Improving Health for Patients With Chronic Low Back Pain in Rural Communities Through Telerehabilitation
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: Standardized Education, Telerehabilitation.
- Who it may be relevant to
- Registry conditions: Chronic Low-back Pain. Basic parameters: from 18 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- United States
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
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Official title
ARBOR Telehealth: Improving Health for Patients With Chronic Low Back Pain in Rural Communities Through Improved Access to Telerehabilitation
Overview
Physical therapy is the first line of treatment for patients with low back pain (LBP) and has been shown to be a cost-effective method for improving pain and disability in patients with chronic LBP; however, despite this effectiveness, only 7-13% of patients go on to receive physical therapy services with patients in rural communities being especially limited to do lack of provider availability, transportation, and missed work time leading to greater rates of LBP-related disability and opioid consumption. With the rapid emergence of digital treatment approaches to physical therapy (i.e., telerehabilitation), access could be improved by reducing or eliminating many barriers that patients report; however, it is unclear how to appropriately incorporate digital treatment approaches into existing health care models. The investigators propose a prospective randomized clinical trial conducted at a health system serving rural communities to determine the effectiveness of innovative risk-informed telerehabilitation versus standard educational control for patients with chronic LBP that will match individual patients with specific physical therapy delivery (physical therapy telehealth visits or psychologically informed physical therapy telehealth visits) based on the patient's psychosocial risk of poor outcomes.
Detailed description
Chronic low back pain (LBP) imposes tremendous burden on affected individuals, healthcare systems, and society. LBP has been identified as the most common cause of disability globally and in the United States (US). LBP is also the largest driver of US healthcare spending ($135 billion in 2016) and the most common diagnoses associated with opioid prescription and consumption. For patients with chronic LBP, physical therapy has been shown to be a cost-effective method for improving pain and disability. In addition, physical therapy has been shown to decrease the risk of advanced imaging, injections, surgery, and opioid use in patients with chronic LBP.
Despite available evidence in support, only 7-13% of patients with LBP, including those with chronic LBP, go on to receive physical therapy services, with patients reporting barriers accessing physical therapy, such as transportation, provider availability and missed work time. Access is especially limited in rural communities where there are approximately 40% fewer physical therapists available per capita compared to metropolitan regions. In addition, patients living in rural communities likely need to travel longer distances to receive physical therapy, requiring additional missed work time and transportation costs. This lack of access to physical therapy in rural communities likely contributes to the greater rates of LBP-related disability and opioid consumption that have been observed in rural communities compared to metropolitan areas. Innovative methods for improving access to physical therapy are urgently needed to address disparities in outcomes for patients with chronic LBP living in rural communities in the US. Telehealth has rapidly expanded during the COVID-19 pandemic. This includes policy changes that have allowed physical therapists to begin providing care remotely, also referred to as telerehabilitation. Telerehabilitation stands to improve access to physical therapy for patients with chronic LBP living in rural communities and may serve as a means of improving outcomes of these patients.
The investigators will conduct a prospective randomized clinical trial addressing key questions to understanding the effectiveness of a risk-informed telerehabilitation to reduce opioid use and LBP-related disability and to improve physical function and health-related quality of life (HRQoL) in patients with chronic LBP. Additionally, the investigators will explore implementation outcomes using a mixed methods approach consisting of electronic surveys and semi-structured interviews with patients, physical therapists, practice managers, and outpatient services administration focusing on perceived quality and impact on barriers to care. The investigators will enroll 434 patients with LBP presenting to primary care clinics serving rural communities (TidalHealth, Salisbury, MD). Eligible patients will provide informed consent and be randomized to either web-based standardized education or risk-informed telerehabilitation (physical therapy telehealth visits, or informed physical therapy telehealth visits). Primary effectiveness outcome is difference in change in LBP-related disability (Oswestry Disability Index) and in opioid use after 8 weeks of treatment.
