Physical Therapy Management of Low Back Pain: An
Exploratory Survey of Therapist Approaches
Abstract
Background and Purpose. Since the release of acute low back pain management guidelines in 1994, little was known about the effect of these guidelines on clinical practice. The purpose of this study was to examine physical therapists' reported management of acute and subacute lumbar impairment. Subjects. One in 10 registered physical therapists who were randomly selected from southern Ontario, Canada, (n=454) and all registered physical therapists from northern Ontario (n=331) were surveyed. Methods. In the questionnaire, case scenarios covered 3 areas related to the management of lumbar impairment: (1) physical examination, (2) treatment and recommendations, and (3) therapists' beliefs regarding its management. Results. Five hundred sixty-nine questionnaires were returned (response rate=72.5%). Only data obtained for therapists (n=274) whose weekly workload included more than 10% of people with lumbar impairment were used in the analysis. Overall, patient education, exercise, and electrotherapeutic and thermal modalities were the preferred interventions for acute lumbar impairment (symptom onset of less than 5 weeks) with or without sciatica, whereas exercise and work modification were preferred for subacute lumbar impairment (symptom onset of 5 weeks or longer). There was a trend of using electrotherapeutic and thermal modalities of uncertain effectiveness. Only 46.3% of the therapists agreed or strongly agreed that practice guidelines were useful for managing lumbar impairment. Discussion and Conclusion. Although the physical therapists surveyed, in general, followed the guidelines in managing acute lumbar impairment, they felt uncertain regarding the value of practice guidelines. Future research should focus on identifying effective treatment approaches and exploring the effectiveness of practice guidelines.
In light of the poor consensus regarding the management of lumbar impairment by clinicians, guidelines have been developed to provide a template for more effective clinical practice. The work of the Quebec Task Force on Spinal Disorders1was updated by multidisciplinary panels in the United States,2 the United Kingdom,3 and New Zealand.4 The US guidelines, which were sponsored by the Agency for Health Care Policy and Research (AHCPR) (now called the Agency for Healthcare Research and Quality [AHRQ]), were released in 1994 based on what the panel considered the best evidence available on the management of acute low back pain (LBP) in adults.2 These guidelines recommended a number of assessment techniques to rule out “red flags,” including cauda equina, inflammatory diseases, fracture, cancer, and infection. In the absence of such “red flags,” according to the guidelines, nonsteroidal anti-inflammatory drugs could be used for pain control. Spinal manipulation was also recommended for the first 4 weeks of symptoms. Activity modification might be required during the acute phase; however, the guidelines advised against bed rest for more than 4 days. The guidelines recommend starting low-impact aerobic activities in the first 2 weeks, and abdominal conditioning exercises could be delayed at least 2 weeks after the onset of symptoms. In addition, the guidelines recommended that patients should be educated on safe and effective methods for symptom management and the means to limit recurrent low back problems.2 Shortly after the release of the guidelines, the Canadian Physiotherapy Association disseminated the information among physical therapists.5 Little is known, however, about how these guidelines affect clinical practice.
The dearth of reliable data on the practice of physical therapists has limited the profession's ability to contribute to policy debates and to assess the impact of regulatory restriction. These concerns prompted our endeavor to study therapists' practice patterns in managing lumbar impairment. Our objective was to document Ontario physical therapists' reported management of acute and subacute lumbar impairment using hypothetical cases. In this study, acute lumbar impairment was defined as the onset of symptoms that last less than 5 weeks, and subacute lumbar impairment was defined as the onset of symptoms that last 5 weeks or longer. The findings will be compared with the recommendations from the AHCPR guidelines.
Method
Subjects
The study population consisted of all 4,892 physical therapists who were licensed to practice in Ontario, Canada, in 1998. A list of registered therapists was provided by the College of Physiotherapists of Ontario in January 1998. The therapists were stratified by region. Of the 4,561 therapists who practiced in southern Ontario, 454 were randomly selected for the survey. This number was based on the conservative estimation that 50% of therapists would use a specific assessment or treatment category (Appendix), a desired precision of 5%, with 95% confidence intervals and an estimated response rate of 78%.6–8 The entire physical therapist population of northern Ontario was surveyed due to the small size of that group (n=331).
