Elsevier

Manual Therapy

Volume 14, Issue 2, April 2009, Pages 189-196
Manual Therapy

Original article
Physiotherapists' use of advice and exercise for the management of chronic low back pain: A national survey

https://doi.org/10.1016/j.math.2008.01.012Get rights and content

Abstract

The objective of the study was to establish the specific use of advice and exercise by physiotherapists, for the management of chronic low back pain (LBP). A questionnaire was mailed to a random sample of 600 members of the Irish Society of Chartered Physiotherapists. Open and closed questions were used to obtain information on treatments provided to chronic LBP patients. Respondents' treatment goals were also investigated, along with the typical methods used to assess treatment outcome. Four hundred and nineteen of the sample returned the questionnaire; 280/419 (67%) indicated that they currently treated LBP of which 76% (n = 214) were senior grade therapists. Advice and exercise, respectively, were the treatments most frequently used for chronic LBP: advice was most commonly delivered as part of an exercise programme, with strengthening (including core stability) the most frequently used exercise type. Supervision of exercise and follow-up advice were underutilised with respect to the recommendations of relevant clinical guidelines. Pain relief was an important treatment goal. Emphasis on exercise programme supervision, incorporating reassurance that its safe to stay active and ‘hurt does not mean harm’, must be more effectively disseminated and promoted in practice. The influence of follow-up advice on exercise adherence warrants further investigation.

Introduction

The intractability of chronic low back pain (LBP; i.e. symptoms > 12 weeks or 3+ recurrent episodes within 12 months) has led to the adoption of a wide variety of treatment approaches by healthcare professionals (Cherkin, 1998, Foster et al., 1999, Gracey et al., 2002, Armstrong et al., 2003, Snook, 2004), with variable results (Cottingham and Maitland, 1997, Carpenter and Nelson, 1999, Miller and Timson, 2004). The resulting socioeconomic implications have been identified by various authors (Maniadakis and Gray, 2000, Bartley and Coffey, 2001, Ehrlich, 2003, Speed, 2004, Waddell, 2004). Current research evidence supports the use of advice and exercise for the management of chronic LBP (Hilde et al., 2002, Liddle et al., 2004, van Tulder et al., 2004, Hayden et al., 2005, Liddle et al., 2007a), and previous surveys investigating the physiotherapeutic management of LBP throughout the UK and Ireland have highlighted the popularity of these treatments (Foster et al., 1999, Gracey et al., 2002, Byrne et al., 2006).

Kerssens et al. (1999), is one of few studies that have investigated the advice given to LBP patients; their report, compiled from a database of private practice consultations within the Netherlands, concluded that physiotherapists' advice for LBP management is often dependent on the individual therapist, with many differences between therapists in the amount of information provided during treatment, and in the provision of follow-up support after treatment. These findings, along with the conclusions from a recently published systematic review of the use of exercise for chronic LBP (Hayden et al., 2005) have underlined the benefits of individually tailored exercise programmes, and the influence of supervision during treatment on adherence. Similarly, when compared to a general exercise programme, one that was individually tailored to the needs and capabilities of the patient was shown to be more effective in reducing the disability and pain experienced by subacute and chronic LBP patients (Descarreaux et al., 2002).

The maintenance of exercise-induced gains is often the most challenging aspect of exercise prescription, being intricately related to the successful integration of exercise science with behavioural techniques, in order to promote adherence and individual goal achievement (ACSM, 2000, p. 140). Kerssens et al. (1999) concluded that the majority of advice or information that was being given to LBP patients was specifically related to home exercises and back care instructions. There is now strong evidence from randomised controlled trials (RCTs) using advice for the management of chronic LBP, to support the use of advice to remain active in addition to specific advice relating to the most appropriate exercise, and/or functional activities for each individual patient (Liddle et al., 2007a). European guidelines for the management of chronic LBP (Airaksinen et al., 2004) support the above, however, there is evidence to suggest that such guidelines and recommendations are frequently not applied in practice (Armstrong et al., 2003, Grol and Buchan, 2006).

