MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN Abstract of the dissertation entitled An Evidence-based Guideline of using Multidisciplinary Primary Care Program in Patients with Chronic Low Back Pain Submitted by Sham Lai Mei for the degree of Master of Nursing at The University of Hong Kong in July 2015 We consider the local setting of five Family Medicine clinics under primary care in Hong Kong, where chronic low back pain (LBP) accounted over a thousand of consultations every year. Patients with chronic LBP are only prescribed with anti-pain oral medication, brief health education and sometimes referral for physiotherapy, but they lack comprehensive and consistent health care intervention. There has been growing evidence that shows multidisciplinary primary care program may help to reduce the level of chronic LBP in adult patients, but there was no systematic review. Therefore, this dissertation aims to develop an evidence-based clinical guideline on multidisciplinary primary care program in patients with chronic LBP. Four electronic databases: Cochrane Library, CINAHL Plus, PubMed, and Medline were searched for randomized controlled trials (RCTs) on multidisciplinary program for patients with chronic LBP. After reading full texts, eight studies remained. Quality appraisal was performed by the Scottish Intercollegiate Guidelines Network (SIGN) checklist for RCTs. Four of the eight RCTs had moderate to good methodological quality. They indicated that multidisciplinary primary care program has a significant effect on reducing pain among patients with chronic LBP and improving quality of life. There was adequate evidence in support of using multidisciplinary program in primary care.
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MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN
Abstract of the dissertation entitled
An Evidence-based Guideline of using Multidisciplinary Primary Care Program
in Patients with Chronic Low Back Pain
Submitted by
Sham Lai Mei
for the degree of Master of Nursing
at The University of Hong Kong
in July 2015
We consider the local setting of five Family Medicine clinics under primary care
in Hong Kong, where chronic low back pain (LBP) accounted over a thousand of
consultations every year. Patients with chronic LBP are only prescribed with anti-pain
oral medication, brief health education and sometimes referral for physiotherapy, but
they lack comprehensive and consistent health care intervention. There has been
growing evidence that shows multidisciplinary primary care program may help to
reduce the level of chronic LBP in adult patients, but there was no systematic review.
Therefore, this dissertation aims to develop an evidence-based clinical guideline on
multidisciplinary primary care program in patients with chronic LBP.
Four electronic databases: Cochrane Library, CINAHL Plus, PubMed, and
Medline were searched for randomized controlled trials (RCTs) on multidisciplinary
program for patients with chronic LBP. After reading full texts, eight studies
remained. Quality appraisal was performed by the Scottish Intercollegiate Guidelines
Network (SIGN) checklist for RCTs. Four of the eight RCTs had moderate to good
methodological quality. They indicated that multidisciplinary primary care program
has a significant effect on reducing pain among patients with chronic LBP and
improving quality of life. There was adequate evidence in support of using
multidisciplinary program in primary care.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN
An evidence-based guideline on multidisciplinary primary care program for
patients with chronic LBP was subsequently developed to guide nurses for the
effective implementation of the program. The SIGN grading system was chosen to
grade the recommendations in the guideline. In our program, patients with chronic
LBP are required to attend theory classes and practice exercises in local clinics for 5
weeks in instructive phase and for 12 months in reinforcement phase. The
evidence-based guideline was considered to be feasible and transferable in the local
clinical setting. There would be a potential saving of HK$ 0.5 million per year with
minimal associated risks to the patients and stakeholders.
The stakeholders are the Consultant of Family Medicine, Medical Officer and the
nurses of the Quality Assurance Team. A working group will conduct regular
meetings to facilitate the implementation of the new guideline. Before full
implementation of the guideline, a 10-month pilot study on chronic LBP patients will
be conducted to assess the feasibility of the guideline. The primary outcome of pain
will be assessed by Visual Analogue Scale (VAS). Secondary outcome measurements
comprise health outcomes, healthcare provider outcomes and system outcomes.
Evaluation study will take approximately 30 months. Patients with chronic LBP will
be assessed before the program, at the end of 5-week instructive phase, followed with
the third, sixth, ninth and 12th
month after the end of instructive phase. After the
13-month program, patients with chronic LBP will be evaluated every three months
over a 12-month follow up period. Finally, the results of innovation will be evaluated
over three months to decide whether the innovation should be continued. The
effectiveness of the guideline will be determined by its ability in reduced pain
intensity, improved nursing acceptance, increased nursing compliance, good
utilization rate and reduced incremental cost of the program.
Running head: MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN
An Evidence-based Guideline of using Multidisciplinary Primary
Care Program in Patients with Chronic Low Back Pain
by
Sham Lai Mei
PcPsy, BSc(N), MSocSc(BH), RN
A dissertation submitted in partial fulfillment of the requirements for
the Degree of Master of Nursing
at The University of Hong Kong
July 2015
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN i
Declaration
I declare that this dissertation represents my own work, except where due
acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this university or to any other institution for a degree,
diploma or other qualifications.
Signed………………………………………………………………………………
Sham Lai Mei
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN ii
Acknowledgements
It has been my immense honor to be a dissertation student of Dr. Daniel Fong. I
would like to extend my sincerest gratitude to my supervisor for his support and
encouragement in this dissertation. I am in tremendous appreciation for all his
valuable, countless hours and patience devoted to guide my work.
