Welcome back to SpineIQ’s Back Blog! Last week we discussed self-management which is recommended as first-line treatment in every clinical practice guideline for low back pain. This week we will be discussing a treatment that is also recommended as first-line treatment in every clinical practice guideline for low back pain: advice.1–3 Patients consider consistent advice on diagnosis, prognosis, treatment options, and self-management strategies to be quite or extremely important.4 Therefore, a new article by Zadro et al. assessed the percentage of guideline concordant advice (e.g., advice to stay active, support self-management, or reassurance) and non-guideline concordant advice (e.g., advice promoting bed rest or time off work) delivered by physical therapists for low back pain.5
Objectives and methods
Along with patients considering advice as important for low back pain, advice is a necessary component of patient centered care. In order to deliver patient centered care, the patient must be given advice on their diagnosis, prognosis, and treatment options through an informed consent process.4 This allows the patient to play a meaningful role in shared-decision making, which is a cornerstone of patient centered care.6 In order to assess whether physical therapists are delivering advice and what type of advice, this study systematically assessed surveys and clinical notes. Guideline concordant advice was determined to be advice to stay active, support self-management, or increase reassurance. Non-guideline concordant advice was determined to be advice promoting bed rest of time off work.
For acute low back pain, 32% of physical therapy visits included guideline concordant advice and 9% of physical therapy visits included non-guideline concordant advice. For post-acute low back pain, 56% of physical therapy visits included guideline concordant and 1% of physical therapy visits included non-guideline concordant advice. For mixed duration low back pain (acute and post-acute), 50% of physical therapy visits included guideline concordant and 26% of physical therapy visits included non-guideline concordant advice
It is great to see that a low percentage of physical therapy visits include non-guideline concordant care. While advice promoting bed rest or time off work is considered guideline non-concordant, some patients and low back pain episodes may benefit from that advice in the short-term. Therefore, it is probably best that advice promoting bed rest of time off work is rare but not 0%. Unfortunately, guideline concordant advice is not delivered every visit with the largest median percentage being 56% for post-acute low back pain. Previous studies have reported that some clinicians believe that patients prefer passive treatment (e.g., massage, manipulation, heat, or ice) over advice to stay active.7 These beliefs may lead to clinicians not delivering guideline concordant advice as commonly as they could. Contrary to these beliefs, studies report that patients expect advice as much or more commonly than passive treatment.4,8 Clinicians should feel confident that patients are expecting consistent advice in understandable language on their diagnosis, prognosis, treatment options, and self-management strategies. This can help patients navigate the wide range of treatment and clinical options. The goal of helping the patient achieve a self-managed life with back pain, as well as seeking appropriate care when required should be the ultimate objective of every clinician.
- National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
- Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
- Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
- Lim YZ, Chou L, Au RT, et al. People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. J Physiother. 2019;65(3):124-135. doi:10.1016/j.jphys.2019.05.010
- Zadro JR, Elkins MR. Advice and education for spinal pain. J Physiother. Published online April 7, 2022. doi:10.1016/j.jphys.2022.03.006
- Greene SM, Tuzzio L, Cherkin D. A Framework for Making Patient-Centered Care Front and Center. Perm J. 2012;16(3):49-53.
- Kunstler BE, O’Halloran PD, Cook JL, et al. “<em>…like you’re pushing the snowball back up hill</em>”—the experiences of Australian physiotherapists promoting non-treatment physical activity: A qualitative study. AIMS Med Sci. 2018;5(3):224-237. doi:10.3934/medsci.2018.3.224
- Kunstler B, Fuller R, Pervan S, Merolli M. Australian adults expect physiotherapists to provide physical activity advice: a survey. J Physiother. 2019;65(4):230-236. doi:10.1016/j.jphys.2019.08.002
This is wonderful. We need to revamp education in the rehabilitation world to reflect this reality. There is no place for bad advice in health care.
Thanks for sharing this interesting work. With spine related disorders, what the clinician does not do is probably more important than what the clinician does ie. avoid imaging unless clear indications, avoid invasive procedures unless clear indications, avoid opioids, avoid passive care unless used as springboard to active care.
So it is reassuring that the guideline discordant care numbers are relatively low.