Implementation of a Self-Management Approach for Low Back Pain in a Public Health Care System

Importance: Self-management is recommended first-line care for chronic low back pain (CLBP). However, implementation of structured self-management models in large public health maintenance organizations (HMO) remains scarce. Objective: To determine the feasibility of implementing the enhanced transtheoretical model intervention (ETMI) in a public HMO in Israel and to compare outcomes of patients who received ETMI-guided vs usual physiotherapy care. Design, Setting, and Participants: In this cohort study, all physiotherapists in 13 outpatient physiotherapy clinics in a public HMO were trained in ETMI in 2022. Data were extracted for all eligible patients aged 18 years and older with CLBP who attended an associated physiotherapy center between January 1, 2022, and July 31, 2023. Exposure: ETMI is a self-management approach focused on reassurance, addressing unhelpful beliefs, and encouraging recreational physical activity, delivered without passive treatments or prescribed exercises. ETMI trains physiotherapists to guide patients in managing their pain independently, helping them avoid future reliance on medical services, medication, or imaging when pain recurs. Main Outcomes and Measures: Implementation outcomes were reach (physiotherapist uptake of ETMI), adoption (number of patients who received ETMI), and fidelity. Clinical outcomes were patient-reported function (0-100), pain (0-10) and fear-avoidance beliefs (0-100), assessed at baseline and discharge. Results: A total of 128 physiotherapists (mean [SD] age, 37.5 [9.3] years; 63 [49.2%] female) were invited to attend ETMI training, 109 (85.1%) attended, and 70 (64.0%) delivered the intervention at least once. Fidelity to ETMI-guided care was good. Of 4193 patients (mean [SD] age, 56.3 [16.7] years; 2454 [58.5%] female), 711 (17.0%) received ETMI-guided care. A total of 1624 patients (39.0%) had complete data and were included in the analysis. Compared with usual care, ETMI was associated with greater improvement in function scores (mean [SD] change, 12.0 [13.7] vs 15.7 [14.1]; adjusted mean difference (aMD), 3.3; 95% CI, 1.5 to 5.1), and fear-avoidance scores (-4.4 [22.7] vs -8.9 [23.8]; aMD, -4.3; 95% CI, -1.7 to -7.0) with no differences observed for pain scores (-1.7 [2.4] vs -2.0 [2.4]; aMD, -0.0; 95% CI, -0.3 to 0.3). ETMI patients had fewer sessions (mean [SD], 5.0 [4.2] vs 6.3 [4.5]; aMD, 1.3; 95% CI, 0.6 to 1.8; P <.001). Conclusions and Relevance: In this cohort study, the implementation of ETMI was feasible and associated with better patient outcomes in fewer treatment sessions than usual care, although its reach was limited.