Abstract
BackgroundAdherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks.ObjectiveAssess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups.MethodsThis was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs.ResultsOf 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention.ConclusionFactors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process.Trial Registrationclinicaltrials.gov NCT02777983.
Highlights
Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks
Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers
We identified all common pharmacological and non-pharmacological interventions utilized for low back pain (LBP), to include pharmaceutical analgesics (NSAIDs, acetaminophen, ketorolac injections, opioid-based pain relievers to include tramadol), acupuncture, dry-needling, manual therapy and spinal manipulation, therapeutic exercise, as well as referrals to specialty care and diagnostic procedures (e.g., x-rays, MRI, CT-scan)
Summary
Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks. The biomedical approach focuses on biological mechanisms as the primary source of symptoms (e.g. a bulging disc, fracture, malalignment of the spine, etc.), which often places patients in a position of perceived frailty and vulnerability [8] This has the consequence of ignoring or minimizing psychological, social, and environmental influences [9]. Diagnostic tests, and opioids focus on finding or treating a biomedical problem, but are not considered high-value care when used as initial treatment options. They can often place patients at higher risk for poor recovery.
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