No previous LBP surveys have specifically investigated the use of both advice and exercise for the management of chronic LBP in current practice, in particular the type and frequency of advice and exercise being offered. Therefore the aim of this survey was to establish the relative importance of advice and exercise for the management of chronic LBP amongst physiotherapists practicing throughout Ireland, with a specific focus on how these treatment approaches would typically be provided. In addition, given the inherent association between therapists' treatment goals, and their choice of treatment, respondents' treatment goals, and typical methods of assessing the outcome of treatment were also investigated.

Section snippets

Survey design

A cross-sectional (self-administered) postal questionnaire was developed to investigate physiotherapists' use of advice and exercise for the management of chronic LBP: the specific information requested within this study precluded the use of any previously validated questionnaire for this purpose. For the purposes of this survey, chronic LBP was defined as representing patients with symptoms of greater than 12 weeks duration, or those with 3 or more recurrent episodes within the previous 12

Respondents

There was a 70% response rate to the survey (n = 419); 67% of respondents (n = 280/419) indicated that they currently treated LBP patients, and therefore completed the entire questionnaire: 43% (n = 119/280) were employed in a public hospital, and 41% (n = 115/280) in private practice. The remaining respondents (n = 139) did not treat LBP: 93 were employed in a public or private hospital, 34 in community care and learning disabilities, 5 in private practice, and 7 in third level education. Twenty-seven

Discussion

The principal findings of this national survey indicate that the most frequently used treatments adopted for chronic LBP, within the Irish health system (public or private sectors), are advice and exercise respectively. However, despite current recommendations that it is safe for this patient subgroup to remain active, that ‘hurt does not mean harm’, and respondents' recognition of the primary importance of functional improvement, it appears that pain relief continues to be a major treatment

Conclusion

The findings of this survey demonstrate that respondents working in the public or private sector throughout Ireland recognise the value of advice and exercise for the management of chronic LBP. There is also evidence that a variety of treatments are being used alongside advice and exercise. The use of exercise programme supervision and follow-up advice, which are both considered important in facilitating the maintenance of advice and exercise-induced treatment gains, are not widely used by

Acknowledgements

The authors gratefully acknowledge the physiotherapists who took part in this study, and the support of the Department of Employment and Learning (Northern Ireland). There are no conflicts of interest.

References (44)

  • A.F. Bendix et al.

    A prospective, randomised 5-year follow-up study of functional restoration in chronic low back pain patients

    European Spine Journal

    (1998)
  • C. Bombardier

    Outcome assessments in the evaluation of treatment of spinal disorders

    Spine

    (2000)
  • C. Bombardier et al.

    Minimal clinically important difference. Low back pain: outcome measures

    Journal of Rheumatology

    (2001)
  • D.M. Carpenter et al.

    Low back strengthening for the prevention and treatment of low back pain

    Medicine and Science in Sports and Exercise

    (1999)
  • D.C. Cherkin

    Primary care research on low back pain: the state of the science

    Spine

    (1998)
  • I. Cohen et al.

    Aggressive exercise as treatment for chronic low back pain

    Sports Medicine

    (2002)
  • J.T. Cottingham et al.

    A three-paradigm treatment model using soft tissue mobilisation and guided movement-awareness techniques for a patient with chronic low back pain: a case study

    Journal of Orthopaedic and Sports Physical Therapy

    (1997)
  • R. Davey et al.

    Group rehabilitation for chronic back pain: a pilot study

    British Journal of Therapy and Rehabilitation

    (1998)
  • R.A. Deyo et al.

    Low back pain

    The New England Journal of Medicine

    (2001)
  • R.A. Deyo et al.

    Outcome measures for low back pain research: a proposal for standardised use

    Spine

    (1998)
  • E.A. Domholdt et al.

    Evaluating research literature: the educated clinician

    Physical Therapy

    (1985)
  • P. Edwards et al.

    Methods to influence response to postal questionnaires (Cochrane methodology review)

    The Cochrane Library

    (2002)
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