Questionnaire Development
The questionnaire, patterned after one used to study Ontario physicians,9 covered 3 areas related to physical therapy management of lumbar impairment: (1) physical examination, (2) treatment and recommendations, and (3) therapists' beliefs regarding treatment of LBP. In order to allow for further analysis to compare findings of this study and the physician survey, the same case scenarios and questionnaire formats were used. Slight modifications were made to include choices of assessment and treatment techniques that were pertinent to physical therapy practice. The 3 case scenarios were: (1) a 28-year-old woman who had acute lumbar impairment with localized symptoms, (2) the same woman 5 weeks later with little change in pain and physical findings, and (3) a 35-year-old man with acute sciatica (Tab. 1). Associated with scenarios 1 and 3 was a list of assessment procedures and treatment modalities (Appendix), whereas only treatment options were provided in scenario 2. Therapists were asked whether they would or would not use a particular item to assess or treat the hypothetical patients. Open-ended questions were used to help determine the assessment and treatment modalities used that were not included in the list. In addition, therapists were asked their opinion on the effectiveness of 8 treatment modalities and on the management of lumbar impairment. The questionnaire was pretested for face and content validity with 9 physical therapists who were practicing in orthopedics and 1 therapist who had a research interest in survey development.
Mailing
A modified Dillman technique10,11 was used for mailing in order to elicit the fullest participation in this survey. Three mailings were conducted between September 8 and October 23, 1998. Each mailing was separated by 3 weeks. All participants received a package, including an information letter, a questionnaire booklet, and a stamped return envelope during the first mailing. A reminder letter was sent to the nonrespondents 3 weeks later; and the complete package was sent again during the third mailing. Those therapists in southern Ontario who had moved during the survey period were replaced.
Statistical Analysis
Only data obtained for those therapists who reported treating people with lumbar impairment for more than 10% of the caseload per week were included in the analysis, because our intent was to describe the practice of therapists who work with these patients on a regular basis. Descriptive analyses, based on frequency distributions and percentages, were used to describe the examinations and treatments used by physical therapists, as well as their beliefs regarding the management of lumbar impairment. Weighted frequencies were calculated for the entire sample based on the proportion of registered physical therapists who practiced in northern and southern Ontario. Although there were no prior studies suggesting regional discrepancies in physical therapy practice in orthopedic conditions, we thought some variations might exist due to differences in therapists' practice characteristics, such as caseload sizes, types of practice settings, and the number of practitioners working in each region. For this reason, the responses of those therapists from the more densely populated southern region of Ontario were compared with those from more rural northern Ontario. All nominal variables were examined using chi-square analysis, and continuous variables were examined using the Student t test.12 A conservative level of significance was used due to the multiple comparisons. An alpha level below .001 was considered statistically significant.
Results
Five hundred sixty-nine physical therapists returned survey questionnaires, yielding a response rate of 72.5%. Twenty-one therapists returned the questionnaires blank and were therefore excluded from the analysis. The reasons for refusal were: (1) the therapist was no longer practicing physical therapy (n=8), (2) retirement (n=5), (3) the therapist was working outside Ontario (n=2), and (4) not specified (n=6). Nine physical therapists in southern Ontario were replaced because their mailing addresses were invalid. In order to obtain information that was representative of therapists who treated patients with lumbar impairment on a regular basis, only those whose weekly caseload consisted of more than 10% of people with LBP were asked to complete the entire questionnaire. Thus, the responses from 274 therapists (48.2%) were included in the analysis.
Most of the eligible respondents practiced full-time (66.8%) and in a multidisciplinary setting (40.0%) (Tab. 2). A multidisciplinary setting was defined as a facility that offered services provided by physical therapists and other allied health care professionals, such as occupational therapists, kinesiologists, and social workers. The average length of time in practice was 14.7 years (SD=10.1), with therapists in southern Ontario practicing longer than their northern counterparts (P <.001). Ninety-three percent of the respondents had completed at least one postgraduate manual therapy course; however, only 8.8% of the respondents had completed a course on joint manipulation.
Table 2.
Demographic and Practice Characteristics of the Physical Therapists
Examination Preference
Associated with scenarios 1 (acute LBP) and 3 (acute sciatica) were questions regarding preferences of assessment techniques (Tab. 3). Almost all of the therapists from the weighted combined sample reported that they would perform back inspection or palpation (99.9%) and lumbar spine range of motion testing (99.3%). Seventy-eight percent stated that they would assess lower-extremity muscle weakness, and 57.5% stated that they would test sensation for the patient with localized symptoms. More than 86% reported that they would assess each of the 2 areas for the patient with sciatica. Most of the therapists stated they would administer the straight-leg-raising test (scenario 1, 89.5%; scenario 3, 97.9%) and reflex tests (scenario 1, 64.7%; scenario 3, 94.6%) for both patients. More than half of the therapists reported that they would use other examination procedures, including McKenzie assessment, lumbar spine scan, sacroiliac joint assessment, and lower-extremity scan. No statistically significant differences were found in assessment preferences between the regions of Ontario.
Table 3.
