Management of work-related low back pain: a population-based survey of physical therapists.

Background and Purpose. Physical therapy often is used in the management of work-related low back pain (LBP). Little information, however, is known about the types of interventions used by physical therapists in the management of this condition. The objective of this study was to describe the interventions used by physical therapists in the treatment of workers with acute or subacute LBP, with or without radiating pain below the knee. Subjects. Clinical management questionnaires for workers without and with radiating pain were returned by 190 and 139 physical therapists, respectively. Methods. For each treatment session, therapists recorded treatment objectives, interventions, and education provided to 2 workers with LBP, 1 with radiating pain and 1 without radiating pain. Results. The majority of physical therapists used stretching and strengthening exercises, spinal mobilizations, soft tissue mobilizations and massage, manual traction, posture correction, interferential current, ultrasound, heat, and functional activities education. With radiating pain, the majority of the therapists also used cold and the McKenzie approach. Treatment objectives pursued by the majority of the therapists were decrease of pain, increase of range of motion, increase of muscle strength (force-generating capacity of muscle), decrease of muscle tension, and worker education. Discussion and Conclusion. Physical therapists use an array of interventions with workers with LBP. The effectiveness of most interventions reported has not been well studied. [Poitras S, Blais R, Swaine B, Rossignol M. Management of work-related low back pain: a population-based survey of physical therapists. Phys Ther. 2005;85: 1168-1181.]

Key Words: Back pain, Health services research, Occupational health, Physical therapy, Practice patterns.

Work-related low back pain (WRLBP) is a major cause of work absenteeism and accounts for a high proportion of occupational disability costs. (1,2) Physical therapists are among the health care professionals most involved in the management of this problem, with the majority of workers with low back pain (LBP) receiving physical therapy treatments. (3,4) It has been shown that workers with LBP account for the majority of patients treated by physical therapists working in the musculoskeletal field. (5-20) Studies also have revealed that the majority of people treated for LBP by physical therapists are in the acute or subacute phase. (4,6,7,11-13) Symptom duration is usually defined in the literature as acute in the first month, subacute between the first and third months, and chronic if symptoms are present longer than 3 months, (14) People in the chronic phase are much less likely to return to work or to recover from their symptoms, (15) a phase that therefore should be prevented. (16-18)

In the occupational setting, the prognosis of WRLBP is influenced by work-related factors. (19) Consequently, specific guidelines for the management of WRLBP have been developed. (20,21) These guidelines recommend the following evidence-based interventions in the management of acute or subacute WRLBP: (1) reassure the worker on the general good prognosis of LBP; (2) advise the worker to continue or return to ordinary activities, including work, as soon as possible; and (3) initiate an exercise program if return to activity is delayed. These guidelines state that exercise generally should be embedded in an occupational setting. Exercises and soft tissue mobilizations and massage also have been recommended as evidence-based interventions in other practice guidelines (14,22,23) and systematic reviews (24-27) on the management of general acute or subacute LBP.

Although physical therapists often are involved in the treatment of people with WRLBP, little is known about the types of interventions used by physical therapists or whether their interventions are evidence-based. Among the studies that have described the practice of physical therapists in the management of LBP, (4,6,7,10-13,28-31) only one study (4) focused on WRLBP, with limited results on physical therapist practice because it was not the main objective of the study. Two of the studies (10,11) showed that, in order to comprehensively describe current practices, it is necessary to examine the entire episode of care because of important variations in intervention choices during the episode. (32,33) However, most studies did not assess actual episodes of care and were limited to case histories, (6,30) physical therapists' preferences, (7) or patient reports. (13) Other studies (4,28,29,31) retrospectively evaluated patient records and, therefore, had problems standardizing the information obtained. Only a small proportion of the samples in the 3 prospective studies (12,32,33) included patients with WRLBP, limiting the generalizablity of these study results to people with occupational disabilities. The prospective studies also demonstrated biases. Convenience samples were used to select physical therapists, and representativeness analyses were not done. (12,32,33) Recall bias was important in one study (32) because information was collected only at discharge. Although certain guidelines state that education is one of the most important interventions in the management of LBP, (22) it is not clear what type of education is given by physical therapists. Only 6 studies (6,13,29-31,33) provided limited information on the type of education given, with each study evaluating only one type of education.

Various treatment objectives can be pursued when treating people with WRLBP, but it is not clear which types of objectives are pursed by physical therapists when treating people with this health problem. Of the studies that have described the practice of physical therapists in the management of LBP, only 3 studies (7,10,11) described the objectives pursued, with a clear emphasis on pain reduction. Because of its occupational impact, we might expect that more functional objectives would be pursued in the management of WRLBP, but this hypothesis has not been assessed.

In order to appropriately characterize people with LBP, the literature suggests that the presence of radiating pain below the knee must be assessed because of its strong association with a poorer prognosis of LBP. (34-37) It is not known, however, whether or how physical therapists adjust their intervention choices in the presence of this clinical symptom.

In response to the need for information on the practice of physical therapists in the occupational field, a descriptive study of practices of physical therapists managing acute or subacute WRLBP was initiated. The objectives of this study were: (1) to describe the treatment objectives and interventions, including education, used by a representative sample of Quebec physical therapists in the treatment of workers absent from work due to acute or subacute WRLBP, (2) to describe the variations in treatment goals and intervention choices over the course of care, and (3) to evaluate the effect of radiating pain below the knee on treatment goals and intervention choices. The findings were compared with current clinical management evidence to assess whether the interventions reported are evidence-based. These findings will help to define what constitutes typical physical therapist management of acute or subacute WRLBP, information that could be useful in the planning of clinical trials in this area.