I would like to extend my heartfelt gratitude to my father and mother whose love
and support have nurtured me constantly throughout my life and my entire learning
endeavor. Thanks so very much for their unconditional positive regards accepting me
as who I am.
I am also grateful to all my friends for their understanding and support during my
graduate study. May I take this opportunity to praise the God for his unending love
embracing me and my family members.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN iii
Contents
Declaration…………………………………………………………………………………. i
Acknowledgements………………………………………………………………………… ii
Table of Contents………………………………………………………………………….. iii
List of Tables……………………………………………………………………………….. vi
List of Appendices…………………………………………………………………………. vii
List of Abbreviations………………………………………………………………………. viii
Chapter 1: Introduction
1.1 Background………………………………………………………………. 1
1.2 Affirming Needs………………………………………………………….. 3
1.3 Objectives and Significance……………………………………………… 5
Chapter 2: Critical Appraisal
2.1 Search and Appraisal Strategies
2.1.1 Search strategies………………………………………………….. 6
2.1.2 Study selection criteria…………………………………………… 6
2.1.3 Data extraction…………………………………………………… 7
2.1.4 Critical appraisal and rating scheme……………………………... 7
2.2 Results
2.2.1 Search results…………………………………………………….. 8
2.2.2 Overview of selected articles and study population……………... 8
from 0-24 with higher score indicates a higher degree of disability. All the
questionnaires will be put together into a pile of assessment forms (Appendix K). In
addition, each patient would be assessed for any complications related to the program
and the data will be documented in the progress notes. Patient acceptance towards the
program is assessed by group qualitative interview.
Second, healthcare provider outcomes include the acceptance level to the
program and the compliance level to the guideline. In view of nursing acceptance
level, change in satisfaction and confidence level of the nurses will be evaluated by
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 35
group qualitative interviews. On the other hand, nursing audit will be conducted for
evaluating nursing compliance to the guideline. The skill and knowledge of the nurses
will be measured by auditing against guideline standard and criteria. Patient progress
documentation and class observation will also be audited by the working group. Data
related to the noncompliance of the nurses will be collected by the working group.
Third, the system outcomes will be used to evaluate the effectiveness in the
utilization of the innovation and the incremental costs of the program. The total
number of the patients cared by this program annually will be recorded. The analysis
of cost-effectiveness estimates the outcomes benefited to the patients and healthcare
system on a yearly basis. The benefits of the program will include the decreased
number of chronic LBP patient, shorter period of consultation, the decreased specialty
and physiotherapy referral and decreased manpower on individual health education.
Meanwhile, the cost of the program will include operational cost such as salary and
material costs such as stationary consumables and exercise equipment.
4.3.3 Plan of measurements
For the patient outcome, the baseline assessment on the health outcomes will be
performed at the beginning of the first session. Outcome measure will be assessed at
the end of the instructive phase measuring short effect. The intermediate effect will be
assessed every three months in the reinforcement phase. The long term effect will be
measured every three months in the 12-month follow up period after the program
(Tavafian 2011 & Tavafian 2013). Evaluation of the guideline will be carried out
every three months (3rd
, 6th
, 9th
, 12th
month). On the other hand, patient acceptance
toward the program will be evaluated by group qualitative interview at the end of the
instructive phase and at the end of reinforcement phase.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 36
For the health care provider outcome, the nursing compliance will be assessed
weekly in instructive phase for 5 weeks and monthly in reinforcement phase for 12
months by nursing audit. Class observation will be done in every class in a total of 10
times over 5 weeks. Progress notes will be examined weekly in instructive phase and
monthly in reinforcement phase for 12 months. It is necessary to conduct nursing
audit in between instructive phase and reinforcement phase to ensure adherence of
guideline. Regarding the nursing acceptance toward the program, group qualitative
interview will be held at the end of instructive phase and at the end of reinforcement
phase, in a total of two times.
For the system outcomes, the total number of patients treated annually and the
annual running costs of the program will be evaluated at the end of the program in a
year base. The operational costs required in implementation of the program will be
analyzed by the working group in a yearly basis. The assessment of the utilization of
the program will be calculated at the end of the program.
4.3.4 Nature and number of the clients
The nature of the clients involved is consistent to the eligibility criteria of the
clinical guidelines. The sample size calculation was based on a two-tailed paired t-test
at a maximum of 5% chance of committing a false positive error and 80% power to
detect a difference of at least 0.3 as the effect size. Using G*Power 3.1.9.2 (Heinrich,
2013), the required sample size was 82 in each collection time point. Accounting 10%
drop out rate, the sample size is taken as 90 for the five clinics in the full scale
implementation.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 37
4.3.5 Data analysis
In data analysis, 5% nominal level of significance will be used in all significance
tests, and 95% confidence intervals will be provided where appropriate.
As the VAS, RMDQ and SF-36 will be used to measure pain, disability and
quality of life at different points in time, repeated measures analysis of variance will
be performed to assess the change of scores over time. The method of analysis for all
the above outcomes will be performed by a two-tailed paired t-test for each follow up
visit. SPSS version 21 statistical software program will be used to perform the
statistical analyses. Independent samples t-test will be used to assess the mean
differences between groups. Regarding patient acceptance towards multidisciplinary
program, valuable comments will be collected by a group qualitative interview. The
main theme will be the satisfaction of the patients toward the new program.
