Elsevier

Physiotherapy

Volume 109, December 2020, Pages 4-12
Physiotherapy

Evaluation of the implementation of the Back Skills Training (BeST) programme using online training: a cohort implementation study

https://doi.org/10.1016/j.physio.2020.07.003Get rights and content

Abstract

Objectives

1) Evaluate implementation of the Back Skills Training (BeST) programme, a group cognitive behavioural approach for patients with low back pain (LBP) developed for a clinical trial, into the National Health Service (NHS) in the United Kingdom; 2) Compare patient outcomes with the BeST Trial results.

Design

Two stage observational cohort implementation study.

Participants

Stage 1: NHS Clinicians enrolled in BeST online training. Stage 2: Patients with LBP attending NHS physiotherapy departments and enrolled in the BeST programme.

Intervention

An online training and implementation programme.

Outcomes

Stage 1: LBP attitudes and beliefs, self-rated competence, intention and actual implementation were collected before, immediately, 4- and 12-months post-training. Stage 2: Patients rated pain, function, recovery and satisfaction before and up to one year after attending the BeST programme.

Results

Stage 1: 1324 clinicians (157 NHS Trusts) enrolled in the training; 586 (44%) clinicians (101 NHS Trusts) completed training; 443/586 (76%) clinicians provided post-training data; 253/443 (57%) clinicians intended to implement the programme; 148/381 (39%) clinicians (54 NHS Trusts) provided follow-up data; 49/148 (33.1%) clinicians (27 NHS Trusts) implemented the programme. Attitudes and beliefs shifted towards a biopsychosocial model post-training. Stage 2: 923 patients were enrolled. Patients reported improvements in function (mean change: 1.55; 95%CI: 1.25, 1.86) and pain (−0.84; −1.1, −0.58) at follow-up. The majority rated themselves improved and satisfied with the programme.

Conclusion

Online training had good reach into NHS Trusts although, not everyone went onto implement the programme. Improvements in function that were consistent with the original trial were demonstrated.

Introduction

Low back pain (LBP) is the largest cause of disability in the United Kingdom (UK), with direct costs per annum of around £2.8 billion [1], [2]. The Back Skills Training (BeST) programme, a cognitive behavioural approach (CBA) for LBP, was effective in reducing pain and disability in a large randomised controlled trial [3], [4]. This group intervention was highly cost-effective at current levels of willingness to pay [3]. Participants attend an individual session (60 minutes) followed by six group sessions (90 minutes each). Topics include pain education, overcoming unhelpful thoughts and behaviours, goal setting, baseline setting, pacing, and the role of exercise [5]. Participants undertake a collaboratively set home exercise programme. Other high-quality trials using similar interventions have added to a body of evidence [6], [7], [8] leading to guidelines recommending such combined physical and psychological interventions [9], [10], [11].

Moving an intervention from research into clinical practice is challenging [12], [13]. In the BeST trial, clinicians received two-days of training from the research team. This is not feasible or sustainable for widespread implementation. Hence, online training was chosen as a viable training option. The theory of constructivism underpinned the organisation of the online training [14], [15]. The Grol and Wensing Implementation of Change Model underpinned the implementation processes [16]. These are described in detail in the successive qualitative and quantitative studies which were undertaken to evaluate and refine the training [17], [18], [19]. The enhanced training was launched in the UK in March 2016.

The aim of the study was to evaluate the effectiveness of the enhanced online training programme as an implementation strategy for BeST in the National Health Service (NHS) in a large cohort of NHS Trust hospitals who had no prior experience of delivering the programme. The objectives were (i) to measure the effect of the online training on learning outcomes for clinicians who completed the training (stage 1), (ii) to estimate the treatment outcomes for patients who received the BeST intervention from clinicians who completed the online training and to compare the patient outcomes to the results of the BeST trial (stage 2). This study also informed the final improvements to the training before making it widely available.

Section snippets

Design

A two-stage observational cohort implementation study.

Recruitment

Clinicians (e.g. physiotherapists, nurses, occupational therapists, psychologists) working with patients with LBP in UK NHS Trusts were eligible for stage 1. No other eligibility criteria were applied. An advertising strategy was used to raise awareness and invite clinicians to enrol in the training including academic publications, articles in professional practice journals [20], advertisements, social media, conference trade stands and

Stage 1

Stage 1 was undertaken between March 2016 and August 2018. A total of 1324 clinicians from 157 NHS trusts enrolled on the training, of which 586 clinicians (44%) from 101 NHS trusts completed the training (Fig. 1). The median number of therapists who enrolled and completed training in each trust was 3 (IQR: 2.8, range: 1–73) and 1 (SD: 0–3, range: 0–40) respectively. Of the training completers, 474/586 (81%) from 88 NHS trusts completed the post-training questionnaire. However, data was only

Discussion

This study evaluated the translation of an evidence-based [3], [4] group CBA for people with persistent LBP into routine care. To aid implementation, an online training was developed to train clinicians to deliver the BeST programme. The use of web based training is increasing [34] and the study demonstrated that clinicians can be trained to deliver a CBA using online training. A relatively high number of NHS clinicians were attracted to the training with a simple marketing strategy, and our

Conclusion

Online training is a feasible and sustainable method of training clinicians to deliver a cognitive behavioural approach for patients with LBP. The training had good reach into NHS Trusts using a simple marketing campaign, although not everyone trained implemented the programme. Worthwhile improvements in function that were consistent with the BeST trial were demonstrated and satisfaction levels were high amongst patients. The online training is now available globally to enable wider

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