Method

Physical Therapist Sample Selection Details of the sample selection procedure are shown in the Figure. The Workers' Compensation Board (WCB) of the province of Quebec, Canada (population, 7.4 million), is responsible for a universal workers' compensation program that covers all workers employed in the province. In order to have a representative picture of physical therapists' management of WRLBP, a random sample of physical therapists working in Quebec was selected. Because the Quebec WCB data show that about 90% of workers with LBP are treated in private clinics, only physical therapists working in these clinics were invited to participate. A list of private clinics that billed the Quebec WCB in 2001 for physical therapy treatments was obtained from the WCB. This list also indicated the volume of workers who received physical therapy at each clinic in 2001. Data showed that the quartile of clinics with the lowest volume treated only 4% of the workers in 2001. Because it would have been difficult for these clinics to recruit eligible workers for the study and because of their low weight in the practice of physical therapy in Quebec, these clinics were excluded. For administrative purposes, the province of Quebec is divided into 16 administrative regions. From the list of clinics, a random sample proportionate to the number of clinics present in the 16 Quebec regions was drawn. An oversampling was done by taking into account an expected participation rate of 50%.

Clinic owners were contacted by letter and asked whether they accepted that we contact the physical therapists of their clinic who treated workers with LBP and, if so, to give us the names of those physical therapists. Eligibility information was obtained from the clinic owners. Clinics were not eligible if one of the following exclusion criteria applied to them: no workers' compensation clientele treated, clinical management was exclusively provided by physical therapist assistants, treatment of only patients with chronic pain, anticipated absence from work (eg, maternity leave, sick leave) of all physical therapists of the clinic, same physical therapists working in other selected clinics (lower-volume clinics excluded), and treatments of a same worker were systematically given by different physical therapists depending on availability. This last criterion was applied because of the projects' prospective methodology. All physical therapists listed by agreeing owners were invited by mail to participate in the study. The same exclusion criteria used with the clinics were applied to physical therapists. This information was obtained from the therapists. Once the written consent of the therapists was received, 2 self-administered questionnaires were sent to them.

Questionnaire Development

Two self-administered questionnaires were designed for this study: 1 to collect information on the characteristics of the physical therapists and 1 to describe the clinical management of workers with LBP (the clinical management questionnaire is shown in the electronic version of the article at http://www.ptjournal.org). The content of the clinical management questionnaire was first developed by consulting the literature defining typical physical therapy management, (38) previous studies describing the management of LBP by physical therapists, (4,6,7,10,11.13,31) and guidelines concerning the management of WRLBP. (21) The content of the questionnaire then was validated during discussions with key informants in Quebec to determine whether it covered all aspects of practice. Informants included a demographically varied sample of practicing physical therapists working in the musculoskeletal field in Quebec, 2 professors in charge of clinical practice in the physical therapy programs of 2 major Quebec universities, a person in charge of physical therapy treatments at the provincial Quebec WCB, and 2 other people in charge of professional practice at the provincial Quebec college of physical therapists.

In order to cover the subacute phase, the clinical management questionnaire allowed for the description of a maximum of 45 treatment sessions. This questionnaire collected information on the characteristics of the worker being treated, the primary and secondary objectives of each treatment session, the interventions used in each session, the education given, and the duration of the session. The therapists determined whether a disabling comorbidity was present at the initial session. Specifically, they asked whether the workers had a health problem that significantly decreased their capacity to accomplish their activities, the type of health problem, and whether it was being treated or had been treated by a health care professional. To describe clinical management used in each session, the physical therapists chose from a list of interventions and education, with an open-ended question to account for any nonlisted item. Because this description was limited to 2 workers, physical therapists were asked at the end of the episode of care to assess on a 4-point ordinal scale (from "very similar" to "very different") the level of similarity of the interventions used for this particular worker with those typically used in the management of other workers with LBP. At this last session, the therapists also were asked to give the reasons for termination of physical therapy by choosing from a list of possibilities.

Data Collection

Questionnaires were sent to participating physical therapists in August and September 2002. The therapists first completed and returned the questionnaire describing their characteristics. They then were asked to use the clinical management questionnaire to describe how they treated the first 2 eligible workers who were absent from work due to acute or subacute WRLBP (1 with and 1 without radiating pain below the knee) and who presented themselves to the clinic for an initial evaluation. The therapists determined the eligibility of the workers with information provided by the worker or his or her attending physician. Workers were excluded if they presented any of the following criteria at the initial visit: currently performing regular work duties; received workers' compensation for more than 3 months for the current WRLBP episode; received workers' compensation for WRLBP during the 3 months preceding the current episode; received physical therapy for LBP during the 3 months preceding the current episode; underwent surgery for the current episode; had LBP as a result of spinal fracture, tumor, infection, or cauda equina syndrome associated with massive hernia; or pregnancy.

The clinical management and descriptive characteristics questionnaires were identified with a confidential identification code attributed to each therapist. The physical therapists had until December 1, 2003, to return the clinical management questionnaires. In order to promote participation, reminder letters were regularly sent throughout the study period. The feasibility of this protocol was tested in a pilot study conducted with 6 physical therapists working in 3 clinics.

Data Analysis

Descriptive data were used to assess the representativeness of the sample of participating clinics and physical therapists. Volume of workers treated in 2001 and regional distribution of clinics were compared among participating and nonparticipating clinics, with independent-sample t and chi-square tests, respectively. The regional distribution variable combined the 16 administrative regions into 5 groups according to the proximity to the 2 major urban centers in Quebec (Montreal and Quebec City): Montreal metropolitan area, Quebec City metropolitan area, peripheral Montreal, peripheral Quebec City, and rural.

