Clinical decision-making in physiotherapy for low back pain in primary health care

Background and Aims: Low-back pain (LBP) is a complex and heterogeneous disorder commonly encountered at physiotherapy clinics, with most cases associated with an unknown cause (NSLBP). Identifying LBP subgroups for targeted treatment has been highlighted as a priority research task. It is unclear how various physiotherapy treatment options are selected and matched to patients with nonspecific low back pain (NSLBP) in primary healthcare. The main purpose of this thesis was to explore physiotherapists’ clinical decision-making in LBP, through the development and evaluation of a new decision-making treatment-strategy-based classification system (TREST) and through interviews with clinical physiotherapists (PTs) in primary healthcare.

Designs and participants: This thesis is based on four studies with divers designs. Study I, a multicase study with descriptive and pre-post-test experimental design, included one single physiotherapist and 16 patients with NSLBP and presents and describes a treatment-strategy-based classification (TREST) process. Study II investigates inter-examiner agreement between 4 experienced and Orthopaedic Manual Therapy (OMT) trained PTs (2 pairs) on the categorization of 64 patients with NSLBP to TREST subgroups and on 5 of its suggested subgroup criteria. Study III employs secondary logistic multiple regression analyses of the 128-examination data collected in Study II to examine the feasibility of subgroup criteria included in TREST. Study IV is a qualitative descriptive study exploring clinical reasoning in the decision-making and treatment of NSLBP in primary healthcare, through semi-structured interviews with 15 clinical PTs care in two different regions in Sweden.

Results: Study I describes the categorization of NSLBP into one of four treatment-based subgroups: pain modulation, stabilization exercise, mobilization, and training and the criteria for each subgroup. Study II shows substantial chance corrected inter-examiner agreement for the categorization to subgroups, whereas agreement on suggested criteria varied from fair (specific segmental signs, specific movement pattern) and moderate (uni-bilateral spinal signs, irritability), to almost perfect (neurological signs and symptoms). Study III identifies how the individual PTs applied criteria in the subgroup categorization and support feasibility of criteria: the presence or absence of neurological signs and symptoms, bilateral spinal signs and segmental signs as well as level of irritability and disability, in the categorization of NSLBP. In Study IV, decision-making was influenced by working approach at workplaces and healthcare priorities, disorder categorization and bodily examination findings, patients’ capabilities and participation and physiotherapists’ convictions and terms as well as their confidence in treatment and themselves, while insufficiency limited their decision-making. Treatment focuses on patient education and physical exercise as well as combining treatments and treating with atypical goals.

Conclusion: TREST can be reliably used by experienced OMT trained physiotherapists to categorize NSLBP to subgroups and inter-examiner agreement was moderate to almost perfect from three out of five examination items. Feasibility are supported for TREST subgroup criteria: neurological signs and symptoms; bilateral spinal signs; segmental signs; as well as level of irritability and disability. Decision-making was influenced by external circumstances (workplace and healthcare priorities), the disorder (categorization and bodily examination findings), patients (capabilities and participation), physiotherapists (personal convictions and terms, confidence in treatments and themselves, while insufficiency limited their decision-making). Treatment focuses on patient education, physical exercise and combined treatments.

List of scientific papers

I. Widerström B, Olofsson N, Arvidsson I. Manual therapy and a suggested treatment based classification algorithm in patients with low-back pain: A pilot study. J of Back and Musculoskeletal Rehabilitation. 2007;20(2,3):61-92.
https://doi.org/10.3233/BMR-2007-202-303

II. Widerström B, Olofsson N, Arvidsson I, Harms-Ringdahl K, Evers Larsson U. Inter-examiner reliability of a proposed decision-making treatment-based classification system for low-back pain patients. Manual Therapy. 2012;17:164-171.
https://doi.org/10.1016/j.math.2011.12.009

III. Widerström B, Olofsson N, Boström C, Rasmussen-Barr E. Feasibility of subgroup criteria included in the treatment-strategy based classification system for patients with non-specific low-back pain. Manual Therapy. 2016;23:90-97.
https://doi.org/10.1016/j.math.2016.01.002

IV. Exploring physiotherapy clinical reasoning in the decision-making and treatment of non-specific low-back pain in primary health care. Widerström B, Rasmussen-Barr E, Boström C. [Manuscript]