For health care worker, the data of nursing compliance will be collected by
nursing audit to sustain the change of practice. The evaluation objectives are to
determine if the knowledge and skills of the nurse meet the standard and criteria of the
guideline. All the audit criteria of the guideline must be met. The audit will run in a
cycle including first data collection, comparison of performance with criteria and
standards, implementation of change, and a second data collection within a year of the
program. On the other hand, the healthcare provider outcomes will evaluate the
change in self-perceived skill and confidence level of nurses in conducting
multidisciplinary program by group qualitative interview. The main theme is the
satisfaction and confidence of the nurses toward the new program.
In the system outcome, the data of cost effectiveness will be collected by
calculating the incremental cost of the program at the end of the program. The
evaluation objectives are to determine if incremental cost is reduced. On the other
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 38
hand, the data of utilization of the innovation will be collected by measuring the
number of patient participated in the program in each session.
4.3.6 Basis for concluding the effectiveness of the guideline
The evaluation of program aims at ensuring the sustainability of implementing
this new innovation in the local setting. As such, the efficacy of multidisciplinary
primary care program comparing usual care in patients with chronic LBP is addressed.
The effectiveness of the guideline will be shown by decreased pain intensity by
decreased VAS, improved quality of life as in scores increased in SF-36 and decreased
disability by decreased scores in RMDQ. The objective is to achieve 25 % reduction
of pain intensity by VAS average pain score. The program will be considered effective
if the paired t-test on mean percentage change in quality of life and pain intensity
before and after program showed a p-value of less than 0.05.
For the health care worker, the effectiveness of the guideline will be based on the
improved nursing acceptance towards the program and increased nursing compliance
to the guideline. For the staff acceptance level, the effectiveness of the guideline will
be based on the increased level of staff acceptance with satisfaction and confidence on
the use of the guideline.
For the system outcomes, the cost effectiveness of the guideline will be based on
the achievement of good utilization rate with near 80% of participation rate. In the
five clinics, there will be in total 90 patients in a month. In a one year of time, there
will be 1080 clients benefited from the new guidelines. The guideline will be
considered as effective if the incremental cost is lowered by 30% significantly after
one year of the program and the operational cost will be expected to be kept below
HK$100,000 per annum.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 39
At the end of the program, the working group will conduct a meeting with the
administrators and present the outcomes of the program. The effectiveness of the
guideline will be concluded by considering the above indicators. The Consultant of
the service will make the final decision of whether the innovation will be
implemented in the local setting.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 40
Appendix A
Result of the Search for Studies on Multidisciplinary Primary Care Program for
Patients with Chronic Low Back Pain
Databases Searched
Search Terms Cochrane
Library
PubMed CINAHL
Plus
MEDLINE
1) Low Back Pain 4878 25477 2033 2550
2) Multidisciplinary 8660 60701 6655 5982
3) Quality of Life
44048 229086 17604 34387
Combined item
1 AND 2 AND 3
57 89 7 15
Limit (Randomized
Controlled Trial)
30 21 0 0
Manual Exclusion by
inclusion & exclusion
criteria
8 7 0 0
Discard Duplicate Paper
0 *7
0 0
Manual Search for
citation selected paper
0 0 0 0
Final number of
Literature can be used 8
*7 PubMed Papers were duplicated with Cochrane library data search
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 41
Appendix B
PRISMA Flowchart
Iden
tification
Eligib
ility Screen
ing
Inclu
ded
168 number of records
identified through database
Zero number of additional records
identified through other sources
79 number of records after duplicates removed
79 number of
records screened
49 number of
records excluded
30 number of full-text
articles assessed for
eligibility
22 number of full-text
articles excluded, with
reasons
8 number of studies included
in qualitative synthesis
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 42
Appendix C
Quality Assessment
Study identification: Kaapa, E.H., Frantsi, K.,
Sarna, S., & Malmivaara, A. (2006) No. 1
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Patient, intervention,
comparison and outcome
measure are specified.
1.2 The assignment of subjects to treatment groups
is randomized.
Yes. The randomization list was
generated by an independent
biostatistician using a table of
random numbers. Blocks of 20
patients
1.3 An adequate concealment method is used. Yes. Randomized each patient
into one of the two groups by
opening an opaque sealed
envelope. Results were kept in
sealed envelopes, one for each
patient
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. The physiotherapist was
not aware of the block size
1.5 The treatment and control groups are similar at
the start of the trial.
Yes. Pt gps look reasonably
similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. 2 groups are treated
equally except intervention
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
Intervention: 10/59=17%
Control: 15/61 = 25%
Overall: 25/120= 21%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes. The results according to
intention to treat did not differ
1.10 Where the study is carried out at more than one
site, results are comparable for all sites.
Does not apply. Only one site
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize bias? High quality (++)
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that
the overall effect is due to the study
intervention?
