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.

Correction: Dufvenberg et al. Six-Month Results on Treatment Adherence, Physical Activity, Spinal Appearance, Spinal Deformity, and Quality of Life in an Ongoing Randomised Trial on Conservative Treatment for Adolescent Idiopathic Scoliosis (CONTRAIS). J. Clin. Med. 2021, 10, 4967.

In the original publication [...].

Measuring the determinants of implementation behavior in multiprofessional rehabilitation.

BACKGROUND: The Determinants of Implementation Behavior Questionnaire (DIBQ) measures facilitators or barriers of healthcare professionals' implementation behaviors based on the current implementation research on practice and policy. The DIBQ covers 18 domains of the Theoretical Domains Framework and consists of 93 items. A previously tailored version (DIBQ-t) covering 10 domains and 28 items focuses on implementing best-practice low back pain care. AIM: To tailor a shortened version of DIBQ to multiprofessional rehabilitation context with cross-cultural adaptation to Finnish language. DESIGN: A two-round Delphi study. SETTING: National-level online survey. POPULATION: Purposively recruited experts in multiprofessional rehabilitation (N.=25). METHODS: Cross-cultural translation of DIBQ to Finnish was followed by a two-round Delphi survey involving diverse experts in rehabilitation (physicians, physiotherapists, occupational therapists, psychologists, nursing scientists, social scientists). In total, 25 experts in Round 1, and 21 in Round 2 evaluated the importance of DIBQ items in changing professionals' implementation behavior by rating on a 5-point Likert Scale (1 = Strongly Disagree, 5 = Strongly Agree) of including each item in the final scale. Consensus to include an item was defined as a mean score of ≥4 by ≥75% of Delphi participants. Open comments were analyzed using inductive content analysis. Items with agreement of ≤74% were either directly excluded or reconsidered and modified depending on qualitative judgements, amended with experts' suggestions. After completing an analogous second-round, a comparison with DIBQ-t was performed. Lastly, the relevance of each item was indexed using content validity index on item-level (I-CVI) and scale-level (S-CVI/Ave). RESULTS: After Round 1, 17 items were included and 48 excluded by consensus whereas 28 items were reconsidered, and 20 items added for Round 2. The open comments were categorized as: 1) "modifying"; 2) "supportive"; and 3) "critical". After Round 2, consensus was reached regarding all items, to include 21 items. After comparison with DIBQ-t, the final multiprofessional DIBQ (DIBQ-mp) covers 11 TDF domains and 21 items with I-CVIs of ≥0.78 and S-CVI/Ave of 0.93. CONCLUSIONS: A Delphi study condensed a DIBQ-mp with excellent content validity for multiprofessional rehabilitation context. CLINICAL REHABILITATION IMPACT: A potential tool for evaluating determinants in implementing evidence-based multiprofessional rehabilitation interventions.

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.

Patients' Perceptions of Exercise-Based Cardiac Telerehabilitation after a Myocardial Infarction-A Qualitative Study.

To be able to design telerehabilitation programs targeting the needs and preferences of end-users, patients' in-depth perspectives are needed. To date, such studies are lacking and, therefore, the aim of the present study was to describe patients' perceptions of performing exercise-based cardiac telerehabilitation after a myocardial infarction (MI). Individual semi-structured interviews were performed with 15 patients (3 women, median age 69 years) after an MI who had participated in exercise-based cardiac telerehabilitation for three months. The interviews were transcribed verbatim and analyzed with inductive content analysis. An overall theme was defined as "Cardiac telerehabilitation-a new alternative for exercising that is easily accessible and up to date". Four categories, including "The important role of a physical therapist with expert knowledge", "Prerequisites playing an important role in the willingness to participate", "Making exercise accessible and adjustable" and "Inspiring future exercise", and 15 subcategories were identified. Understanding the patient's perspective is an important key to further improving and successfully implementing exercise-based cardiac telerehabilitation, as an alternative or adjunct to traditional, centre-based programs. The findings can serve to improve patient-physiotherapist interactions and to inform important aspects related to exercise, technology and a sense of security from an exercise-based cardiac telerehabilitation program.

The remote exercise SWEDEHEART study-Rationale and design of a multicenter registry-based cluster randomized crossover clinical trial (RRCT).

