Physiotherapy in primary care for working-age patients with early back and neck pain. Screening tools, interventions and outcomes

Abstract: Patients with back and neck pain are frequently seen in primary care, where they are directed to physiotherapy as first-line treatment. The condition affects both the individual, by causing pain and disability, and society, because of high costs caused by work disability and health care consumption. Clinicians need tools to identify, at an early stage, patients at risk of poor outcome, in order to tailor interventions. We also need more knowledge about what interventions can promote work ability and prevent long-term disability. The overall aim of this thesis was to obtain deeper knowledge on health care interventions in primary care for working-age patients with acute or subacute back and neck pain, by studying screening tools, physiotherapy interventions and self-reported outcomes regarding function, health-related quality of life and work ability.Methods: Study I was a cross-sectional validation study where we compared the concurrent validity of the STarT Back Tool (SBT) and the ÖMPSQ-short form questionnaires, including psychometric properties and clinical utility, for patients with acute or subacute back and/or neck pain (n=315). Study II was a prospective psychometric validation study where we studied the predictive validity of the SBT for the outcomes work ability and health-related quality of life at long-term follow-up (n=238). Study III was a secondary analysis of self-reported function, health-related quality of life and work ability, in a prospective cluster-randomised controlled trial (WorkUp) with one-year follow-up (n=352). The intervention was a workplace dialogue (CDM) as an add-on to structured physiotherapy treatment. Study IV was a descriptive cohort study nested within the WorkUp trial where we described type and number of physiotherapy interventions provided for patients with neck and back pain at risk of work disability. We also examined whether patients in the intervention group received more occupational medicine interventions (n=343). Results and Conclusions: The correlations between the SBT and the ÖMPSQ-short scores were moderately strong for individuals with acute or subacute back and/or neck pain, and the SBT was feasible to use in clinical practice. We therefore suggest that SBT can be used in primary care to identify individuals with both back and neck pain at risk of long-term pain and disability. We found that the SBT also can be used to identify patients at risk for a poor long-term health-related quality of life and/or work ability outcome in a population with acute or subacute back and/or neck pain. We found no effect of the CDM, as an add-on to structured physiotherapy, on self-reported function, health-related quality of life and work ability (point prevalence) at the 12-months follow-up. All self-reported outcomes improved over time in both the intervention and the reference group. We found that patients with neck and back pain at risk of work disability were offered many different types of interventions in primary care, with physical exercise being the most frequently used treatment category. Patients in the intervention group received more occupational medicine-oriented interventions than patients in the reference group. This thesis has deepened the knowledge on health care interventions in primary care for working-age patients with acute or subacute back and neck pain. The Swedish STarT Back Tool, a brief screening tool designed for tailored interventions based on risk stratification/triage, has been validated for individuals with acute or subacute back and neck pain in primary care. Long-term effects of a workplace dialogue as an add-on to structured physiotherapy on self-reported measures have been evaluated. The broad spectrum of interventions used by primary care physiotherapists for patients with back and neck pain in working-age are described.