Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial.
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2021-04
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Abstract
Background
Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability.Methods
We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: ClinicalTrials.gov NCT02647658.Findings
Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2ยท1, 95% CI -4.9-0.6; p = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups.Interpretation
There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines.Funding
Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867.Type
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Delitto, Anthony, Charity G Patterson, Joel M Stevans, Janet K Freburger, Samannaaz S Khoja, Michael J Schneider, Carol M Greco, Jennifer A Freel, et al. (2021). Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. EClinicalMedicine, 34. p. 100795. 10.1016/j.eclinm.2021.100795 Retrieved from https://hdl.handle.net/10161/22739.
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Steven Zachary George
Dr. Georgeโs primary interest is research involving biopsychosocial models for the prevention and treatment of chronic musculoskeletal pain disorders. His long term goals are to 1) improve accuracy for predicting who is going to develop chronic pain; and 2) identify non-pharmacological treatment options that limit the development of chronic pain conditions. Dr. George is an active member of the American Physical Therapy Association, United States Association of the Study of Pain, and International Association for the Study of Pain.
Dr. Georgeโs research projects have been supported by the National Institutes of Health, Department of Defense, and Orthopaedic Academy of the American Physical Therapy Association. Dr. George and his collaborators have authored over 330 peer-reviewed publications in leading medical, orthopaedic surgery, physical therapy, rehabilitation, and pain research journals. He currently serves as Editor-in-Chief for the Physical Therapy & Rehabilitation Journal. Dr. George has also been involved with clinical practice guideline development for the Academy of Orthopaedic Physical Therapy and the American Psychological Association.
Dr. George has been recognized with prestigious research awards from the American Physical Therapy Association, American Pain Society, and International Association for the Study of Pain. For example from the American Physical Therapy Association: he was named the 21st John H.P. Maley Lecturer, recognized as a Catherine Worthingham Fellow in 2017, and selected for the Marian Williams Award for Research in Physical Therapy in 2022.
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