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Dr. Jordan Miller and his team

Testing new models of care to address the challenge of low back pain

By Dr. Jordan Miller

Low back pain is a common experience. An estimated 75-85% of people will experience some form of back pain during their lifetime. For the majority, it will improve quickly, but about half will experience recurrences within a year. For many, low back pain can lead to suffering and disability that interferes with participation in usual life roles and activities. In fact, Global burden of disease studies provide evidence that low back pain is the leading contributor to years lived with disability worldwide.

When people seek care for low back pain, the most common first point-of-contact with the healthcare system are family physicians. However, a growing population that is increasing in age and experiencing more chronic health concerns is making it difficult for family doctors to meet the diverse needs of patients. One way to support family physicians is to build a team of healthcare providers to help address the needs of patients. For people with low back pain, integrating physiotherapists (PTs) at the first-point of contact within primary care teams may provide a more focused low back pain consultation, improve patient outcomes, and reduce the workload for family doctors. Dr. Jordan Miller is a leading a multidisciplinary and international team of researchers and knowledge users who are conducting research to determine the effectiveness and cost-effectiveness of integrating PTs at the first point of contact within primary care teams for patients with low back pain. Team members include co-investigators Dr. Catherine Donnelly and Dr. Kathleen Norman from the School of Rehabilitation Therapy, and Dr. Michael Green and Dr. David Barber from the Department of Family Medicine at Queen’s.

Dr. Miller and his team have completed a pilot cluster randomized trial with four sites to determine the feasibility of conducting a fully powered cluster randomized trial. This pilot study was supported by a Catalyst grant ($100,000) from the Canadian Institutes of Health Research (CIHR). The pilot demonstrated feasibility through high rates of recruitment, retention, and  outcome measurement completion, as well as ability to implement the new model of care with high fidelity. These results suggest it is feasible to proceed with a fully powered trial.

Embedded within this pilot trial was a qualitative study to explore the perspectives and experiences of primary care providers and patients involved in the new PT-led primary care model for low back pain. Both primary care providers and patients described a positive experience with the new model of care. They suggested that they highly valued the thorough assessment, support for active management, improved access to rehabilitation, enhanced communication, and better continuity of care resulting from the integration of a PT in the primary care team. Primary care providers also suggested they felt the added musculoskeletal health expertise increased what they were able to offer to patients and provided opportunities for interprofessional learning amongst the team members. Patients expressed an appreciation for the additional time the PT was able to provide to listen to their experiences and concerns, and to demonstrate their understanding of the challenges patients were experiencing. They also expressed that the PT helped them to feel more involved in their own care, and to feel motivated, confident, and empowered to manage their back pain.

The next steps for Dr. Miller and his team are to carry out the fully powered cluster randomized trial, funded by a CIHR project grant (~$1.4 million). This fully powered trial will provide high quality evidence on the effectiveness and cost-effectiveness of the PT-led primary care model for low back pain. The results will provide important evidence to inform clinical practice and health system planning with the ultimate goal of improving health outcomes for people with low back pain.