Which Model of Care is the Most Cost-effective in the Treatment of Musculoskeletal Disorders?
Is a Stepped Model of Care Cost-effective Compared to Usual Care for Musculoskeletal Disorders? a Randomized Controlled Trial
Laval University
369 participants
Jan 31, 2025
INTERVENTIONAL
Conditions
Summary
As musculoskeletal disorders (MSKDs) reach epidemic proportions in Canada, access to the public health system for those who suffer from them is increasingly difficult. One of the main barriers is the delays to see a publicly funded health professional. New models of care must therefore be developed to ensure better access. We have previously shown that not all patients with a MSKD need to be closely followed by a health professional as for a large proportion of patients simply educating them is enough to resolve their MSKD. A stepped care model where education would be given first before deciding if patients need a more extensive follow-up should be explored. This project will compare the effectiveness of a Stepped Care Model to that of the two most widely used models of care: Usual Medical Care and Usual Rehabilitation Care. We think that a Stepped Care Model will be as effective to reduce functional limitations, but will lead to lower healthcare costs. Adults (n=369) with a MSKD will be randomly assigned to one of the intervention groups: Stepped Care, Usual Medical Care (physician-led intervention: e.g., advice/education, pharmacological pain management), or Usual Rehabilitation Care (physiotherapist-led intervention: e.g., advice/education, exercises). Participants in the Stepped Care Group will take part in two education sessions during the first 6 weeks. After 6 weeks, those who still have clinically important symptoms will receive follow-up rehabilitation interventions, while those who don't will be considered recovered and will have no further intervention. Primary (functional limitations) and secondary (e.g., pain, quality of life) outcomes will be assessed at baseline, and at 6, 12 and 24 weeks, and costs estimate will be established for each model of care. Knowing the urgent need for an overhaul of services to reduce wait times, the Stepped Care Model proposed could be a solution to improve access to health services without compromising quality of care.
Eligibility
Inclusion Criteria6
- present with one of the four targeted MSKDs (low back pain, neck pain, anterior knee pain, rotator cuff-related shoulder pain).
- have had pain for at least 6 weeks.
- For low back pain (LBP): 1) non-specific LBP with or without radiation to the lower limbs, 2) minimal score of 15 on the ODI.
- For neck pain : 1) non-specific neck pain with or without radiation to the upper limbs, 2) minimal score of 21 on the NDI.
- For anterior knee pain : 1) anterior knee pain during walking, running or going up or down stairs, or during at least two activities among: kneeling, squatting, and resisted knee extension, 2) maximum score of 79 on the KOS-ADL.
- For rotator cuff-related shoulder pain : 1) minimal score of 15 on the QuickDASH, and 2) shoulder pain attributed to a rotator cuff-related shoulder pain using diagnostic guidelines of the British Elbow and Shoulder Society.
Exclusion Criteria11
- Unavailable to participate during the 24 weeks of the study.
- Do not understand French or English.
- Diagnosis of rheumatoid, inflammatory or neurodegenerative diseases.
- Received a corticosteroid injection in the previous 3 months.
- Cognitive problems interfering (Mini-Mental State Examination ≥ 24).
- Received a corticosteroid injection in the previous 3 months.
- Less than 6 weeks since an intervention for their condition (including performing prescribed condition-specific exercises or taking prescribed medication).
- For low back pain (LBP): 1) LBP related to specific conditions (e.g., vertebral fracture, infections, neuropathic pain \[\>4 at the DN4 questionnaire\]), 2) history of spine surgery or signs of upper motor neuron lesions (bilateral paresthesia, hyperreflexia or spasticity)..
- For neck pain : 1) neck pain related to specific conditions (e.g.; vertebral fracture, infections, neuropathic pain \[\>4 at the DN4 questionnaire\]), 2) history of spine surgery or signs of upper motor neuron lesions.
- For anterior knee pain : 1) history of knee surgery or patellar dislocation, 2) pain believed to originate either from meniscus or from any knee ligament.
- For rotator cuff-related shoulder pain : 1) history of shoulder surgery, dislocations, fractures or capsulitis, 2) full thickness rotator cuff tear identified by imagery or clinical tests (lag signs and gross weakness).
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Interventions
During the first education session, participants will be provided with information pertaining to painful area, basic pain science, injury specific advice on load management, pain and activity management, lifestyle factors and physical activity. A general physical activity will be recommended (150-300 minutes of moderate-intensity activity per week). Then, participants will be directed to a website developed by the research team and patient partners. The website includes explanations of the various topics discussed during the session , explanatory videos, and summarized information. During the second educational session, the participant's condition will be reviewed, and their understanding of the topics covered in the first session and on the website will be assessed. A follow-up on the website will also be conducted. The physiotherapist will then answer the participant's questions and provide personalized advice based on their condition, along with long-term recommendations.
The pragmatic rehabilitation program will include exercises aimed at improving strength, endurance, flexibility, capacity to sustain mechanical load and dynamic control. Manual therapy may be provided during the sessions, based on pragmatic clinical decision-making. Participants will also receive information pertaining to the painful area and advice on pain and load management, and on activity modification, integrated across the sessions.
The pragmatic medical intervention may include pharmacological management, education, physiotherapy referral or referral to a specialist as deemed necessary.
Locations(1)
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NCT06832852