BACKGROUND: Despite proven benefits of exercise-based cardiac rehabilitation (EBCR), few patients with myocardial infarction (MI) participate in and complete these programs. STUDY DESIGN AND OBJECTIVES: The Remote Exercise SWEDEHEART study is a large multicenter registry-based cluster randomized crossover clinical trial with a planned enrollment of 1500 patients with a recent MI. Patients at intervention centers will be offered supervised EBCR, either delivered remotely, center-based or as a combination of both modes, as self-preferred choice. At control centers, patients will be offered supervised center-based EBCR, only. The duration of each time period (intervention/control) for each center will be 15 months and then cross-over occurs. The primary aim is to evaluate if remotely delivered EBCR, offered as an alternative to center-based EBCR, can increase participation in EBCR sessions. The proportion completers in each group will be presented in a supportive responder analysis. The key secondary aim is to investigate if remote EBCR is as least as effective as center-based EBCR, in terms of physical fitness and patient-reported outcome measures. Follow-up of major adverse cardiovascular events (cardiovascular- and all-cause mortality, recurrent hospitalization for acute coronary syndrome, heart failure hospitalization, stroke, and coronary revascularization) will be performed at 1 and 3 years. Safety monitoring of serious adverse events will be registered, and a cost-effectiveness analysis will be conducted to estimate the cost per quality-adjusted life-year (QALY) associated with the intervention compared with control. CONCLUSIONS: The cluster randomized crossover clinical trial Remote Exercise SWEDEHEART study is evaluating if participation in EBCR sessions can be increased, which may contribute to health benefits both on a group level and for individual patients including a more equal access to health care. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (Identifier: NCT04260958).

Neurological outcomes after surgery and postoperative rehabilitation for cervical radiculopathy due to disc disease: a 2-year-follow-up of a randomized clinical trial.

Reports on neurological outcomes in patients with cervical radiculopathy (CR) undergoing surgery and postoperative rehabilitation are important to inform prognosis. This 2-year-follow-up of a randomized clinical trial aimed to compare secondary neurological outcomes between structured postoperative rehabilitation and a standard approach after surgery for CR. A secondary aim was to increase knowledge about recovery of neurological impairments in relation to patient-reported neck disability. Neurological outcomes included assessment of sensibility, motor function, arm reflexes and the Spurling test. A total of 153 and 135 participants (> 70% response rate) completed the clinical examination. Between-group differences, changes over time, and associations between persistent neurological impairments and the Neck Disability Index were investigated. No between-group differences were reported (p > 0.07), and neurological impairments in sensibility, motor function, and a positive Spurling test decreased over time in both groups (p < 0.04). Persistent impairments in sensibility and reflex arm were most frequent at follow-up, whereas, a persistent positive Spurling test, and impairments in motor function were associated with higher NDI score. Neurological outcomes improved over time in patients undergoing surgery for CR with no between-group differences., However, persistent neurological impairments were common, and associated with poorer outcome for patient-reported neck disability.Clinical registration: clinicaltrial.gov NCT01547611, 08/03/2012, Title: Outcome of physiotherapy after surgery for cervical disc disease: a prospective multi-centre trial.

Effectiveness of a behavioral medicine intervention in physical therapy on secondary psychological outcomes and health-related quality of life in exercise-based cardiac rehabilitation: a randomized, controlled trial.

BACKGROUND: Interventions promoting adherence to exercise-based cardiac rehabilitation (exCR) are important to achieve positive physical and psychological outcomes, but knowledge of the added value of behavioral medicine interventions for these measures is limited. The aim of the study was to investigate the added value of a behavioral medicine intervention in physical therapy (BMIP) in routine exCR on psychological outcomes and health-related quality of life (HRQoL) versus routine exCR alone (RC). METHODS: A total of 170 patients with coronary artery disease (136 men), mean age 62.3 ± 7.9 years, were randomized at a Swedish university hospital to a BMIP plus routine exCR or to RC for four months. The outcome assessments included HRQoL (SF-36, EQ-5D), anxiety and depression (HADS), patient enablement and self-efficacy and was performed at baseline, four and 12 months. Between-group differences were tested with an independent samples t-test and, for comparisons within groups, a paired t-test was used. An intention-to-treat and a per-protocol analysis were performed. RESULTS: No significant differences in outcomes between the groups were shown between baseline and four months or between four and 12 months. Both groups improved in most SF-36 domains, EQ-VAS and HADS anxiety at the four-month follow-up and sufficient enablement remained at the 12-months follow-up. CONCLUSION: A BMIP added to routine exCR care had no significant effect on psychological outcomes and HRQoL compared with RC, but significant improvements in several measures were shown in both groups at the four-month follow-up. Since recruited participants showed a better psychological profile than the general coronary artery disease population, further studies on BMIP in exCR, tailored to meet individual needs in broader patient groups, are needed. Trial registration number NCT02895451, 09/09/2016, retrospectively registered.

