Management of Nonspecific Low Back Pain by Physiotherapists in Britain and Ireland: A Descriptive Questionnaire of Current Clinical Practice.

Management of Nonspecific Low Back Pain by Physiotherapists in Britain and Ireland: A Descriptive Questionnaire of Current Clinical Practice Foster NE, Thompson KA, Baxter GD, Allen JM (School of Health and Social Sciences, Coventry University, Coventry, UK; School of Social and Health Sciences and Education, Coleraine, University of Ulster, Jordanstown, North Ireland; University of Ulster, Jordanstown, North Ireland), Spine. 1999;24:1332-1342.

The purpose of this study was to use a descriptive questionnaire to discover how physical therapists in Britain and Ireland are currently managing low back pain (LBP). The popularity of specific techniques and the reasons for their popularity were analyzed. The authors believed that data gathered from this study could help focus research on relevant and meaningful areas of the physical therapy profession.

The survey instrument was divided into 3 sections: background information on the respondents, patient information, and treatment methods and outcomes. The survey was conducted over a period of 18 months from 1994 to 1996. Using cluster sampling by geographic region, 2,654 questionnaires were distributed to members of the Chartered Society of Physiotherapy and the Irish Society of Chartered Physiotherapists (30,000 members total). Responses were sent back from 1,548 physical therapists (58.3%), 813 of whom reported being currently involved in the management of LBP.

The results of this survey revealed that the majority of the respondents (72.5%) practiced in outpatient settings, followed by sports injury clinics (4.9%). On average, patients with LBP comprised 32% of the caseload of the physical therapists. Most therapists (58.9%) had more than 10 years of experience in managing patients. The most frequently attended continuing education courses were on Maitland vertebral mobilization grades I-IV (53.9%) and McKenzie part A, the lumbar spine (53.2%).

Most of the patients with LBP were either between the ages of 36 and 45 years (47%) or 46 and 55 years (31.4%), and slightly more women than men were seen by physical therapists. Choosing from a list of LBP diagnoses, therapists reported that they most frequently treated patients with LBP associated with degenerative changes (96.8%), sciatica (96.4%), postural problems (96%), or disk prolapse (93.4%). A specific LBP diagnosis was dependent on the continuing education course the physical therapist had attended. For example, there was a significant association between physical therapists who attended a McKenzie course and an LBP diagnosis associated with poor posture ([Chi square]=4.29, df=1, P=.038).

For the physical therapists, the most important treatment goal was relief of pain; increasing spinal range of motion (ROM) was not considered an important goal. Most therapists (53.9%) saw patients with LBP for 4 to 6 visits, and 30.9%, saw patients with LBP for 7 to 10 visits. Those therapists who saw these patients for more than 10 visits usually had less than 3 years of experience ([Chi square]=21.75, df=9, P=.009). The LBP treatments that were "used most often" were Maitland mobilization grades I-IV (58.9%) and the McKenzie approach (46.6%). Other treatments included abdominal exercise, passive stretching, and neural tension. Only 2.8% of the respondents used manipulation as the most common form of treatment for patients with LBP. The preferred electrophysical modalities chosen by the respondents were interferential therapy (44.1%), ultrasound (22.3%), pulsed shortwave diathermy (11.2%), and transcutaneous electrical nerve stimulation (9.7%). The 2 most common outcome measures used by the therapists treating patients with LBP were ROM and the location of the pain.

The authors noted the ease with which the physical therapists diagnosed LBP, and they contrasted this with a statement in the literature that suggests that 90% of patients with LBP cannot have the source of their pain accurately diagnosed. According to the authors, this would suggest that either the physical therapists are better than other health care professionals at diagnosing the source of LBP or that the physical therapists may be overconfident about their diagnostic skills. The authors found it interesting that the primary outcome measures used by the physical therapists were ROM and pain distribution, even though only 10.3% of the respondents reported that an increase in ROM was their most important treatment goal. The authors also noted that there were numerous different approaches used to treat patients with LBP, suggesting a lack of consensus within the profession on the best method to manage this patient population.

Only 23.2% of the respondents used manipulation as a treatment technique. Of these therapists, approximately one fifth used it as a primary form of treatment. The authors stated that apparently only a few physical therapists received continuing education training in manipulation, and some of these therapists reported having a confidence level that was too low to allow them to use this type of treatment on their patients. The authors suggested that this low confidence level was an indication of the effectiveness of continuing education training in manipulation and reflected a need for periods of retraining.

The authors also stated that "many of the approaches used by physiotherapists are supported only by fragmentary and unconvincing evidence." They subsequently made the following recommendations for future research: (1) large-scale controlled clinical trials of those methods that are currently in wide use by therapists and that are believed to be clinically beneficial (such as the McKenzie and muscle imbalance approaches) and (2) an evaluation of therapeutic methods that are most often and least often used in order to separate those methods requiring vigorous defense of their effectiveness from those that should be discarded.

John C Gray, PT OCS
Sharp Rees-Stealy Medical Center
San Diego, Calif