No statistically significant
differences between the two
treatment gps after
rehabilitation, 6, 12 and 24
month FU in outcome measure
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Only general well being
after rehabilitation
2.4 Level of evidence 1+
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 43
Study identification: Dufour, N., Thamsborg, G.,
Oefeldt, A., Lundsgaard, C. & Stender, S. (2010)
No.2
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Patient, intervention,
comparison and outcome
measure are specified.
1.2 The assignment of subjects to treatment
groups is randomized.
Yes. According to random
number chart for each
subgroup
1.3 An adequate concealment method is used. Yes. Allocated by an separate
secretary
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. Physician was blinded
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. P value >0.05 (not sig).
Pt gps look reasonably
similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. 2 groups are treated
equally except intervention
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
11 pts in each group: Gp A 9%
& Gp B 8% dropped out
during treatment period
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes. Data were analyzed using
ITT principle.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize
bias?
High quality (++)
Because of ITT applied
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes. Chi square testes, student
paired and unpaired t tests.
ANOVA
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes. Result of SF 36 &
RMDQ are applicable. VAS
no significant different
2.4 Level of evidence 1++
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 44
Study identification: Morone, G., Paolucci, T.,
Alcuri, M.R., Vulpiani, M.C., Matano, A. et al. (2011)
No. 3
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and
clearly focused question.
Yes. Patient, intervention,
comparison and outcome
measure are specified.
1.2 The assignment of subjects to treatment
groups is randomized.
Yes. Pts were randomly inserted
in BSG and CG in a ratio of
3:2.
1.3 An adequate concealment method is used. Can’t say. Extraction each time
on a group of 15 pts. 5 pts were
allocated in a tx gp, other 4 pts
in similar treated gp and the last
6 in the control gp.
1.4 Subjects and investigators are kept blind
about treatment allocation.
Yes. single-blind study (patient)
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. P value >0.05 (not sig). Pt
gps look reasonably similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. Back School program and
control group
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
3/73 x 100% = 4.1%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No. the drop out pt is not
included in the data analysis.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize bias? Low quality (1-). Because of
3:2 ratio & no ITT
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes. One way ANOVA &
Mann Whitney u-test
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Result of SF-36, VAS &
ODI are applicable
2.4 Level of evidence 1-
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 45
Study identification: Abbasi, M., Dehghani, M.,
Keefe, F.J., Jafari, H., Behtash, H., Shams, J. (2012)
No. 4
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Patient-oriented
multidisciplinary pain mx program
vs stand medical care was extracted
to answer question
1.2 The assignment of subjects to treatment
groups is randomized.
Yes. randomized to the three groups
in blocks of 12 using a
software-generated randomization
plan.
1.3 An adequate concealment method is used. Yes. Patients were coded
consecutively
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. Participants were blinded to
their random assignment, but
investigators and treatment staff
were not blinded to the
randomization.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. Pt gps look reasonably
similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. SA-MPMP vs P-MPMP
vs standard medical care
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
4/33= 12.1%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No. no intention to treat and
the sample size is very small
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize
bias?
Acceptable (+)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes. But the sample size is
rather low.
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes. Only RQD, Tampa scale
of Kinesiophobia and VAS
2.4 Level of evidence 1-
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 46
Study identification: Monticone, M., Ferrante, S.,
Rocca, B., Baiardi, P., Farra, F.D. & Foti, C. (2013)
No. 5
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Patient, intervention,
comparison and outcome
measure are specified.
1.2 The assignment of subjects to treatment groups
is randomized.
Yes. PI randomizes the pts to
one of the 2 programs using a
list generated by statistician.
1.3 An adequate concealment method is used. Yes. Randomization with
blinded treatment codes.
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. Patients and PI and
statisticians are blinded.
Physiotherapies could not be
blinded.
1.5 The treatment and control groups are similar at
the start of the trial.
Yes. Yes. P value is not sig. Pt
gps look reasonably similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. 2 groups are treated
equally except intervention
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Does not apply. No patient is
switched to another group.
1.10 Where the study is carried out at more than one
site, results are comparable for all sites.
Does not apply. Only one
study site.
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize bias? High quality (++)
Because of low bias
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that
the overall effect is due to the study
intervention?
Yes. Linear mixed model
analyses and Mann-Whitney
test are used with significant
result.
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Result of RMDQ & SF 36
are applicable.
2.4 Level of evidence 1++
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 47
Study identification: Nazzal, M.E., Saadah, M.A., Saadah, L.M.,
Al-Omari, M.A., Al-Oudat, Z.A., Nazzal, M.S. El-Bashari, M.Y.,
Al-Zaabi, A. A., Alnuaimi, Y.I. (2013)
No. 6
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Management options
include multidisciplinary
rehabilitation.
1.2 The assignment of subjects to treatment
groups is randomized. Yes. according to a random
number chart
1.3 An adequate concealment method is used. Yes. allocated by a separate
secretary
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. Single blinded
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. P value >0.05 (not sig).
Pt gps look reasonably
similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. 2 groups are treated
equally except intervention
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Does not apply
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize bias? High quality (++)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes. Fisher’s exact
test to generate p-values for
categorical data
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
some. only VAS, McGill
pain, Oswestry disability.