Dizziness and balance outcomes after two different postoperative rehabilitation approaches following neck surgery: analyses of a multicenter randomized controlled trial.

BACKGROUND: Dizziness and balance problems are common symptoms in patients with cervical radiculopathy. OBJECTIVE: To evaluate the effect of neck surgery postoperatively combined with either structured rehabilitation or standard approach in patients with cervical radiculopathy and dizziness and/or balance problems, and investigate factors influencing dizziness and balance at 6-month follow-up. METHODS: Individuals (n = 149) with cervical radiculopathy and dizziness and/or balance problems were randomized preoperatively to structured postoperative rehabilitation or standard postoperative approach. Outcomes were intensity of dizziness and subjective balance, and clinical measures of balance. RESULTS: Self-reported measures improved at three months (p ˂ 0.001 to p = .007) and the standing balance at six months (p = .008). No between-group differences. Baseline values, neck pain, and physical activity level explained 23-39% of the variance in 6-month outcomes for self-reported measures. Baseline values and physical activity level explained 71% of the variance in walking balance, and lower baseline scores were significantly associated with standing balance impairments (OR 0.876). CONCLUSION: Patients improved significantly in dizziness and subjective balance intensity shortly after surgery, and in standing balance at 6 months, independent of postoperative rehabilitation. Neck pain, physical activity, and neck muscle function influenced dizziness and balance, although preoperative values and neck pain were of most importance for 6-month outcomes.

Improved adherence to clinical guidelines for low back pain after implementation of the BetterBack model of care: A stepped cluster randomized controlled trial within a hybrid type 2 trial.

BACKGROUND: The BetterBack model of care (MoC) for low back pain (LBP) was recently developed in Swedish physiotherapy (PT) primary care. OBJECTIVE: To evaluate if PTs' adherence to LBP clinical practice guidelines (CPGs) improves after implementation of the BetterBack MoC (intervention). METHODS: This was a stepped, single-blinded cluster randomized controlled trial. Patients nested in the three clusters were allocated to routine care (n = 222) or intervention (n = 278). The primary outcome was referral to specialist consultation. This was among five best practice recommendations divided into an assessment quality index (no referral to specialist consultation and no medical imaging) and a treatment quality index (use of educational interventions; use of exercise interventions; no use of non-evidence-based physiotherapy). For overall adherence, patients had to be treated with all five recommendations fulfilled. Logistic regression was used for between-group comparisons. RESULTS: The proportion of patients receiving referral to specialist consultation during the PT treatment period was low in both groups with no between-group differences. However, patients in the intervention group showed significantly higher assessment quality index, treatment quality index and overall adherence compared to routine care. Adherence to the separate recommendations showed improved stratified number of visits, use of exercise was maintained high, patient educational intervention increased and use of non-evidence-based physiotherapy decreased. A reduction of medical imaging during the physiotherapy treatment period was also observed. CONCLUSIONS: The adoption of CPGs could be substantially improved by introducing a MoC through PT training and supportive materials.

Learning from the past to plan for the future: A scoping review of musculoskeletal clinical research in Sweden 2010-2020.