Regional distribution and volume of clientele of workplace were compared between physical therapists who returned a clinical management questionnaire and eligible physical therapists. Additionally, therapists who returned a clinical management questionnaire were compared with therapists who returned a descriptive characteristics questionnaire on the following data: sex, years of practice, proportion of clientele with LBP seen in the past 6 months, proportion of clientele receiving workers' compensation in the past 6 months, and university of graduation. Three universities in Quebec offer a physical therapy program, 1 French university and 1 English university in Montreal and 1 French university in Quebec City.

The following descriptive analyses of the interventions used by the physical therapists were conducted: proportion of therapists who used the intervention at least once during the episode of care and mean frequency of use of the intervention during the episode of care among therapists who used the intervention at least once. The mean frequency of use was selected to give equal weight to all therapists, independent of the number of treatment sessions. The episode of care was divided into 3 parts, with the first and third parts having the same number of sessions and the middle part having a difference of no more than 1 session from the other 2 parts.

The frequency of use of each intervention was calculated for each third of the episode of care, and significance of change in frequency across the thirds was assessed with a generalized linear model for repeated measures. These analyses also were performed on the session objectives and the education provided to the workers. All analyses were performed separately for the clinical management of workers with and without radiating pain. Chi-square and t tests were used to assess whether significant differences in the management of the 2 groups of workers existed. Because of the multiple testing, an alpha level below .01 was considered significant for all analyses. Only objectives, interventions, and education provided at least once during the episode of care by at least 10% of the physical therapists are presented.

Results

Sampling

The Figure maps the sampling results of the clinics and the physical therapists. Two hundred twenty-two clinic owners agreed to participate and provided the names of the physical therapists working in their clinic, yielding a response rate of 60.5%. There were no significant differences in geographic distribution (P = .12) and volume of workers treated at the clinic (P = .31) between participating and nonparticipating clinics.

Three hundred twenty-eight physical therapists returned a questionnaire describing their characteristics (response rate of 81.4%). Two hundred twelve therapists returned at least 1 clinical management questionnaire, with 63.7% being female with an average number of years of practice of 9.3 (SD = 7.4, range = 0-43). One hundred ninety therapists returned a clinical management questionnaire for workers without radiating pain (response rate of 47.1%), and 139 therapists returned a clinical management questionnaire for workers with radiating pain (response rate of 34.5%). For the clinical management of workers without radiating pain, only university of graduation was significantly different (P<.01) between therapists who returned a questionnaire and those who did not, with an under-representation of graduates from the English-speaking university. As for clinical management of workers with radiating pain, only the proportion of clientele with LBP in the past 6 months and the proportion of clientele receiving workers' compensation in the past o months were significantly different (P<.10) between therapists who returned a questionnaire and those who did not, with therapists with lower proportions being under-represented.

Characteristics of Workers and Episodes of Care

Table 1 describes the characteristics of the workers treated in the study. Only work status during the initial session was significantly different between the 2 groups, with workers with radiating pain being absent from work more frequently than workers without radiating pain. The following proportions of workers with radiating pain still had pain radiation at each corresponding period of the episode of care: 57.7% at the beginning of the second third of the episode, 33.8% at the beginning of the last third of the episode, and 25.2% at the last session. At the time of the last study session, 51.5% of workers with radiating pain and 37.4% of workers without radiating pain were still absent from work.

As for the characteristics of the episodes of care, the number of treatment sessions was significantly different between the 2 groups of workers, with a mean number of sessions for workers with radiating pain of 27.4 (SD = 13.1) and a mean of 20.7 (SD = 13.0) for those without radiating pain. Median durations of sessions were 60 and 45 minutes for workers without and with radiating pain, respectively. For both groups, approximately 90% of the physical therapists reported that the clinical management used was similar or very similar to their typical care. When indicating the reasons for the last session of the episode of care, the highest proportion of therapists judged that the patient had sufficiently recovered (57.4% of therapists for workers without radiating pain and 43.9% of therapists for workers with radiating pain).

Clinical Management

Treatment objectives. Tables 2 and 3 outline the primary and secondary treatment objectives followed by the physical therapists during the episode of care. The most frequent treatment objectives for both groups were pain reduction, increase in range of motion, increase in strength, and decrease of muscle tension (Tab. 2). There were differences between groups in frequency of objectives followed during the episode of care, with pain reduction more frequently followed with workers with radiating pain and increase in strength and education more frequently followed with workers without radiating pain (Tab. 2). For both groups, there was a significant decline in the frequency of use throughout the episode of care for pain reduction and muscle tension reduction and a rise in the frequency of use for increase in strength (force-generating capacity of muscle), increase in endurance, and improvement of function (Tab. 3).

Interventions. Tables 4 and 5 describe the interventions used in the management of workers with LBP. The interventions most used for both groups of workers included stretching exercise, strengthening exercise, spinal mobilization, interferential current, soft tissue mobilization and massage, ultrasound, heat, manual traction, and posture correction (Tab. 4). A significantly higher proportion of physical therapists used manual traction, mechanical traction, cold, and the McKenzie approach for workers with radiating pain.

As for the frequency of use (Tab. 4), the following interventions were used in the majority of sessions of the episodes of care for both groups: heat, stretching exercise, spinal mobilization, interferential current, strengthening exercise, soft tissue mobilization and massage, and ultrasound. Only strengthening exercises were more frequently used with workers without radiating pain. Table 5 shows that almost all interventions demonstrated significant change in frequency of use throughout the episode of care for both groups. Generally, electrotherapy and manual techniques tended to decrease with time, whereas exercise tended to increase.

