A:  

Shawn Farrokhi (SF): This project is near and dear to my heart because I became a clinician before I became a scientist, and the idea originated from my own experiences as a physical therapist (PT). Improving the quality of care for our patients is important to me and was the impetus behind writing this proposal. Low back pain is a serious issue in physical therapy and is one of the top diagnoses that PTs see—and more so within the military and VA settings, where it is consistently the number one diagnosis that we encounter.

Our focus within the trial is not the patient, but the provider—the physical therapist. Low back pain is extremely frustrating for patients and clinicians alike because often patients don’t get better and we, as care providers, often don’t know what’s causing their pain.  In our efforts to get the patient better, we try different strategies to figure out what works best for that patient. The established clinical practice guidelines (CPGs) are one way to allow us to be a little bit more systematic in those efforts, using evidence-based interventions for our patients.  Previous research into PT CPGs has shown that if providers adhere to the recommendations, patients have better outcomes—in general, and in terms of pain and function, and decreased use of opioids. They also need less future health care interventions, such as surgeries, injections, and other specialist visits outside of the PT setting. Yet, only about 40 to 45% of PTs adhere to the CPGs. This project is a strategy to improve adherence to the CPGs which that’s about therapy environment.


In this trial, we’re using an education, audit, and feedback strategy.  We provide participating PTs with education on the use of CPGs, including psychologically informed PT (one of the main recommendations of the CPGs). The education comes in the form of continuing education courses that providers would take anyway in order to fulfill their licensing requirements.  Once they receive the education, we audit their patient outcomes to see how well their patients are doing as compared to their colleagues and to everyone within the DOD or the VA that’s a part of our trial. This gives the providers a point of reference as to their patients’ progress.  We then provide the PTs with what percentage of their patients receive CPG-adherent care. If patients aren’t getting better and the PT is not adhering to the CPGs, it’s clear what needs to happen: PTs need to adhere to the clinical practice guidelines.


This feedback is provided to the PTs monthly and is anonymous, so they see only their own feedback about how well they are adhering to GPGs and how their patients are doing. Providers can see trends over time to see if making a change today means patient improvement in the coming months.  We want everything we do to be very streamlined and something that could be easily implemented within the PT environment.  Patients won’t see any difference in terms of the care that they’re receiving since they are all receiving the standard of care that their PT would usually provide and we don’t have an experimental group per se, where a novel approach would affect the patient. This format has allowed us to have a large sample for our trial, with the goal of enrolling 3,500 to 7,000 individuals into the study.

A:  

SF: As a part of our trial, we created new educational modules because they didn’t exist previously. There are a lot of different CPGs for managing low back pain from different associations. We focus more on American Physical Therapy Associations (APTA) recommendations because it’s closer to how we practice and most PTs are more comfortable taking recommendations from the APTA (which published its own CPG in 2012 with an updated being released this year), as opposed to the recommendations that may come from other organizations that represent different providers, perspectives, and approaches to low back pain management. For instance, the Association of American Physicians and Surgeons will have different practice recommendations because its members can order treatments that we can’t, such as prescribing medications. We’ve incorporated updated APTA CPGs within the educational modules to be consistent with the new recommendations that are coming out in November. We think providing education for PTs can remedy the fear and other barriers to engagement that lower utilization of active treatments, and psychologically-informed PT which is an important part of the APTA recommendations.


Patient education is important, but continuing education for providers is also an essential component of care that needs to be highlighted during initial practitioner education, when their practice is more flexible in accepting new skills—like active interviewing, which is one of the aspects our educational sessions address. Developing a therapeutic alliance with patients where the patient trusts the PT enough to talk about barriers to pain management, like the fear of moving or exercising. This is not a common skill that most PTs have, and it isn’t always easy to practice or insert the discussion in PT appointments. In our education sessions, we do a lot of role-playing to practice engaging a patient in talking about their fears, like, “I’m afraid of sleeping at night because my back pain wakes me multiple times.” We have a clinical psychologist as a part of our educational team that helps us establish some of those paradigms and make them applicable in PT-patient interactions. We have clinicians that talk about graded exercise and graded exposure and other techniques that we use in terms of dealing with some of the psychosocial barriers to recovery.