2.4 Level of evidence 1+
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 48
Study identification: Tavafian, S.S., Jamshidi, A.R.,
Mohammad, K. (2011)
No. 7
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Patient, intervention,
comparison and outcome
measure are specified.
1.2 The assignment of subjects to treatment
groups is randomized. Yes. Through random
permutation blocking of every
6 participants.
1.3 An adequate concealment method is used. Yes. The sequence of allocation
was concealed to the physcians
by pt saying nothing about the gp
assignment
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. Due to the nature of the
intervention, full blinding of patients
was impractical. The physician and
statistical analyst were blinded to
the group assignment
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. P value >0.05 (not sig).
Pt gps look reasonably
similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. 2 groups are treated
equally except intervention
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
9/197=4.56%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No. As there were not a
considerable number of participants
who did not fulfill the protocol of
the study, no intention-to-treat
analysis was performed
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize bias? Acceptable (+)
Patient not fully blind
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the statistical
power of the study, are you certain that the overall
effect is due to the study intervention?
Yes. Fisher exact test,
independent t test
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes. Only QDS is
significant
2.4 Level of evidence 1+
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 49
Study identification: Tavafian, S.S., Jamshidi, A.R.,
Mohammad, K. (2014)
No. 8
Study Type: RCT
Section1: Internal Validity
1.1 The study addresses an appropriate and clearly
focused question.
Yes. Patient, intervention,
comparison and outcome
measure are specified.
1.2 The assignment of subjects to treatment
groups is randomized. Yes. through random
permutation blocking of every
6 participants.
1.3 An adequate concealment method is used. Yes. The sequence of allocation
was concealed to the physcians
by pt saying nothing about the gp
assignment
1.4 Subjects and investigators are kept blind about
treatment allocation.
Yes. Due to the nature of the
intervention, full blinding of patients
was impractical. The physician and
statistical analyst were blinded to
the group assignment
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. P value >0.05 (not sig).
Pt gps look reasonably
similar.
1.6 The only difference between groups is the
treatment under investigation.
Yes. 2 groups are treated
equally except intervention
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. All outcome measures
were accounted in the analysis
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
Ix gp: 10/97= 10.3%
Control: 9/100= 9%
1.9 All the subjects are analyzed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes. Intention to treat was
performed.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
Section 2: Overall Assessment of the Study
2.1 How well was the study done to minimize bias? Acceptable (+)
Patient not fully blind
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the statistical
power of the study, are you certain that the overall
effect is due to the study intervention?
Yes. 12 month
intervention & FU is
more effective than 6
month Ix & FU
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes. SF36, QDS,
RDQ
2.4 Level of evidence 1+ (intention to tx)
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 50
Appendix D
Estimated Cost of Multidisciplinary Chronic LBP Program in 2015 (1 Year Period)
Set Up Cost for Multidisciplinary Chronic LBP Program
Item Description Cost (HK$)
Salary in training Registered Nurse Mid-Point Salary (Point 20)
[$177/hr X 10 hr + $177/hr X 6hr] x 10 persons
28,320
Nursing Officer Mid-point Salary (Point 30)
[$281/hr X 10 hr+ $281 x 6 hr]x 5 persons
22,720
Physiotherapist II Mid-point Salary (Point 18)
[$160/hr X (2+6) hr]x 1 person
1,280
Clinical Psychologist Mid-point Salary (Point 33)
[$323/hr X (2+6) hr]x 1 person
2,584
Medical and Health Officer Mid-point Salary (Point 36)
[$349/hr X 2 hr] x 1 person
698
Salary in Power Point Registered Nurse Mid-Point Salary (Point 20)
[$177/hr X 10 hr + $177/hr X 12hr] x 5 persons
19,470
Buying Equipment Resistance Exercise Band
($112 +$118+$128+$150+$158+$215+$270) x 5 Sets
5,755
Yoga Mat (173 x 61 x 6mm PVC)
$120/each X 50 set
6,000
Total set up cost 86,827
Operational Cost (for 1 Year Program)
Item Description Cost (HK$)
Salary in Room
preparation
Workman II Mid-Point Salary (Point 4)
[$70/hr X 5 hr + $70/hr X 12hr] x 5 person
5,950
Salary in Conduct Program Registered Nurse Mid-Point Salary (Point 20)
[$177/hr X 10 hr + $177/hr X 24hr] x 5 persons
30,090
Team Leader Salary in
Evaluation
Registered Nurse Mid-Point Salary (Point 20)
[$177/hr X 5hr + $177/hr X 12hr] x 5 person
15,045
Salary in Supervision Nursing Officer Mid-Point Salary (Point 30)
[$218/hr X 5 hr + $218/hr X 12hr] x 5 person
18,530
Salary in equipment
cleaning
Workman II Mid-Point Salary (Point 4)
[$70/hr X 10 hr + $70/hr X 24hr] x 5 person
11,900
Salary in booking & filing
progress record
Clerical Assistant Mid-Point Salary (Point 5)
[$78/hr X 5 hr + $78/hr X 12 hr] x 5 person
5,950
Total operational cost in a year 87,465
Total cost of the program (set up cost + operational cost) 174,292
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 51
Appendix E
Cost Gain after Implementation of the One Year Program
Items Description Cost (HK$)
Family Medicine
Consultation fee
(Medication excluded)
$150/each x 90 patients in 5 clinics 13,500/Year
Medication
(Analgesics &
Famotidine)
$ 120/ each x 90 patients in 5 clinics 10,800/ Year
Physiotherapy
(Lumbar spine) by
physiotherapy in HA
$380/hr x (5+12) hrs x 90 patients in 5
clinics 581,400/ Year