Education provided. Tables 6 and 7 describe the topics of education provided to the workers. The following topics were discussed at least once by the majority of physical therapists with both groups of workers (Tab. 6): stretching exercise program, explanation of physical cause of LBP, strengthening exercise program, pain control, increase in home activities, activities of daily living (ADL) advice, ergonomics and work tasks advice, and posture education. Decreasing home activities was recommended by the majority of therapists to workers with radiating pain, with this advice being given significantly more often to these workers than to those without radiating pain.

As for frequency of education during the episode of care (Tab. 6), stretching and strengthening exercises were the most frequent topics. Only ergonomics and work tasks advice demonstrated a significant difference in frequency between groups of workers, with workers without radiating pain being given more education on this topic than those with radiating pain.

The following topics demonstrated a significant decrease in frequency for both groups (Tab. 7): posture education, lumbar roll use, ADL advice, pain control, explanation of physical cause of LBP, and decrease in home activities. There was an increase in frequency for the following topics for both groups: strengthening exercise program, increase in home activities, cardiorespiratory exercise program, and increase in work activities. For workers without radiating pain, decrease in work activities significantly declined, whereas ergonomics and work tasks advice significantly increased.

Discussion and Conclusion

The study results demonstrate that the following interventions were used by the majority of the physical therapists in the management of workers with work-related acute or subacute LBP" stretching exercises, strengthening exercises, spinal mobilizations, soft tissue mobilizations and massage, manual traction, posture correction, interferential current, ultrasound, and heat. Additionally, cold and the McKenzie approach were used by the majority of the therapists with patients with radiating pain. Education corresponding to the preceding interventions also was used by the majority of the therapists, with the addition of functional activities education (ADL or work tasks). The majority of the therapists used these interventions to pursue the following primary and secondary objectives: decrease pain, increase range of motion, increase strength, decrease muscle tension, and educate the worker. Over the course of the episode of care, the use of passive interventions (eg, electrotherapy and manual techniques) aimed at reducing pain and muscle tension tended to decrease, whereas the use of active interventions (eg, exercise) aimed at improving strength, endurance, and function tended to increase.

When determining whether the interventions reported are evidence-based, most of the interventions typically reported have not been well studied (eg, spinal mobilizations, posture correction, manual traction, interferential current, ultrasound, heat, cold, and transcutaneous electrical nerve stimulation). (14,22) Exercise in general, which was very frequently used in various ways, has demonstrated effectiveness in the management of subacute LBP, but it is not clear which types of exercises are most effective. (14,25,27) However, the results of this study demonstrated that cardiorespiratory exercises were used far less than other types of exercises. Soft tissue mobilizations and massage, which also were frequently used, have been shown in recent reviews (24,26) to be beneficial, although it is not known which kind are most effective.

One of the evidence-based interventions in the management of WRLBP is advising the worker to return to normal activities, including work, as soon as possible. (20,39) This study showed that physical therapists tend to be congruent with this evidence by advising workers more often to increase rather than decrease their home and work activities. However, this was less often the case for workers with radiating pain, with a large proportion of therapists recommending a decrease in home activities, which seems to go against current guidelines. Physical therapists probably use a more cautious approach with workers with radiating pain. This cautious approach is reflected in the objectives followed with workers having radiating pain, with objectives aiming more to decrease pain and less to increase strength. Cold also was more frequently used with these workers, indicating that the therapists either thought that an inflammatory process was present or that a stronger analgesic was needed. The therapists probably adjusted their management in relation to the poorer condition of workers with radiating pain. People with radiating pain tend to be more affected in their functional capacities than people without radiating pain. (40-45) In this study, workers with radiating pain tended to be absent from work more often than those without radiating pain both at the beginning and at the end of the episodes of care, with more treatment sessions being provided to these workers. However, it has not been demonstrated whether a more cautious approach is needed with this type of clientele.

The McKenzie approach and manual and mechanical traction also were used more often with workers with radiating pain than with those without radiating pain. These interventions are typically used when a compressed spinal nerve is suspected and a reduction of the compression is pursued in order to decrease back and radiating pain. (46,47) This finding suggests that the therapists may have believed that radiating pain was mostly caused by a nerve compression in the spine. However, the exact cause of radiating pain is unknown. (48) The effectiveness of traction, both manual and mechanical, on people with radiating pain has not been well studied. (14,49) As for the McKenzie approach, only one study evaluated its effectiveness in the presence of radiating pain compared with an appropriate control group, with favorable results. (50,51)

Functional interventions (simulation of ADL or work tasks) were used by only about a third of the physical therapists, but function was addressed by the majority of the therapists through education. It is not known, however, whether functional interventions are needed in the treatment of people with acute or subacute WRLBP (52) or whether a general exercise program is sufficient. Improving function was listed as a main goal for only a minority of the therapists. These results are consistent with those of other studies (8,53) that showed that physical therapists tend to address impairment instead of disability by focusing on pain, range of motion, muscle tension, and strength instead of function. However, current WRLBP management guidelines are based more on disability than on impairment (20) in order to act on the psychosocial factors related to chronic disability. (19) There appears to be incongruence between the models underlying the guidelines and those underlying the management used by physical therapists.

Although the physical therapists treated subjects with similar characteristics, the results indicate that the therapists used a large variety of interventions. Variations in practice often are seen when there is uncertainty in the management of a clinical condition. (54) Although management guidelines exist, studies have demonstrated that the majority of physical therapists rarely consult the literature (55,56) and, when they do, give it varying credibility (57-59) or disagree with parts of its contents. (60) This uncertainty probably is fueled by the fact that the effectiveness of most interventions used by physical therapists in the management of WRLBP has not been studied.

