Rapid Stratified Telehealth and usual care protocol
| Treatment group and subgroup | Intervention protocol |
| Rapid Stratified Telehealth | |
| Low risk of persistent pain (Keele STarT MSK tool score 0–4) | Participants will receive a telephone call by a Rheumatology Advanced trainee. Participants without suspected serious spinal pathology or potential radiculopathy (score of 3 or more on a clinician-developed screening questionnaire; online supplemental file 3) will be told their condition does not warrant further formal treatment as they have a good prognosis and their pain will likely resolve on its own. They will be encouraged to gradually increase their daily walking (or other activities) as pain permits, temporarily modify their activities to manage their symptoms, take a regular dose of paracetamol if required, and receive written educational material on LBP from the Agency for Clinical Innovation (https://bit.ly/3iGfGrX). Participants will be instructed to call back if their condition does not improve over the next 6 weeks. |
| Medium risk of persistent pain (Keele STarT MSK tool score 5–8) | Participants will receive a telephone call by a rheumatology advanced trainee. Participants without suspected serious spinal pathology or potential radiculopathy (score of 3 or more on a clinician-developed screening questionnaire) will be offered telehealth physiotherapy. The number of telehealth consultations will be determined by the physiotherapist (maximum of 12 over 6 months). The type of physiotherapy provided will include advice and education to support self-management (eg, advice to exercise, modify activities, lose weight or take simple pain medications if needed), and may include an exercise programme delivered via an App (PhysiTrack). PhysiTrack has over 5000 physiotherapy exercises and over 1000 specific to LBP. The physiotherapist will tailor the exercise programme to participants’ activity goals and level of function and be free to select any type and dosage of exercise. Exercise progression will be at the discretion of the treating physiotherapist. The physiotherapist will have the option to print out the exercises if the participant is not comfortable using the app. All physiotherapists in the trial have completed online training modules developed by the Sydney Local Health District and Agency for Clinical Innovation to facilitate the use of the PhysiTrack App. |
| High risk of persistent pain (Keele STarT MSK tool score 9–12) | Participants will receive a telephone call by a rheumatology advanced trainee. Participants without suspected serious spinal pathology or potential radiculopathy (score of 3 or more on a clinician-developed screening questionnaire) will be offered telehealth physiotherapy. The number of telehealth consultations will be determined by the physiotherapist (maximum of 12 over 6 months). The physiotherapist will provide advice and education to support self-management (eg, advice to exercise, modify activities, lose weight or take simple pain medications if needed), and may provide interventions to address psychological barriers to recovery (eg, pacing, graded exposure), and an App-based exercise programme (PhysiTrack; as described for participants at medium risk of persistent pain). The physiotherapist will direct participants to complete an online self-directed pain education programme developed by the Agency for Clinical Innovation. The programme (Pain Management: For Everyone https://www.aci.health.nsw.gov.au/chronic-pain/for-everyone) is publicly available and includes seven modules: (1) Introduction to pain (6:47 min); (2) Getting help from your healthcare team (5:56 min); (3) Pain and physical activity (12:43 min); (4) Pain: Lifestyle and nutrition (8:41 min); (5) Pain and role of medications (9:57 min); (6) Pain and thoughts (10:27 min); (7) Pain and sleep (11:08 min). Participants will be encouraged to go through the programme at their own pace and bring any questions to their next consultation. Participants in this subgroup can be referred to see a psychologist if the Rheumatology Advanced trainee and physiotherapist agree it would be valuable. |
| Potential radiculopathy (score of 3 or more on a clinician-developed screening questionnaire; see online supplemental file 3) | Participants will receive a telephone call by a rheumatology advanced trainee. Participants without suspected serious spinal pathology but with potential radiculopathy (score of 3 or more on a clinician-developed screening questionnaire) will be prioritised for a face-to-face consultation with a rheumatologist in the LBP Clinic. The rheumatologist will take participants’ medical history (including past history), conduct a physical and neurological examination, review any previously undertaken investigations (eg, imaging, pathology tests), formulate a management plan, and monitor progress. The number of face-to-face consultations will be determined by the rheumatologist (maximum of 4 over 6 months). If necessary, the rheumatologist will refer participants to receive a course of face-to-face physiotherapy. The type of physiotherapy provided will include any advice and education to support self-management (eg, advice to exercise, modify activities, lose weight, or take simple pain medications if needed), and may include a combination of any type and dosage of exercise tailored to patients’ activity goals and level of function, graded activity, graded exposure, and spinal manipulative therapy. The treating physiotherapist will ensure that participants at high-risk of persistent pain receive interventions to address psychological barriers to recovery (eg, pacing) and are referred to see a psychologist if necessary. The number of face-to-face physiotherapy consultations will be determined by the physiotherapist (maximum of 12 over 6 months). |
| All participants | Rheumatology advanced trainees and physiotherapists will be able to overrule the stratified care matched treatment protocol if they feel doing so is clearly needed (eg, not improving, dissatisfaction with care, poor health literacy). Participants can also be referred to a specialised pain clinic if the treating clinicians agree participants are not improving and physiotherapy treatment is no longer beneficial. |
| Usual care | |
| All participants | Participants will join the waiting list to receive a face-to-face appointment with a rheumatologist in the LBP Clinic. The rheumatologist will take patients’ medical history (including past history), conduct a physical and neurological examination, review any previously undertaken investigations (eg, imaging, pathology tests), formulate a management plan, and monitor progress. The number of face-to-face consultations will be determined by the rheumatologist (maximum of 4 over 6 months). If necessary, the rheumatologist will refer patients to receive a course of face-to-face physiotherapy as typically provided in Sydney government hospitals. The type of physiotherapy provided will include any advice and education to support self-management (eg, advice to exercise, modify activities, lose weight, or take simple pain medications if needed), and may include a combination of any type and dosage of exercise tailored to patients’ activity goals and level of function, graded activity, graded exposure, and spinal manipulative therapy. The number of face-to-face consultations will be determined by the physiotherapist (maximum of 12 over 6 months). Participants can be referred to a specialised pain clinic or to see a psychologist if the treating clinicians agree it would be valuable. |
LBP, low back pain.