Reported Use of Physical Assessment Techniques by Ontario Physical Therapists for Low Back Pain (LBP)
Treatment Preference
Participants were asked to comment on the type of treatment they would prescribe for the patient in each of the 3 scenarios (Tabs. 4 and 5). When patients had acute LBP with or without sciatica, patient education (scenario 1, 99.0%; scenario 3, 99.2%) and exercise at home (scenario 1, 95.9%; scenario 3, 91.5%) and at the clinic (scenario 1, 83.9%; scenario 3, 80.6%) were the interventions most preferred by physical therapists. However, exercise at home (96.4%), exercise at the clinic (93.4%), and work modification (84.3%) were reported to be the major focus when managing lumbar impairment at 6 weeks.
Table 4.
Treatment Preference for Ontario Physical Therapists for the Three Low Back Pain (LBP) Scenarios
Table 5.
Comparison of Treatment Preference Between Physical Therapists Who Practiced in Northern and Southern Ontario
Spinal mobilization was preferred by 83.7% of the physical therapists for treating patients with subacute lumbar impairment. In contrast, the use of spinal manipulation was selected by less than 10% of the respondents for all 3 scenarios. More than 65% reported that they would use modalities ranging from ice or heat to magnetic therapy in their treatment, regardless of the nature of the patient's symptoms (Tab. 6). Only a small percentage of therapists indicated that they would recommend bed rest for patients with acute LBP (5.8%) or subacute LBP (1.5%) with localized symptoms, and 25.2% of the respondents reported that they would recommend bed rest when sciatica was present. For the latter scenario, 93.1% stated they would prescribe 1 to 4 days of bed rest. There were no statistically significant differences between regions in the choice of treatment (Tab. 5).
Beliefs Concerning Management of LBP
When therapists were asked to comment on the effectiveness of 8 treatment modalities, 81.9% and 65.7% agreed that ice and heat were effective for acute lumbar impairment, respectively (Tab. 7). However, a majority of the therapists also agreed that ultrasound (61.4%) and transcutaneous electrical nerve stimulation (TENS) (53.0%) were effective interventions, even though the practice guidelines suggest otherwise.2 Only 0.1% of the therapists agreed that bed rest should be prescribed to patients with lumbar impairment until pain subsides, and 97.7% agreed that physical activity is crucial in the recovery from lumbar impairment. Seventy-six percent of the therapists agreed that back education programs are effective in reducing recurrences of LBP. Most of the therapists (84.9%) indicated that they were comfortable managing patients with lumbar impairment. There were no regional differences in therapists' beliefs.
Table 7.
Physical Therapists' Beliefs Concerning the Management of Low Back Pain (LBP) (in Percentage Agree/Strongly Agree)
Two statements were included in the questionnaire to assess therapists' opinions on practice guidelines. Although 58.6% of the respondents agreed that practice guidelines would be useful in managing clinical conditions, only 48.3% thought they were helpful in the management of lumbar impairment (Tab. 7).
Discussion and Conclusion
This study adds to our knowledge concerning physical therapy practice in managing lumbar impairment. Our findings suggest that Ontario physical therapists followed most of the recommendations from the AHCPR guidelines. A majority of the respondents chose assessment procedures that would help to rule out “red flags” such as cauda equina, inflammatory diseases, fracture, cancer, and infection.2 Patient education and exercise were the interventions most frequently reported by therapists as part of the treatment for acute lumbar impairment. These findings also match the results of other studies. Battié et al13 found that 86% of the therapists in the state of Washington would include patient education for patients with acute LBP and that 71% of the therapists would include patient education for patients with sciatica. In a more recent study, Mielenz et al,14 who interviewed 1,580 patients with LBP in North Carolina, found that therapeutic exercise (83%) and heat treatment (74%) were the interventions that were most commonly prescribed by physical therapists. However, the use of patient education was not reported in this study.
With regard to bed rest, the guidelines suggest that 2 to 4 days of bed rest may be an option only for patients with severe initial symptoms of sciatica.2 This recommendation was supported by a study by Malmivaara et al,15 which showed that patients with LBP who were assigned a 2-day bed rest recovered more slowly than those who had maintained ordinary activities. In our survey, more than 94% of the respondents advised against bed rest for someone with localized symptoms. About a quarter of the therapists indicated they would recommend bed rest for the patient with acute sciatica, but 93% of those therapists reported that they would prescribe no more than 4 days of bed rest. These findings are in agreement with the guideline recommendations.
In the subacute LBP scenario, a shift in therapists' treatment focus from education to physical activity and work modification was noticed. Most of the therapists (84.4%) stated that they would refer the hypothetical patient to her family physician for further investigation, and this decision is congruent with the guideline recommendations. About 85% of our respondents indicated that they felt very comfortable managing the condition. This finding is similar to the result of the Washington State study, in which 82% of the therapists felt well prepared to manage LBP.13
A few discrepancies between the reported practice and guideline recommendations were identified. First, the reported use of spinal manipulation was low in our study. Only 5% of the therapists reported that they would use spinal manipulation to treat patients with acute lumbar impairment, as compared with more than a third of the therapists who indicated that they would use mobilization. This discrepancy could be explained by the small number of therapists who were trained to perform spinal manipulation. Although most of the respondents had received postgraduate training in manual therapy, only 8.8% completed courses that included joint manipulation. This is an area where physical therapy practice can improve in the future.