Several factors limit a direct comparison of our results with those of other prospective studies describing the management of back problems in the general population. (12,32,33) Most of the descriptive analyses used were different from those used in the present study, including differences in units of analysis (eg, physical therapists versus patients or interventions). Physical therapists in other studies (12,32,33) were not restricted in the number of patients treated, with some therapists treating more patients than others, thus differentially weighting the analyses. In addition, patients in the other studies (12,32,33) could be treated by different physical therapists, leaving each therapist's respective contribution unknown.

Nonetheless, compared with those of the other prospective studies, (12,32,33) our results showed that physical therapists appear to use a wider variety of interventions when treating people with WRLBP, with more emphasis on exercise. This difference may be related to the context of WRLBP, the differences in methods used, the specificity of physical therapist practice in Quebec, or the integration of recent evidence encouraging the use of exercise in LBP management. Because interventions focusing on improving function were not addressed in the other prospective studies, comparisons with our study results are not possible.

Although the present study was not designed to evaluate the effectiveness of physical therapist management of WRLBP, it appears that the therapists were moderately successful at returning workers to work. At the end of the episode of care, 37.4% of workers without radiating pain and 51.5% of workers with radiating pain were absent from work. However, it is not known whether workers immediately returned to work following the last treatment session. When analyzing work status at the last session with respect to reason for treatment termination, the results indicated that the therapists judged that there was sufficient recovery in 30.3% of workers still absent from work at the last session. These workers could have returned to work shortly after the end of the episode of care, but we did not evaluate work status following the episode of care.

This study has a number of limitations. Because self-administered questionnaires were used, it is not possible to assess whether the practices reported truly represented actual clinical management. The use of questionnaires, however, probably is less susceptible to bias than case scenarios because it involves actual patient care. (61,62) We presume that the type of education used was underreported because it has been shown that physical therapists tend to underdeclare education when it is self-reported, (63) probably because of its subjective nature. Although the therapists were instructed to select the first 2 eligible workers who presented themselves at the clinic after receiving the questionnaires, it is not possible to verify whether they did so. Selection bias tends to appear in experimental studies where treatment preferences of patients and clinicians can influence participation (64-67) or in observational studies where consent or active participation is required of the subjects. (68,69) Because both of these criteria do not apply to this study, selection bias was minimized. The response rate probably was affected, in part, by the exclusion criteria for workers. These criteria were chosen to decrease the effect of external factors that could influence treatment choices of physical therapists. Although the response rate was as anticipated for workers without radiating pain, it was lower than expected for workers with radiating pain. The fact that radiating pain below the knee accounts for a minority of people with LBP (35-37,40,42) could partly explain the lower response level for this group of workers. Although analyses were conducted to determine sample representativeness, most of the variables examined were available only for those therapists who returned a descriptive characteristics questionnaire. In this regard, therapists who returned a clinical management questionnaire appeared representative of therapists who returned a descriptive characteristics questionnaire. When compared with all eligible physical therapists, those who returned a clinical management questionnaire appeared representative with respect to location and volume of clientele at the workplace. Finally, the results may not be generalizable to clinics operating in health systems outside Canada.

This study provides valuable information because it is the first longitudinal study based on a representative sample of physical therapists describing actual episodes of care of workers with LBP. These cases account for the majority of patients seen by physical therapists working in the musculoskeletal field, cases that can lead to high disability costs. This study also provides insight into the physical therapist management of radiating pain, a clinical symptom highly prognostic of chronicity. Because of the relative scarcity of evidence on the effectiveness of physical therapist management of WRLBP, future trials are needed. However, this study has shown that numerous interventions and education topics are used by physical therapists in the management of WRLBP. In order to reflect current practices, some authors (70,71) have noted that trials evaluating the effectiveness of LBP management by physical therapists should include a combination of interventions typically used, in the form of a pragmatic randomized trial. The results of the present study may help to define, for a future trial, the contents of typical physical therapist management of WRLBP, both with and without radiating pain.

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S Poitras, PT, PhD, is Research Fellow, Groupe de Recherche Interdisciplinaire en Sante, Universite de Montreal, CP 6128, Succursale Centre-ville, Montreal, Quebec, Canada H3C 3J7 ([e-mail]). Address all correspondence to Dr Poitras.

R Blais, PhD, is Full Professor, Groupe de Recherche Interdisciplinaire en Sante, Universite de Montreal.

B Swaine, PT, PhD, is Associate Professor, Ecole de Readaptation, Universite de Montreal, and Researcher, Centre de Recherche Interdisciplinaire en Readaptation du Montreal Metropolitain, Montreal, Quebec, Canada.

M Rossignol, MD, is Associate Professor, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, and Researcher, Department of Public Health of Montreal, Montreal, Quebec, Canada.

All authors provided concept/idea/research design. Dr Poitras, Dr Blais, and Dr Swaine provided writing. Dr Poitras provided data collection, and Dr Poitras and Dr Blais provided data analysis. Dr Poitras provided project management. Dr Blais, Dr Swaine, and Dr Rossignol provided fund procurement. Dr Rossignol provided consultation (including review of manuscript before submission).

Ethical approval for the study was obtained from the Research Ethics Committee, Faculty of Medicine, University of Montreal.

This study was supported by a research grant from the Institut de Recherche en Sante et Securite au Travail (IRSST) and by doctoral research awards to Dr Poitras from the following organizations: the Canadian Institutes of Health Research (CIHR), the Canadian Health Services Research Foundation (CHSRF), and the Canadian Institute for the Relief of Pain and Disability (CIRPD).

This article was received January 19, 2005, and was accepted May 19, 2005.