Interventions
- Behavioral Standardized Education
Patients randomized to the standardized education group will receive registered access to a study website with access to evidence-based education for patients with chronic LBP. Each participant will have unique login credentials to allow for tracking of individual patient use. The website will include important education on the etiology of chronic LBP and evidence-based suggestions for self-management of symptoms. Education will focus on the importance of maintaining healthy levels of physical a - Behavioral Telerehabilitation
Based on prior SBTS risk stratification, participants in the risk-informed telerehabilitation group will receive subsequent care using an evidence-based treatment protocol designed for video visits to be informed by a participant's baseline risk score with elements ranging from standard physical therapy telehealth visits (low-to-medium risk) to PIPT telehealth visits (high-risk).
Primary outcome measures
- Change in Oswestry Disability Index [Time frame: Change from baseline to 12 weeks after treatment initiation]
- Participants with Opioid Use [Time frame: Post treatment initiation 12 weeks]
Secondary outcome measures (12)
- Change in Patient-Reported Outcomes Measurement Information System (PROMIS-29) Physical Function [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in Patient-Reported Outcomes Measurement Information System (PROMIS-29) Physical Function by Biological Sex [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in Patient-Reported Outcomes Measurement Information System (PROMIS-29) Physical Function by Age Group [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in Patient-Reported Outcomes Measurement Information System (PROMIS-29) Physical Function by Baseline Opioid Use [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in PROMIS Preference Score (PROPr) [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in PROMIS Preference Score (PROPr) by Biological Sex [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in PROMIS Preference Score (PROPr) by Age Group [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Change in PROMIS Preference Score (PROPr) by Baseline Opioid Use [Time frame: Change from baseline to 26- and 52-weeks after treatment initiation]
- Percent of participants using non-opioid LBP-Related Healthcare Use [Time frame: 26- and 52-weeks after treatment initiation]
- Percent of participants using non-opioid LBP-Related Healthcare Use by Biological Sex [Time frame: 26- and 52-weeks after treatment initiation]
- Percent of participants using non-opioid LBP-Related Healthcare Use by Age Group [Time frame: 26- and 52-weeks after treatment initiation]
- Percent of participants using non-opioid LBP-Related Healthcare Use by Baseline Opioid Use [Time frame: 26- and 52-weeks after treatment initiation]
Eligibility criteria
Inclusion criteria
- Primary care visit in the past 90 days with an LBP-related International Classification of Diseases (ICD-10) diagnosis.
- Age 18 years or older.
- At least moderate levels of pain and disability requiring Oswestry score ≥24% and average pain rating ≥ 4/10 points.
- Meets NIH Task Force definition of chronic LBP based on two questions: 1) How long has LBP has been an ongoing problem? and 2) How often has LBP been an ongoing problem over the past 6 months? A response of greater than 3 months to question 1, and "at least half the days in the past 6 months" to question 2 is required to satisfy the NIH definition of chronic LBP.
- Can speak and understand English.
- Access to video-enabled device and Internet.
Exclusion criteria
- Recent history (last 6 months) of lumbar spine surgery.
- Possible non-musculoskeletal cause for low back pain symptoms (e.g., pregnancy).
- Evidence of serious pathology as a cause of LBP including neoplasm, inflammatory disease (e.g., ankylosing spondylitis), vertebral osteomyelitis, etc.
- Neurological disorder resulting in severe movement disorder, or schizophrenia or other psychotic disorder.
- Knowingly pregnant.
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Open label
- Primary purpose
- Treatment
Study locations
United States · 2 centers
- Johns Hopkins University School of Medicine — Baltimore
- Tidalhealth — Salisbury
Publications
- Skolasky RL, Colantuoni E, Wegener ST, Ali KJ, McLaughlin KH. ARBOR-Telehealth study: an examination of telerehabilitation to improve function and reduce opioid use in persons with chronic low back pain in rural communities - protocol of a pragmatic, individually randomised group treatment trial. BMJ Open. 2025 Jun 10;15(6):e102773. doi: 10.1136/bmjopen-2025-102773. PMID 40499966
Identifiers
NCT: NCT06471920 · IRB00437961 · UG3AR083838