital Basel, Orthopaedics and Traumatology, Basel, Switzerland
Background: Clinical guidelines consistently recommend patient education and exercise therapy for management of low back pain (LBP). However, guidelines are not routinely implemented in clinical practice and do not offer tools for implementation. Therefore, we developed GLA:D® Back, a standardised intervention that integrates patient education and supervised exercises with the aim to support self-management of LBP.
Purpose: This pilot study tested the feasibility of implementing GLA:D® Back in clinical practice in Denmark by delivering a course for physiotherapists and chiropractors and providing access to ready-to-use patient education materials and exercise programs. The pilot study should further inform the planning of a large-scale implementation-effectiveness study using a pre-post group design.
Methods: Thirty-one clinicians from nine clinics participated. Feasibility of implementation was evaluated in terms of adoption of the intervention 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 one week two months before clinicians attended the GLA:D Back course (n=85), 2) LBP patients consulting during one week two months after the course (n=76), and 3) those enrolled in GLA:D® Back during 4 months after implementation (n=96). Patient data were collected at baseline and after 4 months.
Results: Clinicians' evaluations of the course were positive, and the clinical intervention was adopted by all test sites. Clinicians suggestions resulted in several modifications to the course. Most patient characteristics were similar across groups. Patients mainly had persistent LBP (72% >3 months) and most had been treated for more than four weeks at inclusion. Patients in GLA:D® Back were more often retired (30% vs. 16% before implementation) and in high risk of poor prognosis (24% vs. 13%). Procedures for collecting patient outcomes were feasible, and patient outcomes after implementation, especially with GLA:D Back®, were as good as or better than before implementation. For example the Oswestry Disability Index improved by 2.4, 4.6 and 6.0 points in the before, after and GLA:D Back groups respectively, and enablement improved by 2.3, 2.0 and 5.7 points. Recruitment of patients by participating clinicians and achievement of comparable pre- and post-group turned out to be difficult.
Conclusion(s): It was feasible to deliver the GLA:D® Back clinician course and to implement this way the clinical intervention in Danish primary care physiotherapy and chiropractic clinics. Both clinicians and patients were satisfied with the program 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 with a pre- post group design for the evaluation of a nation-wide implementation.
Implications: GLA:D® Back shows good promise for implementing a standardised, evidence-based intervention in primary care by a 2-days clinician course and access to patient materials. Further, the standardised intervention integrating patient education and exercise therapy potentially results in better outcomes for patients with persistent back pain. Rather than conducting a nation-wide effectiveness trial, the pilot study informs the evaluation of implementation and the design of a focused effectiveness trial.
Keywords: Back pain, Implementation, Patient Education
Funding acknowledgements: No funding received
Purpose: This pilot study tested the feasibility of implementing GLA:D® Back in clinical practice in Denmark by delivering a course for physiotherapists and chiropractors and providing access to ready-to-use patient education materials and exercise programs. The pilot study should further inform the planning of a large-scale implementation-effectiveness study using a pre-post group design.
Methods: Thirty-one clinicians from nine clinics participated. Feasibility of implementation was evaluated in terms of adoption of the intervention 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 one week two months before clinicians attended the GLA:D Back course (n=85), 2) LBP patients consulting during one week two months after the course (n=76), and 3) those enrolled in GLA:D® Back during 4 months after implementation (n=96). Patient data were collected at baseline and after 4 months.
Results: Clinicians' evaluations of the course were positive, and the clinical intervention was adopted by all test sites. Clinicians suggestions resulted in several modifications to the course. Most patient characteristics were similar across groups. Patients mainly had persistent LBP (72% >3 months) and most had been treated for more than four weeks at inclusion. Patients in GLA:D® Back were more often retired (30% vs. 16% before implementation) and in high risk of poor prognosis (24% vs. 13%). Procedures for collecting patient outcomes were feasible, and patient outcomes after implementation, especially with GLA:D Back®, were as good as or better than before implementation. For example the Oswestry Disability Index improved by 2.4, 4.6 and 6.0 points in the before, after and GLA:D Back groups respectively, and enablement improved by 2.3, 2.0 and 5.7 points. Recruitment of patients by participating clinicians and achievement of comparable pre- and post-group turned out to be difficult.
Conclusion(s): It was feasible to deliver the GLA:D® Back clinician course and to implement this way the clinical intervention in Danish primary care physiotherapy and chiropractic clinics. Both clinicians and patients were satisfied with the program 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 with a pre- post group design for the evaluation of a nation-wide implementation.
Implications: GLA:D® Back shows good promise for implementing a standardised, evidence-based intervention in primary care by a 2-days clinician course and access to patient materials. Further, the standardised intervention integrating patient education and exercise therapy potentially results in better outcomes for patients with persistent back pain. Rather than conducting a nation-wide effectiveness trial, the pilot study informs the evaluation of implementation and the design of a focused effectiveness trial.
Keywords: Back pain, Implementation, Patient Education
Funding acknowledgements: No funding received
Topic: Musculoskeletal: spine; Primary health care
Ethics approval required: No
Institution: Region of Southern Denmark
Ethics committee: he Regional Committees on Health Research Ethics for Southern Denmark
Reason not required: According to Danish law and the committees evaluation, the project did not need approval (ref.no. S-20172000-93)
All authors, affiliations and abstracts have been published as submitted.
