Coordination of primary health care for back pain - A randomized controlled trial

Study Design. A randomized controlled trial comparing usual care with a pro gram for the coordination of primary health care (CORE) for the treatment o f subacute low-back pain patients. Objectives. To measure the effectiveness of the CORE program as a mean for implementing clinical practice guidelines for low-back pain in an urban com munity. Summary of Background Data. Clinical practice guidelines have been develope d for primary care physicians and patients on the clinical management of lo w-back pain. The implementation of the guidelines in a large community is d ifficult with the multiplicity of medical and nonmedical back care provider s and products. The CORE. program was designed to make the guidelines fit i n this complex environment. Methods. One hundred ten workers compensated for row-back pain for 4 to 8 w eeks in metropolitan Montreal were randomized in two groups: usual care (N = 56) and the CORE program (N = 54). Coordination of primary health care wa s performed by two primary care physicians and a nurse in liaison with the treating physicians, and included a complete examination, recommendations f or the clinical management, and support to carry out the recommendations. A ll workers were followed for 6 months. Back pain and functional status were assessed at baseline, 3 months, and 6 months. Results. In the 6 month follow-up, the CORE group returned to work 6.6 days (standard error = 8.9) quicker than the control group, a difference that w as not statistically significant. However, the CORE group showed a sustaine d improvement in pain and functional status with two fold differences at th e end of the 6 months of follow- up. This represented nine points on the Os westry scale (P=0.02) and 12 points on the Quebec Back Pain Disability Scal e (P=0.01). The CORE group also used three times less specialized imaging t ests of the spine at 3 months (P<0.01) and exercised twice as much at 6 mon ths (P<0.05) than the controls. Conclusions. The therapeutic results for workers with low-back pain could b e improved by implementing the clinical practice guidelines with primary ca re physicians in a large community, without delaying the return to work. Th e CORE intervention for hack pain patients is highly relevant to primary ca re practice. It is simple in its application, flexible to accommodate physi cians' and patients' preferences in health care, and it is effective on pat ients' clinical outcome.