Background: The aims of this study are to 1) determine the scope of musculoskeletal (MSK)-related clinical research in Sweden; 2) collate the amount of first-tier funding received; 3) discuss strategies and infrastructure supporting future MSK clinical trials in Sweden. Methods: A systematic scoping review protocol was applied in PubMed, Scopus, and SweCRIS databases. The articles were examined, and data were extracted in multiple stages by three blinded authors. Results: The search strategy resulted in 3,025 publications from 479 Swedish-affiliated authors. Primary health care was the basis for 14% of the publications, 84% from secondary health care, and 2% from occupational health care with a similar proportional distribution of first-tier research grant financing. Approximately one in six publications were randomized controlled trials (RCTs), while the majority were of observational cohort design. The majority of publications in primary and occupational health care were related to pain disorders (51 and 67%, respectively), especially diagnosis, prognosis, and healthcare organizational-related interventions (34%) and rehabilitation (15%) with similar proportional distribution of first-tier research grant financing. In secondary health care, rheumatic inflammatory disorder-related publications were most prevalent (30%), most frequently concerning diagnosis, prognosis, and healthcare organizational-related interventions (20%), attracting approximately half of all first-tier funding. Publications related to degenerative joint disorders (25%), fractures (16%), and joint, tendon, and muscle injuries (13%) frequently concerned surgical and other orthopedic-related interventions (16, 6, and 8%, respectively). Pain disorder-related publications (10%) as well as bone health and osteoporosis-related publications (4%) most frequently concerned diagnosis, prognosis, and healthcare organizational-related interventions (5 and 3%, respectively). Conclusions: Swedish-affiliated MSK disorder research 2010-2020 was predominantly observational cohort rather than RCT based. There was skewed first-tier funding allocation considering prevalence/incidence and burden of disease. Use of infrastructure supporting register-based RCTs, placebo-controlled RCTs, and hybrid effectiveness-implementation studies on prevention and clinical intervention is important strategies for the future in all healthcare sectors.

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.

Work Ability After Anterior Cervical Decompression and Fusion Followed by a Structured Postoperative Rehabilitation: Secondary Outcomes of a Prospective Randomized Controlled Multi-Centre Trial with a 2-year Follow-up.

Purpose Information on work ability after ACDF and postoperative rehabilitation is lacking. The aim of the present study is therefore to investigate the work ability benefits of a structured postoperative treatment (SPT) over a standard care approach (SA) in patients who underwent anterior cervical decompression and fusion (ACDF) for cervical radiculopathy and factors important to the 2-year outcome. Methods Secondary outcome and prediction model of a prospective randomized controlled multi-centre study with a 2-year follow-up (clinicaltrials.gov NCT01547611). The Work Ability Index (WAI) and Work Ability Score (WAS) were measured at baseline and up to 2 years after ACDF in 154 patients of working age who underwent SPT or SA after surgery. Predictive factors for the WAI at 2 years were analysed. Results Both WAI and WAS significantly improved with SPT and SA (p < 0.001), without any between-group differences. Thoughts of being able to work within the next 6 months, Neck Disability Index (NDI), and work-related neck load explained 59% of the variance in WAI at the 2-year follow-up after ACDF. Conclusions Patients improved over time without group differences, suggesting the improvement to be surgery related. Expectation to work within the next 6 months, self-reported neck functioning and work-related neck load were important to work ability and are central factors to ask early after ACDF, to identifying further interventions promoting return to work.

Six-Month Results on Treatment Adherence, Physical Activity, Spinal Appearance, Spinal Deformity, and Quality of Life in an Ongoing Randomised Trial on Conservative Treatment for Adolescent Idiopathic Scoliosis (CONTRAIS).

Adolescents with idiopathic scoliosis (AIS) often receive conservative treatments aiming to prevent progression of the spinal deformity during puberty. This study aimed to explore patient adherence and secondary outcomes during the first 6 months in an ongoing randomised controlled trial of three treatment interventions. Interventions consisted of physical activity combined with either hypercorrective Boston brace night shift (NB), scoliosis-specific exercise (SSE), or physical activity alone (PA). Measures at baseline and 6 months included angle of trunk rotation (ATR), Cobb angle, International Physical Activity Questionnaire short form (IPAQ-SF), pictorial Spinal Appearance Questionnaire (pSAQ), Scoliosis Research Society (SRS-22r), EuroQol 5-Dimensions Youth (EQ-5D-Y) and Visual Analogue Scale (EQ-VAS). Patient adherence, motivation, and capability in performing the intervention were reported at 6 months. The study included 135 patients (111 females) with AIS and >1-year estimated remaining growth, mean age 12.7 (1.4) years, and mean Cobb angle 31 (±5.3). At 6 months, the proportion of patients in the groups reporting high to very high adherence ranged between 72 and 95%, while motivation ranged between 65 and 92%, with the highest proportion seen in the NB group (p = 0.014, p= 0.002). IPAQ-SF displayed significant between group main effects regarding moderate activity (F = 5.7; p = 0.004; ηp2 = 0.10), with a medium-sized increase favouring the SSE group compared to NB. Walking showed significant between group main effects, as did metabolic equivalent (MET-min/week), with medium (F = 6.8, p = 0.002; ηp2 = 0.11, and large (F = 8.3, p = < 0.001, ηp2 = 0.14) increases, respectively, for the SSE and PA groups compared to NB. From baseline to 6 months, ATR showed significant between group medium-sized main effects (F = 1.2, p = 0.019, ηp2 = 0.007) favouring the NB group compared to PA, but not reaching a clinically relevant level. In conclusion, patients reported high adherence and motivation to treatment, especially in the NB group. Patients in the SSE and PA groups increased their physical activity levels without other clinically relevant differences between groups in other clinical measures or patient-reported outcomes. The results suggest that the prescribed treatments are viable first-step options during the first 6 months.