Table 1. Characteristics of Workers

                                       No Radiating Pain
                                       (n=190)
Characteristics                        [bar.X]   SD

Age (y)                                38.7      10.9
No. of days before first treatment     21.3      16.1

                                       N         %
Sex
  Male                                 133.0     70.0
  Female                                57.0     30.0
Comorbidity
  Lower extremities                      4.0      2.1
  Upper extremities                      1.0      0.5
  Cervical region                        6.0      3.2
Work status at initial session
  Absent from work                     147 (a)   77.4
  Light duties                          43.0     22.6
Work status at last session of study
  Absent from work                     71.0      37.4
  Light duties                         59.0      31.1
  Regular work                         59.0      31.1
  Other work                            0.0       0.0
  Unemployed                            1.0       0.5

                                       Radiating Pain
                                       (n=139)

Characteristics                        [bar.X]   SD

Age (y)                                41.6      10.2
No. of days before first treatment     24.5      17.0
                                       N         %
Sex
  Male                                 90.0      64.7
  Female                               49.0      35.3
Comorbidity
  Lower extremities                     3.0       2.2
  Upper extremities                     2.0       1.4
  Cervical region                       5.0       3.6
Work status at initial session
  Absent from work                     126 (a)   90.6
  Light duties                         13.0       9.4
Work status at last session of study
  Absent from work                     71.0      51.5
  Light duties                         32.0      23.0
  Regular work                         34.0      24.5
  Other work                            1.0       0.7
  Unemployed                            1.0       0.7

(a) Significant difference (P<.01) between groups of workers

Table 2.
Proportion of Physical Therapists Pursuing Given Objectives at Least
Once During the Episode of Care and Mean Proportion of Sessions Where
Objectives Were Pursued During the Episode of Care

                                       % of Physical Therapists

                                       No
                                       Radiating   Radiating
                                       Pain        Pain
Objective                              (n=190)     (n=139)

Primary objective
  Decrease pain                        84.2        92.1
  Increase range of motion             65.8        63.3
  Increase strength                    50.5        48.9
  Decrease muscle tension              36.8        33.8
  Increase endurance                   30.5        30.9
  Educate patient                      27.9        30.2
  Improve function (ADL (b) or work)   21.1        19.4
  Evaluation                           18.4        14.4
  Improve posture                       8.4        15.1
Secondary objective
  Decrease pain                        70.5        71.2
  Increase range of motion             67.9        70.5
  Decrease muscle tension              67.4        68.3
  Educate patient                      56.3        46.8
  Increase strength                    50.0        50.4
  Increase endurance                   38.9        39.6
  Improve function (ADL or work)       31.6        34.5
  Improve posture                      24.7        30.9

                                       Mean % of Sessions (SD)

                                       No
                                       Radiating
                                       Pain
Objective                              (n=190)

Primary objective
  Decrease pain                        37.9 (30.2) (a)
  Increase range of motion             32.9 (23.3)
  Increase strength                    28.4 (19.9) (a)
  Decrease muscle tension              22.7 (19.7)
  Increase endurance                   26.6 (19.9)
  Educate patient                      10.0 (7.0) (a)
  Improve function (ADL (b) or work)   20.4 (18.6)
  Evaluation                            8.4 (7.1)
  Improve posture                      11.6 (12.8)
Secondary objective
  Decrease pain                        24.3 (19.0)
  Increase range of motion             24.5 (18.7)
  Decrease muscle tension              25.1 (19.5)
  Educate patient                      11.6 (9.5)
  Increase strength                    19.4 (14.5)
  Increase endurance                   19.8 (14.0)
  Improve function (ADL or work)       14.3 (12.1)
  Improve posture                      14.7 (12.9)

                                       Radiating
Objective                              Pain
                                       (n=139)
Primary objective
  Decrease pain                        49.2 (29.1) (a)
  Increase range of motion             30.3 (25.0)
  Increase strength                    21.5 (17.7) (a)
  Decrease muscle tension              13.9 (15.0)
  Increase endurance                   19.2 (16.1)
  Educate patient                       5.5 (2.6) (a)
  Improve function (ADL (b)or work)    17.3 (16.9)
  Evaluation                            6.0 (3.5)
  Improve posture                       9.7 (9.1)
Secondary objective
  Decrease pain                        24.1 (19.6)
  Increase range of motion             25.9 (19.1)
  Decrease muscle tension              28.3 (25.9)
  Educate patient                       9.1 (7.3)
  Increase strength                    18.2 (14.6)
  Increase endurance                   16.8 (13.1)
  Improve function (ADL or work)       15.3 (16.1)
  Improve posture                      10.9 (9.5)

(a) Significant difference (P<.01) between groups of workers.

(b) ADL=activities of daily living.

Table 3.
Objectives Showing Significant Change (P<.01) in Frequency of Use
Across the Episode of Care

                                     No Radiating Pain (n=190)
                                     Mean % of Sessions

                                     Initial   Middle   Final
Objective                            Third     Third    Third

Primary objective
Decrease pain                        56.4      32.5     23.4
Increase strength                    11.9      35.2     38.2
Increase endurance                   10.4      26.6     42.6
Improve function (ADL (a) or work)    5.2      14.6     41.0
Secondary objective
Decrease pain                        28.6      26.7     16.8
Decrease muscle tension              39.2      21.0     14.9
Increase strength                     9.3      24.3     23.8
Increase endurance                    6.3      20.6     32.6
Improve function (ADL or work)        6.9      14.7     21.1

                                     Radiating Pain (n=139)
                                     Mean % of Sessions

                                     Initial   Middle   Final
Objective                            Third     Third    Third

Primary objective                    67.2      48.0     31.9
Decrease pain                         4.7      22.7     37.3
Increase strength                     3.2      19.4     35.5
Increase endurance                    5.3      11.5     36.6
Improve function (ADL (a) or work)
Secondary objective                  NS (a)    NS       NS
Decrease pain                        36.5      26.7     21.3
Decrease muscle tension              11.3      20.1     23.0
Increase strength                     6.5      16.7     27.1
Increase endurance                    8.5      16.5     20.9
Improve function (ADL or work)

(a) ADL=activities of daily living.