X Ray Lumbar Spine
in HA
$610/case x 90 patients in 5 clinics 54,900/ Year
Nurse Salary on
Referral
Registered Nurse Mid-Point Salary
(Point 20)
[$177/hr X 40 hr] x 5 persons
35,400/ Year
Shoff Salary on
booking consultation
& filing
Clerical Assistant Mid-Point Salary
(Point 5)
[$78/hr X 40 hr] x 5 persons
15,600/ Year
Total gain after implementation of the program in a year 711,600
Total cost – Total gain
Balance
711,600-174,292
537,308
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 52
Appendix F
SIGN 50: A Guideline Developer’s Handbook---
Level of Evidence and Grade of Recommendations
SIGN Grading System 1999-2012
LEVELS OF EVIDENCE
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a
very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk
of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort or studies
High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2- Case control or cohort studies with a high risk of confounding or bias and a
significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
GRADES OF RECOMMENDATIONS
A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 53
Appendix G
An Evidence-based Guideline of using Multidisciplinary Primary Care Program in
Patients with Chronic Low Back Pain
Public Health Nursing Division Documentation No. xxxx-xxxxxx-001-xx
Issue Date 1st July 2015
An Evidence-based Guideline of using Multidisciplinary
Primary Care Program in Patients with Chronic Low
Back Pain
Review Date 1st July 2016
Page 1 of 10
An Evidence-based Guideline of using Multidisciplinary Primary
Care Program in Patients with Chronic Low Back Pain
Version Effective Date
1 1st July 2015
Document Number xxxx-xxxxxx-001-xx
Author SHAM Lai-mei, Phoebe
Registered Nurse
Custodian Public Health Nursing Division
Approved by Consultant &
Principal Nursing Officer
Approval Date 31st July 2015
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 54
Background
Chronic low back pain (Chronic LBP) is estimated as the top 10 diseases or
injuries that account for the highest number of Disability Adjusted Life Years (DALYs)
worldwide (WHO, 2014). The lifetime prevalence of non-specific LBP is estimated at
60% to 70% and the peak of prevalence reaches between the ages of 35 and 55 (WHO,
2014). Chronic LBP has the highest prevalence among female individual aged 40-80
(Hoy et al., 2012). In Hong Kong, overall 34.9% of the population reported chronic
LBP lasting more than 3 months (Wong & Fielding, 2011).
Chronic LBP bears substantial costs to society through healthcare expenditure and
reduced work productivity that imposes a high economic burden on the individuals
and communities. At present, chronic LBP is treated mainly by oral analgesics (WHO,
2014). Alternative treatments include physical therapy, rehabilitation and spinal
manipulation. Disc surgery remains the last option when all other strategies have
failed (WHO, 2014). Treatment for chronic LBP remains notoriously difficult and
none of the interventions are universally endorsed.
In order to reduce the rate of chronic LBP in the target population, several
components would integrate as a comprehensive multidisciplinary primary care
program for the prevention and treatment of chronic LBP in the community level. A
set of intervention using biopsychosocial approaches which consists of physical,
mental and social aspects of the patients is developed and administered by specialists
from different backgrounds (Tavafian, et al., 2014). It has been shown to be effective
and safe in improving quality of life and reducing pain intensity in patients with
chronic LBP when combined with usual care such as anti-pain medication and brief
health education (Kamper, 2014 & Monticone, 2013).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 55
Since the development of Family Medicine services in the local setting, the
guidelines on health education for chronic LBP only focus on individual counseling
with pamphlet given. The content of the health education information is mainly
postural hygiene and general back exercise. There is a need to develop guidelines
directed by primary care nurses, physicians, physiotherapist, occupational therapist
and psychologist. The guideline will allow specialists within the local setting to
contribute their professional roles into the multidisciplinary care program according to
the established service protocols. This is very different from the traditional
physician-directed chronic LBP intervention, which only involved referral from
physicians to out-service physiotherapist and pharmaceutical regime.
Multidisciplinary primary care program is proven as safe and effective as
physician-directed intervention (Tavafian, et al., 2014), Furthermore, it also can
improve quality of life and decrease pain in patients with chronic LBP (Nazzal et al.,
2013). This innovation can be translated into the local setting as a nurse-led
evidence-based guideline in clinical practice.
Aim & Objectives of the Guideline
The aim of this guideline is to provide evidence-based guidance on the
management of patients with chronic LBP using a multidisciplinary primary care
program in a local clinic. The objectives of the guideline are to:
i. Summarize and formulate clinical evidences for the interventions of patients with
chronic LBP based on the best evidence available
ii. Streamline and standardize the interventions of patients with chronic LBP in
Families clinics of a government unit
iii. Standardize the management of patients with chronic LBP
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 56
Target Population
The target population is the patients presented with chronic LBP attending
Families Clinics of a government unit. The inclusion criteria are 1) aged 18 or above,
2) having LBP for more than 3 months, and 4) Patients who are eligible to have
medical treatment under Families clinics of a government unit. They are civil servant,
dependent of civil servant, retired civil servants and dependents of retired civil servant.
