Treatment-Based Classification versus Usual Care for Management of Low Back Pain

Rationale: This award will provide CPT (P) Rhon with a very successful orthopaedic research experience. The mentorship team he has assembled has collectively published over 200 manuscripts in orthopaedic-related medical research. The plan that has been established includes promoting independence with publishing protocols, submitting abstracts to present research at related national and international medical conferences, attending research development conferences, becoming a reviewer for orthopaedic and rehabilitation journals, and substantial one-on-one time with three well-accomplished leaders/mentors who are currently at the forefront of national and international orthopaedic rehabiliation research.

Of the 11 million workdays lost each year by members of the U.S. Armed Forces, low back pain (LBP) is the most common contributor. LBP is also a significant problem during war as it is the number one cause for medical evacuations out of Iraq and Afghanistan. The stress and strain of war add to the prevalence of LBP and make it one of the largest causes of attrition in Soldiers in combat. As few as 2% of all Service Members that are evacuated for LBP ever go back to their combat units. Understanding effective interventions to manage this condition and decrease the associated healthcare burden should be a top priority in military healthcare.

This proposed research project will compare the effectiveness and subsequent healthcare use associated with early physical therapy access compared with a stepped care approach. Active duty Soldiers with a recent onset LBP will be randomized into one of two groups. One group will be managed with stepped 'usual care' approach, and the other with early implementation of a Treatment Based Classification (TC) algorithm within physical therapy. Outcomes will include measures of disability, pain, patient satisfaction, and direct medical costs for care out to 1 year. This study will permit an examination of the impact of translating preliminary evidence supporting the use of TBC into clinical practice by comparing the effectiveness of the approach to a usual stepped care approach. The overall hypothesis guiding the study is that the additional initial treatment expense incurred by early implementation will result in superior short-term clinical effectiveness, and will be more cost-effective in the long-term due to reduced healthcare utilization. If found to be effective, the application of this would be significant across the entire military healthcare system. It could potentially benefit all of our deployed Service Members with a promise for significant impact on what is currently the highest cause for attrition in combat.

A significant amount of medical literature is emerging proving the effectiveness of a TBC approach for managing LBP. No research has validated this in a military population dealing with combat-related LBP. Additionally, more research is needed to determine if this is more effective than the standard 'usual care' approach commonly used.

The research project described in this proposal seeks to address this important military healthcare problem by providing evidence regarding effective treatment as well as cost-effective management strategies for patients with LBP at the typical point of entry into the healthcare system, primary care. Additional evidence is needed to determine if early access to a physical therapy regimen using a TBC is more effective than a 'usual care' stepped approach. This could provide significant insight into how to best manage our Service Members with combat-related low back pain and potentially establish a baseline from which to study further parameters in the future.