NS=nonsignificant change.

Table 4.
Proportion of Physical Therapists Using Given Interventions at Least
Once During the Episode of Care and Mean Proportion of Sessions Where
Interventions Were Used During the Episode of Care

                                              % of Physical Therapists

                                              No
                                              Radiating   Radiating
                                              Pain        Pain
                                              (n=190)     (n=139)
Intervention

Stretching exercise                           93.2        93.5
Strengthening exercise                        88.9        84.9
Spinal mobilization                           87.4        87.8
Interferential current                        74.7        80.6
Soft tissue mobilization/massage              74.7        78.4
Heat                                          71.1        66.9
Ultrasound                                    71.1        81.3
Manual traction                               61.6 (a)    89.9 (a)
Posture correction                            60.5        68.3
Cardiorespiratory exercise                    43.7        42.4
Cold                                          43.2 (a)    59.7 (a)
Transcutaneous electrical nerve stimulation   41.6        47.5
McKenzie approach                             37.4 (a)     63.3 (a)
Simulation of activities of daily living      30.5        30.9
Simulation of work tasks                      30.5        28.8
Osteopathic approach                          14.7        15.8
Mechanical traction                           14.2 (a)    30.9 (a)
Spinal manipulation                           14.2        13.7
Neuromuscular electrical stimulation          13.7        16.5
Gym ball exercise                             11.6         7.9
Muscle re(education exercise                  11.6        12.9
Laser                                          8.9        12.9
Neural mobilization                            8.9        12.9

                                              Mean % of Sessions (SD)

                                              No
                                              Radiating
                                              Pain
                                              (n=190)
Intervention

Stretching exercise                           68.1 (29.4)
Strengthening exercise                        60.3 (26.7) (a)
Spinal mobilization                           65.0 (29.4)
Interferential current                        61.1 (31.8)
Soft tissue mobilization/massage              59.7 (33.3)
Heat                                          71.0 (30.0)
Ultrasound                                    55.3 (29.7)
Manual traction                               46.3 (30.9)
Posture correction                            28.2 (23.5)
Cardiorespiratory exercise                    49.1 (26.5)
Cold                                          43.2 (33.4)
Transcutaneous electrical nerve stimulation   39.2 (33.4)
McKenzie approach                             43.2 (32.2)
Simulation of activities of daily living      14.6 (14.9)
Simulation of work tasks                      19.5 (16.8)
Osteopathic approach                          31.2 (28.3)
Mechanical traction                           28.3 (19.7)
Spinal manipulation                           26.5 (29.9)
Neuromuscular electrical stimulation          42.1 (30.3)
Gym ball exercise                             25.8 (16.2)
Muscle re(education exercise                  30.4 (30.4)
Laser                                         17.4 (20.2)
Neural mobilization                           22.2 (21.2)

                                              Radiating
                                              Pain
Intervention                                  (n=139

Stretching exercise                           61.2 (31.2)
Strengthening exercise                        51.4 (28.7) (a)
Spinal mobilization                           63.0 (63.0)
Interferential current                        65.2 (29.5)
Soft tissue mobilization/massage              50.8 (34.0)
Heat                                          59.8 (35.9)
Ultrasound                                    51.4 (27.4)
Manual traction                               54.9 (29.4)
Posture correction                            22.5 (21.2)
Cardiorespiratory exercise                    41.6 (26.3)
Cold                                          47.9 (35.9)
Transcutaneous electrical nerve stimulation   35.1 (31.5)
McKenzie approach                             45.6 (31.3)
Simulation of activities of daily living      15.9 (15.4)
Simulation of work tasks                      16.3 (16.6)
Osteopathic approach                          27.1 (24.4)
Mechanical traction                           25.5 (26.8)
Spinal manipulation                           35.3 (28.9)
Neuromuscular electrical stimulation          32.0 (23.6)
Gym ball exercise                             21.3 (21.5)
Muscle re(education exercise                  26.3 (21.6)
Laser                                         24.5 (22.3)
Neural mobilization                           35.6 (34.8)

(a) Significant difference (P<.01) between groups of workers.

Table 5.
Interventions Showing Significant Change (P<.O1) in Frequency of Use
Across the Episode of Care

                                         No Radiating Pain (n=190)
                                         Mean % of Sessions

                                         Initial   Middle   Final
Intervention                             Third     Third    Third

Decrease
  Interferential current                 69.7      62.2     51.9
  Ultrasound                             67.3      55.5     42.8
  Manual traction                        NS (a)      NS       NS
  Cold                                   56.6      42.0     31.1
  McKenzie approach                      52.5      39.3     33.0
  Soft tissue mobilization/massage         NS        NS       NS
  Transcutoneous electrical              46.7      40.2     29.8
   nerve stimulation
  Posture correction                     40.2      24.5     18.9
Increase
  Strengthening exercise                 36.3      68.6     75.8
  Cardiorespiratory exercise             17.8      56.0     73.0
  Gym ball exercise                       8.3      28.1     40.6
  Simulation of work tasks                6.8      20.7     31.3
  Neuromuscular electrical stimulation   27.6      44.5     55.7

                                         Radiating Pain (n=139)
                                         Mean % of Sessions

Intervention                             Initial   Middle   Final
                                         Third     Third    Third