The exclusion criteria are 1) having received or planned to have spine operation, 2)
having diagnosis as spinal stenosis, malignancy, fracture, kyphosis or scoliosis, and 3)
pregnant women.
Keys to Level of Evidence and Grade of Recommendation
In this evidence-based guideline on nurse-led multidisciplinary primary care
program in patients with chronic LBP , Scottish Intercollegiate Guidelines Network
(SIGN, 2014) was used to indicate the level of evidence and grade of recommendation
in each evidence based recommendation.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 57
Evidence Supporting the Recommendations
I. Assessment of Chronic LBP
Recommendation 1
Assess physical and psychosocial factors of chronic LBP using Visual Analog Scale
(0-10cm), Short Form-36 and Roland Morris Disability Questionnaire to measure pain
intensity, disability and quality of life of patients with chronic LBP. (Grade of
Recommendation: B)
Available Evidence:
Multidisciplinary program significantly improved VAS score showing reduced
pain and enhanced mobility. McGill pain score and Oswestry disability index
demonstrated significant differences (Nazzal, et al., 2013).
Disability was assessed by specific tools such as RMDQ and SF-36 scale
(Tavafian, et al., 2011).
II. Patient Recruitment of Multidisciplinary Primary Care Program
Recommendation 2
Group based multidisciplinary program is consisted of a group with 6-9 patients with
chronic LBP. (Grade of Recommendation: A)
Available Evidence:
Group-based treatment of 6-8 patients provided an opportunity for peer group
support (Monticone, et al., 2013).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 58
Recommendation 3
Treat patients with chronic LBP using multidisciplinary primary care program plus
usual care (medication). (Grade of Recommendation: B)
Available Evidence:
This program was complimented of physical components and pharmacologic
management of chronic LBP (Nazzal, et al., 2013).
Addition of a multidisciplinary program to usual care with oral medications for
patients with chronic LBP (Tavafian, et al., 2011).
III. Delivery of Multidisciplinary Chronic LBP Primary Care Program
Recommendation 4
Provide five sessions of chronic LBP treatment in instructive phase, two hours per day,
two days per week to a total of five weeks. (Grade of Recommendation: A)
Available Evidence:
The main changes occurred during the first five weeks (Monticone, et al., 2013).
The program was implemented for 120min per week to a total of five weeks
(Tavafian, et al., 2014).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 59
Recommendation 5
Provide 12 sessions of chronic LBP monthly booster class in reinforcement phase.
Two hours per day over one day per week in once per month, to a total of 12 months.
(Grade of Recommendation: A)
Available Evidence:
Patients had improvement in disability due to monthly meetings for a year
(Monticone et al., 2013).
Initial classes were followed by monthly booster class: monthly motivational
consultation and monthly telephone counseling (Tavafian et al., 2014).
Recommendation 6
Use motivational telephone counseling to motivate patients performing home exercise
in reinforcement phase and using stress management techniques in daily life. Exercise
as 60 minutes per day over twice per week in one month to a total of 12 months.
(Grade of Recommendation: A)
Available Evidence:
The monthly telephone reminders established a controlled situation during
reinforcement phase (Monticone, et al., 2013).
Monthly motivational telephone counseling, following initial classes in instructive
phase, encouraged patients to use stress management techniques in their daily life
(Tavafian, et al., 2014).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 60
IV. Content of Multidisciplinary Chronic LBP Primary Care Program
Recommendation 7
Multidisciplinary program should involve a team of specialists such as nurse,
physician, psychologist and physiotherapist. (Grade of Recommendation: A)
Available Evidence:
A well-integrated multidisciplinary team was consisted of physicians,
psychologist and physiotherapists (Monticone, et al., 2013).
The program involved a team of local specialists such as clinical psychologist,
physiotherapists and physicians (Tavafian, et al., 2014).
Recommendation 8
Multidisciplinary program should use comprehensive biopsychosocial approaches
which focused on physical, mental and social aspects of the patients with chronic LBP.
It includes cognitive-behavioral therapy, stress management, physical exercise and
health education. (Grade of Recommendation: B)
Available Evidence:
Biopsychosocial program focused on physical dimensions of chronic LBP as well
as mental and social aspects of the patients. Providing information to patients with
chronic LBP could have positive impact (Tavafian, et al., 2014).
Long tasting multidisciplinary program included cognitive behavioral therapy
(Monticone, et al., 2013).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 61
Recommendation 9
Multidisciplinary program should have a strong psychological component included
stress management, active coping strategies and problem solving which is based on
model of change and linking fear avoidance to disability. The program discussed and
practiced avoidance of movement and ways to overcome fear. (Grade of
Recommendation: A)
Available Evidence:
Multidisciplinary program has a strong psychological component based on
developing a precise model of change, and linking fear avoidance to disability
(Monticone, et al., 2013).
Psychological coping strategies included stress management, active coping
strategies and problem solving. Avoidance of movement and the ways to
overcome this fear were discussed and practiced (Tavafian, et al., 2011).