The AHCPR guidelines recommend that clinicians should teach self-application of heat or cold for pain control and discourage the use of modalities such as TENS, ultrasound, and biofeedback, which possess uncertain effectiveness for managing acute lumbar impairment.2 Our results suggested that, although the use of heat and cold was preferred by the respondents, some still used modalities that have questionable effectiveness. For example, mechanical spinal traction, which has consistently been shown to be of little benefit for acute and subacute lumbar impairment15–18 and is not recommended by the guidelines, was preferred by about 30% of the therapists for acute sciatica.
The selection of interventions by clinicians may be associated with a combination of clinical and nonclinical factors. In a study with 2,491 patients (50% with lumbar impairment), treated by 462 physical therapists, Jette and Jette19 found that the use of heat and cold modalities was related not only to the acuity and severity of lumbar impairment, but also to the therapist's academic degree. Furthermore, patients were more likely to receive endurance or strengthening exercises and spinal manipulation or mobilization from therapists who worked in practices with lower caseloads. Jette and Jette suggested that the uncertainties regarding the underlying cause of lumbar impairment and the effectiveness of treatments in reaching desired outcomes might have led clinicians to develop a practice style that is affected by idiosyncratic factors.
Another potential explanation for the discrepancies may include therapists' perceptions about the utility of practice guidelines. Our results showed that only half of the therapists confirmed the usefulness of practice guidelines in managing any clinical conditions, including LBP. This finding may indicate some reluctance among physical therapists to embrace guidelines, especially for managing acute lumbar impairment. Some of the reasons may include patients' demands,20excessive commitment to particular modes of therapy,21 and the therapists' own perceptions of treatment effectiveness.22 Although most of the respondents in our survey believed that TENS and ultrasound were effective for managing acute lumbar impairment, only 30% said the same about spinal manipulation. Further research, therefore, is needed to explore the value of practice guidelines, the factors that hinder their use, and the potential solutions.
In our survey, we used written case scenarios as a proxy measure of Ontario physical therapists' practice patterns. Although this is a commonly used method, it is questionable whether clinicians' responses indeed match their responses to actual clinical encounters.23,24 Although some therapists may report treatments that they may not perform under usual practice constraints, others may adopt an overcautious style in their answers. Validation of this method would involve a direct comparison with the actual clinical practice (gold standard). However, due to the constraints in resources, this process was not used in our study; thus, it serves as a limitation. Another issue is related to the development of case scenarios. In this study, therapists were required to make decisions about the choice of interventions based on the patient's medical history and complaints. The 3 scenarios were adopted from an earlier survey of family physicians in Ontario.9Because one of our goals was to compare the results of our survey with those of the physician survey,9 the same scenarios were used with few modifications. However, it is possible that the lack of impairment data, such as posture and limitations in range of motion or strength, might have an impact on therapists' choices of interventions, as might the lack of other measurements that therapists may have wanted in their decision making.
Despite the limitations, we believe that the findings from this survey are important. To our knowledge, this is the first study documenting the practice behaviors of Canadian physical therapists in treating people with musculoskeletal impairments. The results may serve as a baseline to guide future education and research in physical therapy management of people with lumbar impairments.
As experts in therapeutic exercise and manual techniques, physical therapists have been assuming the role of major health care providers in treating people with spinal impairments.25 However, some research has suggested that ordinary physical activities, when performed within pain tolerance, are superior to specific back-mobilizing exercises for treating patients with acute LBP.15 Cherkin et al26also suggested that merely providing minimal intervention by giving patients with acute lumbar impairment an education booklet could achieve cost-effectiveness surpassing that of McKenzie exercises and “chiropractic manipulation.” Although their study was criticized for excluding patients with sciatica and those with a history of back surgery,27–29 these findings may signal the need for physical therapists to revisit our roles in managing acute lumbar impairment.
Appendix
Footnotes
- Ms Li and Dr Bombardier provided concept/research design, fund procurement, and consultation (including review of manuscript before submission). Ms Li provided writing, subjects, data collection and analysis, and project management. Dr Bombardier provided facilities/equipment and administrative support.The study protocol was approved by the research ethics board of the University Health Network.This study was partially supported by a research grant from the Physiotherapy Foundation of Canada.
- Received September 8, 1999.
- Accepted October 18, 2000.
- Physical Therapy
References
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