The minimal important change for the seven-item disability of the arm, shoulder, and hand (DASH 7) questionnaire - Assessing shoulder function in patients with subacromial pain.

BACKGROUND: The DASH 7 is a recently published activity-related 7-item short form of the disability of the arm, shoulder, and hand (DASH) questionnaire developed to assess shoulder function in patients with subacromial pain. Before implementation in both intervention studies and in clinical practice, it is essential to evaluate its responsiveness. The objective of this study was to determine the minimal important change (MIC) in the DASH 7 questionnaire for patients with subacromial pain after a 3 months exercise intervention in a primary care context. METHODS: In this psychometric study the anchor-based MIC-distribution method was used to establish the MIC. The Patient Global Impression of Change (PGIC) was used as external criterion. Data from a clinical implementation study, aimed to implement a specific exercise strategy for patients with subacromial pain among physiotherapists in primary care, were used. Data from 70 patients were included in the analyses. RESULTS: The correlation coefficient between Patient Global Impression of Change and the DASH 7 score change was 0.67 and the area under the curve was 0.94 (95% confidence interval: 0.88-1.0). The MICROC for improvement was detected at a mean change in 6.5 points with the sensitivity at 0.98 (98%) and the specificity at 0.78 (78%), and the MIC95% limit for improvement was detected at a mean change of 25.7 points. There were 77% of the patients who reached at least this MICROC and 51% who reached at least the MIC95% limit after 3 months of exercise intervention. CONCLUSION: The DASH 7 is responsive to change over time and can discriminate between patients considered to be improved and patients considered not improved. These MIC values for patients with subacromial pain in the primary care setting can be used in clinical practice and in intervention studies as an indication on the patients clinically important level of score change for improvement.

Heterogeneity among patients with subacromial pain - variabilities within clinical presentation and its impact on daily life.

OBJECTIVE: The primary aim was to describe the variability within clinical presentation of patients with subacromial pain in primary care, secondly to investigate associations between clinical presentation and self-reported pain intensity, shoulder function, level of anxiety and depression, and health-related quality of life. DESIGN AND SETTING: A cross-sectional study based on data from two clinical studies in primary care, one randomized controlled trial and one implementation study. Three components: active range of motion (AROM), rotator cuff function and scapular kinematics were analyzed to describe variability within clinical presentation and patient-reported measurements were used to investigate the impact on daily life. PARTICIPANTS: Patients aged 30-67 years, describing pain for more than two weeks, with positive signs for a minimum of three out of the following five clinical tests: impingement sign according to Neer, impingement test according to Hawkins-Kennedy, Pattes maneuver, Jobe's test, and painful arc. RESULTS: Among the 164 patients included, 24% displayed dysfunction in one, 50% two and 24% in all three components. Limited AROM was seen in 46%, rotator cuff dysfunction in 91% and scapular dyskinesia in 57% of the patients. CONCLUSIONS: These results reveal a heterogeneity among primary care patients with subacromial pain confirming a large variability regarding the components AROM, rotator cuff function and scapular kinematics. All three components appear unique (not significantly correlated) where a rotator cuff dysfunction is very frequent while limited AROM and scapular dyskinesia are more inconsistent. There are significant, but rather weak, associations between clinical presentation and impact on daily life.

Adapting the determinants of implementation behavior questionnaire to evaluate implementation of a structured low back pain programme using mixed-methods.