Recommendation 10
Physical activity (exercise) in both instructive and reinforcement phase include
education component, joint mobilization, strengthening and stretching exercise,
aerobic exercise, resistive and endurance exercise, relaxation and complying with
correct vertebra position. (Grade of Recommendation: A)
Available Evidence:
Subcategory included education and joint mobilization, stretching, aerobic, and
resistive and endurance exercise (Nazzal, et al., 2013).
The program includes relaxation, strengthening and stretching exercises and
complying correct vertebra position (Tavafian, et al., 2011).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 62
Recommendation 11
Individual motivational nurse consultation targets on the specific needs of each patient.
The consultation includes cognitive reconditioning, re-learning and exchanging
information between patient and the nurse. (Grade of Recommendation: A)
Available Evidence:
Individual session target treatment goals to the specific needs of each patient,
ensuring cognitive reconditioning and re-learning, and exchanging information
between patient and specialist of multidisciplinary team (Monticone, et al., 2013).
Booster classes reviewed all learned behaviors and skills (Tavafian, et al., 2014).
V. Patient Follow Up
Recommendation 12
Provide follow up for 12 months after completion of multidisciplinary chronic LBP
primary care program. (Grade of Recommendation: A)
Available Evidence:
A further improvement in disability was observed and maintained until the end of
the 1 year follow up (Monticone, et al., 2013).
Addition of a multidisciplinary program to usual care with oral medications for
chronic LBP improved quality of life and disability in the 12-month period of
follow up (Tavafian, et al., 2014).
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 63
Operational Protocol
Setting: Health Education Room of Families Clinics
1. Referral and Assessment
i. Patients with chronic LBP can be referred to multidisciplinary primary care
program by physicians or nurses by completing the program referral from.
ii. Patients shall be assessed by physicians to exclude any evidence of other
pathology.
iii. Multidisciplinary program nurses should confirm that the patient fulfills all
the eligibility criteria
iv. At the first multidisciplinary session, patients will be asked to fill in
questionnaires on quality of life and condition of LBP (Short-Form (36)
Health Survey, Visual Analog Scale and Roland Morris Disability
Questionnaire).
2. Intervention
i. In instructive phase, patient education and exercise will be given in the first
to fifth session which last for two hours.
ii. In reinforcement phase, the patient will be phone contacted by nurse for
motivation on exercise practiced (twice a week) at home.
iii. In reinforcement phase, monthly booster class will be carried out once per
month to a total of 12 months.
iv. After each session, the program nurse will complete the progress note for
each patient.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 64
3. Termination of Treatment
i. Treatment shall be terminated when a total of 5 weeks and 12 months
program have been completed.
ii. Treatment shall be withheld when a patient develop discomfort. The patient
shall be assessed and the treatment may be resumed or discontinued on the
recommendation of the physician.
iii. When signs and symptoms of spine or limb injury developed during the
physical activity, the program shall be terminated for that patient and whom
shall be referred to a physician for further management.
4. Follow-up and Evaluation
Patients shall be followed up at third months, sixth months, ninth months and one
year after the program. Evaluation on pain intensity, disability and quality of life will
be repeated at the end of instructive phase, at the end of the program and every three
months during the 12-month follow up period.
MULTIDISCIPINARY PRIMARY CARE IN CHRONIC LOW BACK PAIN 65
Combined Summary of Proposed Multidisciplinary Chronic LBP program---Instructive Phase
Session Time Content Remarks
1stwk Gp A: Mon & Thu
2:30-3:30
Gp B: Tue & Fri
2:30-3:30
Physiotherapy Theory Class
Explain the anatomy and physiology of the spine, lifestyle factors that can moderate the chronic LBP
process, and the preventive back injury techniques. Patients will understand how correct posture of the
vertebra can protect the vertebral column from injury.
9 patients/
group in
Clinic
Activity
Room
Instructive
Phase
(Total 5
session)
Gp A: Mon & Thu
3:30-4:30
Gp B: Tue & Fri
3:30-4:30
Exercise
1. Passive mobilization of spine (Manual Therapy): The passive mobilization involves manual therapy
for accessory and physiological movements to improve the range of motion.
2. Stretching muscle: The stretching is segmentary and involve the groups of lower limb and back
muscles.
3. Strengthening muscle: Basic exercises are gradually introduced to improve spinal deep muscle
awareness, and the patients learn a specific strengthening technique for the same muscles.
4. Postural control: Postural control is developed by means of exercises aimed at developing motor
control of the spine and pelvis.
5. Ergonomic advice: Ergonomic advice is provided by means of a booklet given to the patients during
the first session to facilitate the modification of daily living activities.
6. Complete an ongoing treatment diary for each session
2nd
wk
Gp A: Mon & Thu
2:30-3:30
Gp B: Tue & Fri
2:30-3:30
Physiotherapy Guided Practice Class
Same nurse evaluate the patients’ skills regarding protecting correct biomechanical posture of the spine
as well as performing stretching, strengthening, and relaxing exercises for the muscles of back, abdomen,
and thigh. Educate patients to maintain correct posture of the vertebral column while walking, sitting,
standing, sleeping, and bending. Instruct the patients to practice specific exercises for back pain.