Decrease
  Interferential current                 72.0      67.8     55.3
  Ultrasound                             64.5      51.8     37.4
  Manual traction                        63.6      57.3     43.9
  Cold                                   60.2      46.8     36.0
  McKenzie approach                      58.3      47.2     31.7
  Soft tissue mobilization/massage       55.7      51.6     45.2
  Transcutoneous electrical              43.2      38.0     24.7
   nerve stimulation
  Posture correction                     35.9      17.6     14.3
Increase
  Strengthening exercise                 27.6      54.9     72.1
  Cardiorespiratory exercise             17.2      45.8     62.8
  Gym ball exercise                        NS        NS       NS
  Simulation of work tasks                4.1      16.8     29.0
  Neuromuscular electrical stimulation     NS        NS       NS

(a) NS-nonsigniflcant change.

Table 6.
Proportion of Physical Therapists Providing Education on Given Topics
at Least Once During the Episode of Care and Mean Proportion of
Sessions Where Education Was Provided During the Episode of Care

                                             % of Physical Therapists
                                             No Radiating Pain
Topic of Education                           (n=190)

Stretching exercise program                  92.6
Explanation of physical cause of back pain   92.1
Strengthening exercise program               84.2
Pain control                                 78.4
Activities at home: increase                 72.6
Activities of daily living                   70.5
Ergonomics/work tasks                        67.4
Posture education                            58.4
Activities at work: increase                 45.8
Activities at home: decrease                 37.4 (a)
Cardiorespiratory exercise                   35.3
Lumbar roll use                              30.0
Activities at work: decrease                 21.6
Lumbar corset use                             7.4

                                             Radiating Pain
Topic of Education                           (n=139)

Stretching exercise program                  91.4
Explanation of physical cause of back pain   93.5
Strengthening exercise program               76.3
Pain control                                 81.3
Activities at home: increase                 67.6
Activities of daily living                   79.9
Ergonomics/work tasks                        56.8
Posture education                            66.9
Activities at work: increase                 35.3
Activities at home: decrease                 59.0 (a)
Cardiorespiratory exercise                   47.5
Lumbar roll use                              43.9
Activities at work: decrease                 23.0
Lumbar corset use                            11.5

Topic of Education                           Mean % of Sessions (SD)

Stretching exercise program                  No Radiating Pain
Explanation of physical cause of back pain   (n=190)
Strengthening exercise program
Pain control                                 53.6 (33.4)
Activities at home: increase                 13.5 (12.4)
Activities of daily living                   46.7 (28.7)
Ergonomics/work tasks                        14.7 (15.9)
Posture education                            31.9 (22.8)
Activities at work: increase                 19.0 (17.8)
Activities at home: decrease                 21.8 (18.8) (a)
Cardiorespiratory exercise                   29.8 (25.6)
Lumbar roll use                              22.6 (18.3)
Activities at work: decrease                 13.1 (16.3)
Lumbar corset use                            27.4 (25.2)
                                             26.9 (27.6)
                                             14.3 (15.3)
                                             12.9 (18.4)
Topic of Education

Stretching exercise program                  47.9 (34.1)
Explanation of physical cause of back pain   12.0 (13.7)
Strengthening exercise program               42.6 (30.8)
Pain control                                 14.4 (16.01)
Activities at home: increase                 28.0 (21.7)
Activities of daily living                   17.4 (16.7)
Ergonomics/work tasks                        15.2 (15.5) (a)
Posture education                            23.6 (24.6)
Activities at work: increase                 18.0 (16.6)
Activities at home: decrease                 13.3 (14.3)
Cardiorespiratory exercise                   25.7 (26.5)
Lumbar roll use                              19.7 (26.5)
Activities at work: decrease                 15.6 (21.2)
Lumbar corset use                            11.2 (18.9)

Table 7.
Education Topics Showing Significant Change (P<.01) in Frequency of Use
Across the Episode of Care

                                  No Radiating Pain (n=190)
                                  Mean % of Sessions

                                  Initial   Middle   Final
Topic of Education                Third     Third    Third

Decrease
  Posture education               43.4      24.0     20.7
  Lumbar roll use                 40.5      22.3     15.2
  Activities of daily living      31.9      14.2     11.7
  Pain control                    29.9       7.5      5.9
  Explanation of physical cause   29.5       5.5      4.8
   of back pain
  Activities at home: decrease    24.0       9.1      5.7
  Activities at work: decrease    23.7      11.6      6.8
Increase
  Strengthening exercise          30.4      52.9     56.1
  Activities at home: increase    20.8      36.3     39.1
  Ergonomics/work tasks           17.1      20.5     28.5
  Cardiorespiratory exercise      14.9      30.9     36.4
  Activities at work: increase     5.0      22.4     40.9

                                  Radiating Pain (n=139)
                                  Mean % of Sessions

                                  Initial   Middle   Final
Topic of Education                Third     Third    Third

Decrease
  Posture education               37.6      19.5     14.2
  Lumbar roll use                 30.5      17.3     12.4
  Activities of daily living      28.5      13.3     10.6
  Pain control                    27.8       9.9      5.3
  Explanation of physical cause   22.9       9.0      4.8
   of back pain
  Activities at home: decrease    24.0       9.4      6.3
  Activities at work: decrease      NS (a)    NS       NS
Increase
  Strengthening exercise          28.3      45.3     54.1
  Activities at home: increase    18.9      29.3     35.3
  Ergonomics/work tasks             NS        NS       NS
  Cardiorespiratory exercise      15.9      27.3     34.8
  Activities at work: increase     2.3      14.6     37.8

(a) NS=nonsignificant change.