Effects of musculoskeletal expert input on low back pain outcomes: A randomised controlled trial

BACKGROUND: Overuse of low-value interventions and delays in accessing appropriate care contribute to the growing burden of low back pain (LBP). Integrating musculoskeletal health experts into care pathways may represent a pragmatic strategy to improve access, referral appropriateness, and efficiency of spine care delivery. PURPOSE: This study evaluated the effects of an evidence-based triage assessment performed by chiropractors on clinical outcomes and care trajectories of patients with LBP referred for a neurosurgical consultation. We hypothesised that the intervention would produce equivalent clinical outcomes while improving care trajectories. STUDY DESIGN: Single-center, parallel-group randomised controlled trial. OUTCOME MEASURES: Patient reported measures were collected at 1 week, 3, 6 and 12 months, including back pain intensity (primary outcome), leg pain intensity, LBP-related disability, quality-of-life, perception of change, and care trajectories. METHODS: One hundred and one adults with LBP were randomized to the intervention (n = 52) or control group (n = 49). All participants underwent a standardized chiropractor-led triage evaluation prior to the neurosurgical consultation. In the intervention group, the chiropractor's assessment findings and recommendations were communicated to the neurosurgeon before the consultation, whereas they were not shared for the control group. Equivalence for the primary outcome (back pain intensity) was assessed at the 3-month primary endpoint using the two one-sided tests procedure. Repeated-measures ANOVAs examined changes in patient-reported clinical outcomes (i.e., back pain and leg pain intensity, LBP-related disability, quality of life and perception of change), while mixed-effects regression models were used to compared care trajectories outcomes between groups. RESULTS: Although equivalence was not statistically demonstrated as the confidence interval extended beyond the predefined equivalence margins of ± 1.2 points on the NRS-11, between-group differences in back pain intensity remained small and not clinically meaningful (0.44 ± 0.54 [95% CI -1.51-0.63]). No significant between-group differences were observed across clinical or care trajectories outcomes, except that, fewer participants in the intervention group reported consulting a general practitioner at 6 months (49.0% vs. 69.2%; p = 0.04). CONCLUSION: These findings suggest that integrating chiropractors into the triage of LBP referrals does not adversely affect clinical outcomes and may influence care trajectories. Although most care trajectory outcomes were similar between groups, participants in the intervention group reported fewer general practitioner consultations at 6 months. Future research should investigate triage strategies implemented in primary care settings, where their potential to optimize patient trajectories may be greater.