Using theory to improve low back pain care in Australian Aboriginal primary care: a mixed method single cohort pilot study

Background: Low back pain (LBP) care is frequently discordant with research evidence. This pilot study evaluated changes in LBP care following a systematic, theory informed intervention in a rural Australian Aboriginal Health Service. We aimed to improve three aspects of care; reduce inappropriate LBP radiological imaging referrals, increase psychosocial oriented patient assessment and, increase the provision of LBP self-management information to patients. Methods: Three interventions to improve care were developed using a four-step systematic implementation approach. A mixed methods pre/post cohort design evaluated changes in the three behaviours using a clinical audit of LBP care in a six month period prior to the intervention and then following implementation. In-depth interviews elicited the perspectives of involved General Practitioners (GPs). Qualitative analysis was guided by the theoretical domains framework. Results: The proportion of patients who received guideline inconsistent imaging referrals (GICI) improved from 4.1 GICI per 10 patients to 0.4 (95 % CI for decrease in rate: 1.6 to 5.6) amongst GPs involved in the intervention. Amongst non-participating GPs (locum/part-time GPs who commenced post-interventions) the rate of GICI increased from 1.5 to 4.4 GICI per 10 patients (95 % CI for increase in rate: .5 to 5.3). There was a modest increase in the number of patients who received LBP self-management information from participating GPs and no substantial changes to psychosocial oriented patient assessments by any participants; however GPs qualitatively reported that their behaviours had changed. Knowledge and beliefs about consequences were important behavioural domains related to changes. Environmental and resource factors including protocols for locum staff and clinical tools embedded in patient management software were future strategies identified. Conclusions: A systematic intervention model resulted in partial improvements in LBP care. Determinants of practice change amongst GPs were increased knowledge of clinical guidelines, education delivered by someone considered a trusted source of information, and awareness of the negative consequences of inappropriate practices, especially radiological imaging on patient outcomes. Inconsistent and non-evidence based practices amongst locum GPs was an issue that emerged and will be a significant future challenge. The systematic approach utilised is applicable to other services interested in improving LBP care

Psychosocial factors and their predictive value in chiropractic patients with low back pain: a prospective inception cohort study

BACKGROUND: Being able to estimate the likelihood of poor recovery from episodes of back pain is important for care. Studies of psychosocial factors in inception cohorts in general practice and occupational populations have begun to make inroads to these problems. However, no studies have yet investigated this in chiropractic patients. METHODS: A prospective inception cohort study of patients presenting to a UK chiropractic practice for new episodes of non-specific low back pain (LBP) was conducted. Baseline questionnaires asked about age, gender, occupation, work status, duration of current episode, chronicity, aggravating features and bothersomeness using Deyo's 'Core Set'. Psychological factors (fear-avoidance beliefs, inevitability, anxiety/distress and coping, and co-morbidity were also assessed at baseline. Satisfaction with care, number of attendances and pain impact were determined at 6 weeks. Predictors of poor outcome were sought by the calculation of relative risk ratios. RESULTS: Most patients presented within 4 weeks of onset. Of 158 eligible and willing patients, 130 completed both baseline and 6-week follow-up questionnaires. Greatest improvements at 6 weeks were in interference with normal work (ES 1.12) and LBP bothersomeness (ES 1.37). Although most patients began with moderate-high back pain bothersomeness scores, few had high psychometric ones. Co-morbidity was a risk for high-moderate interference with normal work at 6 weeks (RR 2.37; 95% C.I. 1.15–4.74). An episode duration of >4 weeks was associated with moderate to high bothersomeness at 6 weeks (RR 2.07; 95% C.I. 1.19 – 3.38) and negative outlook (inevitability) with moderate to high interference with normal work (RR 2.56; 95% C.I. 1.08 – 5.08). CONCLUSION: Patients attending a private UK chiropractic clinic for new episodes of non-specific LBP exhibited few psychosocial predictors of poor outcome, unlike other patient populations that have been studied. Despite considerable bothersomeness at baseline, scores were low at follow-up. In this independent health sector back pain population, general health and duration of episode before consulting appeared more important to outcome than psychosocial factors