Physiotherapists' experiences of implementation of the BetterBack model of care for low back pain in primary care - a focus group interview study.

INTRODUCTION: The BetterBack model of care (MoC), a best practice physiotherapy MoC for low back pain (LBP), was implemented in Swedish primary care to improve management of patients with LBP and provide patients with support tools to better self-manage episodes of LBP. PURPOSE: The objective was to describe how physiotherapists in primary care experienced the implementation of the BetterBack MoC for LBP. METHODS: Focus group interviews were conducted with physiotherapists in 2018-2019, 14-18 months after the introduction of the BetterBack MoC. Data were analyzed using qualitative content analysis. RESULTS: Five focus group interviews with 23 (15 female and 8 male) physiotherapists, age range 24-61 years were analyzed. A supportive organization and adaptation to the local culture, combined with health care professionals' attitudes and collaboration between physiotherapists emerged as important factors for a successful implementation and for long-term sustainability of the MoC. Physiotherapists had differing opinions if the implementation led to change in clinical practice. Improved confidence in how to manage patients with LBP was expressed by physiotherapists. CONCLUSIONS: Several barriers and facilitators influence the implementation of a best practice physiotherapy MoC for LBP in primary care, which need to be considered in future implementation and sustainability processes.

Are illness perceptions and patient self-care enablement mediators of treatment effect in best practice physiotherapy low back pain care? Secondary mediation analyses in the BetterBack trial.

INTRODUCTION: A best practice physiotherapy model of care (BetterBack MoC) for low back pain (LBP) aimed to improve patients' illness perceptions and self-care enablement, according to the Common-Sense Model of Self-Regulation (CSM). OBJECTIVE: To confirm if illness perceptions and patient self-care enablement, in line with the CSM, are mediators of treatment effects on disability and pain of the BetterBack MoC for patients with LBP compared to routine primary care. A secondary aim was to explore if illness perceptions and patient self-care enablement are mediators of guideline adherent care. METHODS: Pre-planned single mediation analyses tested whether hypothesized mediators at 3 months mediated the treatment effect of the MoC (n = 264) compared to routine care (n = 203) on disability and pain at 6 months. Secondary mediation analyses compared guideline adherent care with non-adherent care. RESULTS: No indirect effects were identified. The BetterBack intervention did not have superior effects over routine care on the hypothesized mediators. Illness perceptions and self-care enablement were significantly associated with disability and pain at 6 months. Secondary analyses showed significant indirect effects of guideline adherent care through tested mediators. CONCLUSION: Despite no indirect effects, patients' illness perceptions and self-care enablement were associated with disability and back pain intensity outcomes and are potentially relevant treatment targets.

The association between patients' illness perceptions and longitudinal clinical outcome in patients with low back pain.

Introduction: Illness perception is suggested to influence outcome in patients with low back pain (LBP). It is unknown if specific illness perceptions are of more importance for longitudinal outcomes, including development of self-management strategies. Objectives: This study explores whether patients' initial illness perceptions were associated with disability, pain, health-related quality of life, and self-care enablement outcomes in patients with LBP after 3 and 12 months. Methods: Four hundred sixty-seven consecutive patients seeking physiotherapeutic primary care for LBP were eligible to participate in this prospective cohort study, providing data at baseline and after 3 and 12 months (mean age 45 years, 56% women). Multiple linear regression analysis was used to explore whether patients' illness perceptions at baseline were associated with outcome in the Oswestry Disability Index (ODI), Numeric Rating Scale-LBP (NRS-LBP), EuroQol Five Dimensions, and Patient Enablement Instrument (PEI). Results: Stronger beliefs that the back problem will last a long time at baseline were associated with worse outcome in ODI, NRS-LBP, and PEI at 3 and 12 months and in EuroQol Five Dimensions at 12 months. Negative beliefs regarding treatment's ability to improve LBP were associated with worse outcome in NRS-LBP and PEI at 3 and 12 months and in ODI at 12 months. Conclusions: Illness perceptions regarding prognosis and treatment's ability to improve symptoms were the most prominent perceptions explaining several longitudinal clinical outcomes. These expectations should be addressed in an early stage in the delivery of interventions for LBP. These expectations were also important for patients' development of coping and self-management strategies.

Effectiveness and Quality of Implementing a Best Practice Model of Care for Low Back Pain (BetterBack) Compared with Routine Care in Physiotherapy: A Hybrid Type 2 Trial.

Low back pain (LBP) occurs in all ages and first-line treatment by physiotherapists is common. The main aim of the current study was to evaluate the effectiveness of implementing a best practice model of care for LBP (intervention group-BetterBack☺ MoC) compared to routine physiotherapy care (control group) regarding longitudinal patient reported outcomes. The BetterBack☺ MoC contains clinical guideline recommendations and support tools to facilitate clinician adherence to guidelines. A secondary exploratory aim was to compare patient outcomes based on the fidelity of fulfilling a clinical practice quality index regarding physiotherapist care. A stepped cluster randomized design nested patients with LBP in the three clusters which were allocated to control (n = 203) or intervention (n = 264). Patient reported measures were collected at baseline, 3, 6 and 12 months and analyzed with mixed model regression. The primary outcome was between-group changes from baseline to 3 months for pain intensity and disability. Implementation of the BetterBack☺ MoC did not show any between-group differences in the primary outcomes compared with routine care. However, the intervention group showed significantly higher satisfaction at 3 months and clinically meaningful greater improvement in LBP illness perception at 3 months and quality of life at 3 and 6 months but not in patient enablement and global impression of change compared with the control group. Physiotherapists' care that adhered to all clinical practice quality indices resulted in an improvement of most patient reported outcomes with a clinically meaningful greater improved LBP illness perception at 3 months and quality of life at 3 and 6 months, significantly greater improvement in LBP illness perception, pain and satisfaction at 3 and 6 months and significantly better enablement at all time points as well as better global improvement outcomes at 3 months compared with non-adherent care. This highlights the importance of clinical guideline based primary care for improving patient reported LBP outcomes.

