Low back pain is a condition amenable to conservative, movement-based care led by physiotherapists, yet it continues to be one of the most common and costly reasons Australians present to emergency departments (EDs).

At APASC25 in Adelaide last October, physiotherapist and researcher Dr Chathurani Sigera, presenting on behalf of a research
team from the University of Sydney, the Institute for Musculoskeletal Health and the Sydney Local Health District, discussed a review of the Back@Home program—a virtual hospital model of care designed to safely manage people with non-serious low back pain in their own homes.

Her presentation offered physiotherapists reassurance that evidence-based physiotherapy translates effectively into virtual care and challenged them to rethink the role of hospital admission and ED presentations in low back pain management.

‘We all know that most people don’t really need to stay in hospital but plenty still do,’ Chathurani told the audience during her presentation.

‘If you look closer, 57 per cent of these admissions would be avoidable because most of them have non-serious low back pain. This can be managed at home.’

In Australia, around 155,000 people present to EDs each year with low back pain and around one-third of them are admitted, Chathurani says. 

Each admission carries an average cost of around $15,000, placing a significant burden on the health system while also exposing the patient to the risk of hospital-acquired complications such as infection or falls.

The Back@Home model was proposed as a direct response to this mismatch between evidence and practice, Chathurani says.

Rather than defaulting to inpatient admission or a potential re-presentation to the ED when pain is severe or mobility is limited, the model asks a different question: can this person be supported to recover at home, with the right clinical oversight, education and reassurance? 

‘This model of care was proposed as a solution to reduce unnecessary admissions and ED re-presentations for low back pain.’

Developed within the Sydney Local Health District Virtual Hospital, Back@Home is a physiotherapy-led hospital service for people presenting to EDs with acute, non-serious low back pain. 

Patients aged 16 to 70 are eligible if they are assessed in ED or by rheumatology, diagnosed with non-serious back pain and deemed safe to discharge home with virtual support.

Patients are excluded if they have serious pathology, are pregnant, have recently had spinal or abdominal surgery or have issues beyond the lumbar spine, as are patients who prefer traditional outpatient care or decline virtual support.

Chathurani told the audience that once enrolled, patients receive coordinated care from a multidisciplinary team led by physiotherapists and supported by GPs, with rheumatology input as needed. 

The team includes senior physiotherapist Min Jiat Teng, who plays a key role in developing the service and delivering care.

Care is delivered through a combination of phone and video consultations, SMS check-ins and, where needed, home visits
by physiotherapists. 

Patients are prescribed tailored exercise programs via the Physitrack app, provided with educational resources in line with the Low Back Pain Clinical Care Standard and sent practical supports such as heat wraps to assist with pain management at home. 

‘We customise this specifically for our program.’

Chathurani notes that the program’s intention is not to simply replicate hospital care virtually but to deliver something better suited to recovery in a real-world environment. 

Importantly, Back@Home patients have access to 24/7 virtual hospital support, a feature that emerged as critical to patient confidence and safety.

The program, Chathurani says, did not evolve in isolation. Its development involved close collaboration between emergency medicine, rheumatology, physiotherapy, other allied health disciplines, consumer representatives and Aboriginal health leadership.

Prior to implementation, a team conducted 13 education sessions involving 238 clinicians to ensure that the referral pathway was understood and trusted. 

Dr Chathurani Sigera.

‘This model of care was developed while working through a low back pain working group, in collaboration with many professionals and consumers.’

To evaluate the program, the research team used a hybrid effectiveness-implementation type 1 study design. 

Implementation occurred between February and July 2023 across three EDs within the Sydney Local Health District, with outcomes examined before and after implementation over a broader time period. 

More than 18,000 episodes of care were included in the analysis, making this one of the largest evaluations of a virtual model of care for low back pain in Australia, Chathurani told delegates at the conference.

Service outcomes focused on admission rates, short-stay admissions and ED re-presentations within 30 days. 

Patient-reported outcomes were collected from a sub-sample of patients and included pain intensity, physical function and satisfaction with care. 

The findings, Chathurani says, challenged some assumptions while strongly supporting others.

Following the implementation of Back@Home, there was no change in overall admission rates. ‘It was not what we expected.’

However, one outcome was striking: ED re-presentations within 30 days were reduced by 41 per cent. 

For health services under increasing pressure, this reduction alone represents a substantial gain, she notes.

Patient-reported outcomes painted an equally compelling picture. 

Patients managed through the Back@Home virtual model reported similar satisfaction with care to those admitted to hospital, along with less pain and better physical function, Chathurani says. 

While the response rate for patient-reported outcomes was relatively low—a limitation Chathurani openly acknowledges—the findings aligned with contemporary evidence supporting early, active management of low back pain.

To better understand patient experiences, the team conducted 17 qualitative interviews with people who had participated in the program. 

Patients consistently described feeling safe, supported and reassured while recovering at home. 

‘Being able to recover in a familiar environment, while still receiving regular check-ins and care from the clinician team, was a positive experience for participants.’

Patients also valued the communication and continuity of care, often comparing it favourably to inpatient experiences. 

‘They really valued the communication and the support over the program compared to a stay in hospital. 

'It was clear that they were satisfied with the care they received.’

Clinical experience was explored through interviews with 19 staff involved in the program, including ED and Back@Home clinicians. 

Overall, clinicians viewed the model positively, particularly in relation to analgesia review and early physiotherapy input. 

One emergency doctor noted that ‘virtual next-day review, especially in regards to analgesia, is really beneficial for a lot of patients’, Chathurani says. 

Another observed that without access to virtual physiotherapy, consultations about pain management would have been significantly more difficult.

Challenges with the program were also outlined by Chathurani during her presentation at the conference. 

She says that technology barriers and patient apprehension about video consultations during periods of high pain levels were common, quoting one program doctor as saying that ‘the challenges are often with people with high levels of pain’. 

‘They’re a little bit apprehensive sometimes to do the video rather than the phone… without this, they’ll be bed resting.’ 

The insights highlighted the importance of flexibility, clinical judgement and strong communication skills in virtual physiotherapy practice, Chathurani says.

In concluding her presentation, Chathurani was measured but optimistic. 

‘Although the Back@Home virtual care model did not show any reduction in overall hospital admissions, it did reduce ED re-presentations. 

'Overall, the virtual model of care provides similar or better outcomes when compared to traditional hospital care.’

The program’s implications for physiotherapists are significant, Chathurani notes. 

Back@Home demonstrates that physiotherapy-led virtual models can safely manage acute low back pain, deliver outcomes comparable to hospital care and improve patient experience—all while reducing pressure on EDs. 

It also reinforces the profession’s central role in contemporary models of acute care, not just as providers of treatment but as leaders in service design, patient education and system-level change.

As health systems continue to grapple with rising demand and constrained resources, programs such as Back@ Home offer a compelling example of how physiotherapy expertise can be leveraged beyond the walls of the hospital. 

In doing so, Chathurani says they invite the profession to reimagine where care happens and how recovery from low back pain is best supported—at home, with the right care, at the right time.