Study Design:
The study was a 6-month quasi-experimental study with pre and post assessment.
Participants and settings:
LBP patients were triaged by physiotherapists within 2 weeks at the ORT SOPC, PWH. The triage was based on the standard spinal assessment forms and the absent of “red flags” indicative of possible serious spinal pathology such as cauda equina, inflammatory arthritis, malignancy, infection and fracture. After that, patients were classified to urgent, semi-urgent and routine (non-urgent) cases and brief self-management education was given. All the triaged reports would be checked again by an ORT specialist to confirm the priority. The waiting time at the ORT SOPC is 1 week for urgent cases, 5 weeks for semi-urgent cases and 182 weeks for routine cases. All patients with routine appointment and fulfilled the eligibility criteria were invited to participate in the study. Inclusion criteria were participants aged ≥ 18 years old; low back pain of any episodic duration; with or without referred leg pain; and understand Chinese (Cantonese/Mandarin) to a level where they can read the questionnaires and consent forms. Exclusion criteria were participants in active work compensation claims; pregnancy related LBP; and co-morbidity severe enough to prevent participation in the model, like attendance at scheduled appointments.
The PRIOR LBP care model:
Eligible participants were referred to primary care physicians with knowledge in musculoskeletal medicine at the FM-ORT clinic for clinical assessment and management. The roles of our primary care physicians were to confirm the diagnosis of LBP and to pick up subtle signs or symptoms suggestive of higher prognostic risks, which would need early interventions or orthopaedics care. The attending physicians would also conduct biomechanical assessment, posture evaluation and muscle testing. Postural advice, simple manual therapy included muscle energy technique and trigger points’ release, and focused exercise prescriptions were offered. Appropriate patients were referred to receive physiotherapy and/or occupational therapy; medications included the use of paracetamols and non-steroidal inflammatory drugs.
Baseline data collection:
The data included age, sex, body mass index (BMI), occupation, duration of LBP and types of previous treatment modalities. Participants were asked to fill in the Subgroup for Targeted Treatment (STarT) screening tool.15 It is a simple prognostic questionnaire that helps clinicians to identify modifiable risk factors (biomedical, psychological and social) for back pain disability. The tool consists of 9 self-reported items capturing 8 prognostics factors: function (2 items), radiating leg pain, pain elsewhere, depression, anxiety, fear avoidance, catastrophizing, and bothersomesness. The score ranges from 0 to 9 and allocates patients into 3 risk groups: low, medium, or high risk of persistent disability.16
Outcome measurements at 3 and 6 months:
- Patient-specific outcomes:
Patient acceptance to the model was measured by the recruitment rate. The Ronald Morris Disability Questionnaire (RDQ) is a self-report health status measure to assess physical disability due to low back pain. 17 The RDQ score is calculated by adding up the number of items checked. The score ranges from 0 (no disability) to 24 (maximum disability). A validated Hong Kong Chinese version of RMDQ will be used in this study.18 The Chinese Pain Self-Efficacy questionnaire, with scores rated from 0-60, is an important psychosocial determinant of pain behavior and predict the outcome of pain management programs with good psychometric properties.19-21 The overall pain was measured by the Numeric Pain Rating Scale from 0 to 10. The numerical global rating of change of scale was also measured, with -10 for the worse change, and +10 for the best change. The health-related quality of life was measured by Euro-Qol-5D.22 An open question on “How do you find your care under this model?” was asked at the 6 months assessment. The numbers of adverse events from treatment were also measured.
- Health service outcomes:
Health service outcomes included the average waiting time for the first FM-ORT consultation, the average number of FM-ORT consultations, the proportion of patients successfully discharged from clinic (discharge rate), the dropout rate from the care model, and the proportion of patients being referred back to ORT SOPC at 6 months. Resources utilization included the number of referrals to physiotherapy and occupational therapy, the number of patients prescribed analgesic medications and the number of patients arranged for Magnetic Resonance Imaging (MRI).
Statistical analysis:
Sample size calculation:
A sample size of 30 had 48% power to detect an acceptable rate of 85% or lower (in terms of recruitment rate), assuming the true acceptance rate in the population was 95% using one-sided binomial test of size α = 0.05.
Statistical analysis:
We used the chi-square test to assess the recruitment rates against the pre-specified thresholds. We conducted a linear mixed models (LMM) analysis for patient-specific outcomes to investigate significant changes over time following the intention to treat principle. One-sample T-test was used for NGRCS. In the LMM models, outcomes were treated as the dependent variables, with time and baseline characteristics treated as covariates. Time was tested as a categorical variable. Age, gender, BMI, back pain duration and the respective baseline outcome were entered to the models for adjustment. Unstructured covariance structure and fixed effect parameters were applied. The statistical package Stata version 24.0 was employed for data analysis. A P value < 0.05 was considered statistically significant.