Patients' experiences of the BetterBack model of care for low back pain in primary care - a qualitative interview study.

Purpose: The aim of this study was to describe patient experiences of received primary care for low back pain (LBP) according to the BetterBack Model of Care (MoC) with a focus on illness beliefs and self-management enablement. Methods: Individual interviews were conducted with 15 adults 4-14 months after receiving treatment according to the BetterBack MoC for LBP in primary care in Sweden. Data were analysed using content analysis. Results: When analysing the data, the following theme emerged; "Participant understanding of their treatment for low back pain and self-management strategies-a matter of support systems", comprising the following categories: "Knowledge translation", "Interaction and dialogue", "The health care professional support" and "Form organization". Participants experienced that they had better knowledge about their LBP and received tools to better manage their health condition. The participants expressed good communication with the treating physiotherapist and provided suggestions to further improve the treatment of LBP. Conclusions: Participants experienced that they had gained new knowledge about their health problems and after the treatment they had the tools to handle their back problems. This suggests that the BetterBack MoC may be used as a basis for a support system to provide valuable tools for self-management for patients with low back pain.

What Mediates Treatment Effects in a Presurgery Physiotherapy Treatment in Surgical Candidates With Degenerative Lumbar Spine Disorders? A Mediation and Conditional Process Analysis of the PREPARE Randomized Controlled Trial.

OBJECTIVES: Treatment guidelines recommend targeting both physical and psychological factors in interventions for degenerative lumbar spine disorders. Studying the treatment mechanisms gives information on key factors explaining the outcome improvement that can refine treatments. This study explores treatment mediators in a physiotherapy treatment on disability, pain intensity, and health-related quality of life in surgical candidates with degenerative lumbar spine disorders compared with waiting-list controls. An additional aim was to evaluate patients' expectation as a moderator of treatment outcome. MATERIALS AND METHODS: Data collected from 197 patients in a single-blinded randomized controlled trial comparing 9 weeks of multifaceted physiotherapy with waiting-list controls were used in this conditional process analysis. Analysis was carried out on group differences for change in Oswestry Disability Index, Pain Visual Analog Scale (VAS) back pain, EuroQol-5D, and EuroQol-VAS. The putative moderation role of expectations and mediation role of change in physical variables and psychosocial variables were tested. RESULTS: Change in self-efficacy mediated improvement in all outcomes. Improvement in Oswestry Disability Index was also mediated by change in depression; VAS was mediated by change in fear-avoidance beliefs; and EuroQol-VAS was mediated by change in activity level and fear avoidance beliefs. Improvements were moderated by patients' treatment expectations. DISCUSSION: Self-efficacy, fear-avoidance beliefs, physical activity level, and patients' treatment expectations were found to be important factors explaining treatment effects. Self-efficacy was the consistent mediator for effects of the presurgical physiotherapy on disability, back pain intensity, and health-related quality of life.

Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial.

BACKGROUND: Degenerative lumbar spine disorders are common among musculoskeletal disorders. When disabling pain and radiculopathy persists after adequate course of rehabilitation and imaging confirms compressive pathology, surgical decompression is indicated. Prehabilitation aiming to augment functional capacity pre-surgery may improve physical function and activity levels pre and post-surgery. This study aims to evaluate the effect and dose-response of pre-surgery physiotherapy on quadriceps femoris strength and walking ability in patients with degenerative lumbar spine disorders compared to waiting-list controls and their association with postoperative physical activity level. METHOD: In this single blinded, 2-arm randomised controlled trial, 197 patients were consecutively recruited. Inclusion criteria were: MRI confirmed diagnosis and scheduled for surgery due to disc herniation, lumbar spinal stenosis, degenerative disc disease or spondylolisthesis, ages 25-80 years. Patients were randomised to 9 weeks of pre-surgery physiotherapy or to waiting-list. Patient reported physical activity level, walking ability according to Oswestry Disability Index item 4, walking distance according to the SWESPINE national register and physical outcome measures including the timed ten-meter walk test, maximum voluntary isometric quadriceps femoris muscle strength, patient-rated were collected at baseline and follow-up. Parametric or non-parametric within and between group comparisons as well as multivariate regression was performed. RESULTS: Patients who received pre-surgery physiotherapy significantly improved in all variables from baseline to follow-up (p < 0.001 - p < 0.05) and in comparison to waiting-list controls (p < 0.001 - p < 0.028). Patients adhering to ≥12 treatment sessions significantly improved in all variables (p < 0.001 - p < 0.032) and those receiving 0-11 treatment session in only normal walking speed (p0.035) but there were no significant differences when comparing dosages. Physical outcome measures after pre-surgery physiotherapy together significantly explain 27.5% of the variation in physical activity level 1 year after surgery with pre-surgery physical activity level having a significant multivariate association. CONCLUSION: Pre-surgery physiotherapy increased walking ability and lower extremity strength in patients with degenerative lumbar spine disorders compared to waiting-list controls. A clear treatment dose-response response relationship was not found. These results implicate that pre-surgery physiotherapy can influence functional capacity before surgical treatment and has moderate associations with maintained postoperative physical activity levels mostly explained by physical activity level pre-surgery. TRIAL REGISTRATION: NCT02454400 . Trial registration date: August 31st 2015, retrospectively registered.