BACKGROUND AND AIMS: Best-practice low back pain (LBP) primary care programmes have been developed based on evidence-based clinical guidelines and implemented in Sweden and Denmark. The theoretical domains framework (TDF) was utilized in the design of the implementation strategy. Based on the TDF domains, the Determinants of Implementation Behavior Questionnaire (DIBQ) has been developed to evaluate implementation determinants, but its feasibility and validity need to be tested and adapted to study specific contexts. This study aimed to tailor the DIBQ for evaluation of implementation for LBP primary care programmes. The objectives were to (a) translate the DIBQ into Swedish and Danish, (b) adapt the DIBQ into DIBQ-tailored (DIBQ-t) to study content validity, (c) test the DIBQ-t for feasibility, and (d) perform validity testing of DIBQ-t. METHODS: We used a mixed-methods design. First, forward translation of the DIBQ, then adaptation into DIBQ-t using qualitative face validity and quantitative content validity was done. Finally, to determine feasibility and construct validity using confirmatory factor analyses, we used data from DIBQ-t collected after the programmes' 2-day course. RESULTS: The final DIBQ-t included 28 items describing 10 of the original 18 DIBQ domains and was considered feasible. A total of 598 clinicians out of 609 responded to the DIBQ-t, with only 2‰ of the items missing. The confirmatory factor analyses showed a good fit after removing two items with the lowest domain loading. The DIBQ-t maintained linkage to all domains within the Behavioral Change Wheel. The clinicians' expectations, according to the DIBQ-t, indicate facilitating determinants outweighing barriers at the initiation of implementation processes. CONCLUSIONS: The study resulted in a feasible and valid version of a questionnaire for evaluating clinicians' expectations regarding implementation determinants of best-practice LBP primary care programmes.

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.

Evaluation of training in guideline-oriented biopsychosocial management of low back pain in occupational health services: Protocol of a cluster randomized trial.

BACKGROUND: To prevent low back pain (LBP) from developing into a prolonged disabling condition, clinical guidelines advocate early stage assessment, risk-screening, and tailored interventions. Occupational health services recommend guideline-oriented biopsychosocial screening and individualized assessment and management. However, it is not known whether training a limited number of health care professionals improves the management process. The primary objective of this study is to investigate whether training in the biopsychosocial practice model is effective in reducing disability. Furthermore, we aim to evaluate health-economic impacts of the training intervention in comparison to usual medical care. METHODS: The occupational health service units will be allocated into a training or control arm in a two-arm cluster randomized controlled design. The training of occupational physiotherapists and physicians will include the assessment of pain-related psychosocial factors using the STarT Back Tool and the short version of the Örebro Musculoskeletal Pain Screening Questionnaire, the use of an evidence-based patient education booklet as part of the management of LBP, and tailored individualized management of LBP according to risk stratification. The control units will receive no training. The study population will include patients aged 18-65 with nonspecific LBP. The primary outcome is a patient-reported Oswestry Disability Index from baseline to 12 months. By estimating group differences over time, we aim to evaluate the effectiveness of the training intervention in comparison to usual medical care, and to undertake an economic evaluation using individual patients' health care records (participant-level data) and the participating units' registries (cluster-level data). In addition, through interviews and questionnaires, we will explore the health care professionals' conceptions of the adoption of, the barriers to, and the facilitators of the implementation of the practice model. DISCUSSION: The evaluation of training in the guideline-oriented biopsychosocial management of LBP in occupational health services is justified because LBP represents an enormous burden in terms of work disability.

Larger pain extent is associated with greater pain intensity and disability but not with general health status or psychosocial features in patients with cervical radiculopathy.

ABSTRACT: Pain as a result of cervical radiculopathy (CR) can be widespread, nondermatomal and individually specific, but the association between pain extent and other clinical features has never been explored. The objective of this study is to investigate whether pain extent relates to clinical variables including pain intensity in addition to health indicators including disability, general health, depression, somatic anxiety, coping strategies or self-efficacy.An observational cohort study was conducted. Participants were recruited from 4 hospital spinal centres in Sweden. Pain extent was quantified from the pain drawings of 190 individuals with cervical disc disease, verified with magnetic resonance imaging (MRI) and compatible with clinical findings (examined by a neurosurgeon), that show cervical nerve root compression. Pain extent was evaluated in relation to neck pain, arm pain, and headache intensity. Multiple linear regression analysis were then used to verify whether pain extent was associated with other health indicators including disability, health-related quality of life, depression, somatic anxiety, coping strategies and self-efficacy.Pain extent was directly related to neck, arm and headache pain intensity (all P < .01). Multiple linear regression revealed that pain extent was significantly associated only to the level of perceived disability (P < .01).Increased pain extent in people with CR is associated with higher headache, neck and arm pain intensity, and disability but not measures of general health, depression, somatic anxiety, coping strategies or self-efficacy.