Effectiveness of stratified treatment for back pain in Danish primary care: A randomized controlled trial

Morsø, Lars; Olsen, Kim Rose; Schiøttz‐Christensen, Berit; Sowden, Gail; Søndergaard, Jens; Christiansen, David Høyrup

doi:10.1002/ejp.1818

Cited by 26 publications

(27 citation statements)

References 53 publications

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“…Overall, positive experiences with the stratified approach of our model were reported from all three perspectives (i.e., patients, physiotherapists, dieticians), which on the one hand is in line with previous qualitative studies [ 4 , 5 , 8 ], but on the other hand is in contrast to the lack of (cost-)effectiveness found in our OCTOPuS-trial [ 9 , 10 ] and recent other trials on stratified exercise approaches [ 14 – 18 ]. Physiotherapists generally intended to continue providing this stratified approach after completion of the OCTOPuS-trial and both dieticians and physiotherapists were enthusiastic about combining their professional expertise for the ‘obesity subgroup’ to achieve the best outcomes for these patients.…”

Section: Discussionsupporting

confidence: 90%

Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

Knoop

Joode

Brandt

et al. 2022

BMC Musculoskelet Disord

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Background We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups (‘high muscle strength subgroup’, ‘low muscle strength subgroup’, ‘obesity subgroup’), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the ‘obesity subgroup’). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements. Methods Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed. Results We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the ‘obesity subgroup’. In this ‘obesity subgroup’, physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the ‘high muscle strength subgroup’, the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these. Conclusion Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the ‘obesity subgroup’. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy. Trial registration The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).

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Section: Discussionsupporting

confidence: 90%

Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

Knoop

Joode

Brandt

et al. 2022

BMC Musculoskelet Disord

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“…Our inconclusive result seems to be consistent with the scarce and conflicting evidence regarding the cost-effectiveness of stratified approaches of physical therapy, with two trials 32 , 48 concluding that stratified care can be cost-effective, three trials 27 , 28 , 30 , 31 concluding that stratified care is unlikely to be a cost-effective option, and a last study 49 concluding that it might be cost-effective for only one out of three subgroups, compared to usual physical therapy. These conflicting results may be indicative for stratified care having only negligible added value to current physical therapy at best, but differences across studies in country, setting, patients groups, and stratification tool could play a role as well.…”

Section: Discussionsupporting

confidence: 77%

“…As reported elsewhere, 21 we found no added value in terms of clinical outcomes of this stratified approach compared to usual exercise therapy. 25 This result aligns with that of multiple other trials in musculoskeletal patient groups, where stratified physical therapy appeared to have no added value, 26 , 27 , 28 , 29 , 30 , 31 with only one trial demonstrating a (minimal) effect of stratified physical therapy over usual care in low back pain. 32 It could be argued, however, that despite having no added value in terms of clinical outcomes, stratified exercise therapy approaches such as ours are potentially more efficient (i.e., similar effect in less consultations).…”

Section: Introductionsupporting

confidence: 81%

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

Knoop¹,

Esser²,

Dekker³

et al. 2023

Brazilian Journal of Physical Therapy

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“…8 The initial trial conducted in United Kingdom found that riskstratified care reduced disability and decreased health care costs compared with usual care. 8 Subsequent randomized trials in the United States (ie, the MATCH and TARGET trials) 9,10 and Denmark 11 did not find this same benefit. Thus, whether risk-stratified care is scalable to health systems outside the United Kingdom remains a challenge for improving LBP outcomes.…”

Section: Introductionmentioning

confidence: 98%

Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

et al. 2023

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ImportanceTailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems.ObjectiveTo assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP.Design, Setting, and ParticipantsThis parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022.InterventionsRisk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants’ general practitioners and may have included a referral to physiotherapy.Main Outcomes and MeasuresThe primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group.ResultsAnalysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, −0.75 points; 95% CI −2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, −1.66 to 1.76 points).Conclusions and RelevanceIn this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care.Trial RegistrationClinicalTrials.gov Identifier: NCT03127826

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Effectiveness of stratified treatment for back pain in Danish primary care: A randomized controlled trial

Abstract: This is an open access article under the terms of the Creat ive Commo ns Attri bution-NonCo mmercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Cited by 26 publications

References 53 publications

Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

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