Targeted interventions to prevent transitioning from acute to chronic low back pain in high-risk patients: development and delivery of a pragmatic training course of psychologically informed physical therapy for the TARGET trial

Jason M Beneciuk,Steven Z George,Robert B Saper,Carol M Greco,Anthony Delitto,Michael J Schneider,Stephen T Wegener

doi:10.1186/s13063-019-3350-3

Abstract

BackgroundLow back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide. Psychologically informed physical therapy (PIPT) is a secondary prevention approach that first aims to identify individuals at high risk for transitioning to chronicity and then provides tailored treatment to reduce that risk. Training models that are feasible to implement with acceptable training quality are needed to improve scalability for widespread implementation of PIPT. This manuscript describes the PIPT training program that was developed for training physical therapists providing PIPT in the TARGET trial.MethodsThe PIPT training program was developed, tested, and modified using an iterative process. Content development consisted of stakeholder engagement, beta testing, modification of training, and confirmation of final course objectives. Methods of delivery consisted of a website that included brief online educational modules followed by a live 8-h workshop that included video-based mock case scenarios and case-based role playing. Attitudes, beliefs, and confidence in implementing PIPT principles were assessed before and immediately after training to measure training quality and impact.ResultsEarly stakeholder engagement and beta testing indicated the need for increased emphasis on experiential learning opportunities and patient-centered communication training. Booster training varied extensively across TARGET sites with involvement of ‘clinician champions’ providing brief follow-up sessions identified as best practice. Favorable post-training changes in physical therapist attitudes and beliefs toward biopsychosocial treatment orientation and increased confidence in implementing PIPT principles were observed.ConclusionsPIPT training for provider participation in the TARGET trial was feasible to deliver. Course content was acceptable to physical therapists and resulted in improved beliefs and confidence in applying PIPT skills during clinical practice. Ongoing consultation and site-based continuing education were methods by which specific TARGET sites maintained or augmented PIPT skill training; however, implementing ongoing training was challenging in general. Due to the pragmatic nature of the TARGET trial, it was not possible to directly measure the effect of PIPT training on treatment fidelity, which was a limitation of our approach.Trial registrationClinicalTrials.gov, NCT02647658. Registered on 6 January 2016.

Highlights

Low back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide
Course content was acceptable to physical therapists and resulted in improved beliefs and confidence in applying Psychologically informed physical therapy (PIPT) skills during clinical practice
Due to the pragmatic nature of the TARGET trial, it was not possible to directly measure the effect of PIPT training on treatment fidelity, which was a limitation of our approach

Summary

Introduction

Low back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide. Informed physical therapy (PIPT) is a secondary prevention approach that first aims to identify individuals at high risk for transitioning to chronicity and provides tailored treatment to reduce that risk. The risk factors for chronic pain are complex and multifactorial including psychological and behavioral features such as pain catastrophizing [6], fear-avoidance beliefs [7], and maladaptive pain coping [8] These factors can be addressed via cognitive-behavioral therapy, typically offered by psychologists and other behavioral healthcare providers; this is seldom addressed through initial treatment delivered by primary care providers or physical therapists. One promising strategy is psychologically informed physical therapy (PIPT), a secondary prevention approach for LBP that first aims to identify individuals at high risk for transitioning to chronicity and provides tailored treatment by merging impairment-focused physical therapy with cognitive behavioral therapy methods as needed to reduce that risk [12, 13]. PIPT optimizes variables predictive of persistent pain and is consistent with a top priority of the Federal Pain Research Strategy (i.e., formalizing individualized treatment recommendations based on risk factors) [14]

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Discussion

Conclusion