Elsevier

Manual Therapy

Volume 11, Issue 4, November 2006, Pages 272-278
Manual Therapy

Original article
Exercise therapy for low back pain: A small-scale exploratory survey of current physiotherapy practice in the Republic of Ireland acute hospital setting

https://doi.org/10.1016/j.math.2005.06.002Get rights and content

Abstract

A small-scale exploratory cross-sectional survey investigated the current use of a range of exercise therapy approaches for low back pain (LBP) by outpatient physiotherapists in the acute hospital setting in the Republic of Ireland, where the majority of publicly funded treatment is delivered.

Of the 120 postal questionnaires distributed to 24 physiotherapy departments, 87 were returned (72.5% response rate). The results showed specific spinal stabilization exercises were the most popular exercise therapy for acute (39%; n=35) and chronic (51%; n=48) LBP, followed by the McKenzie approach (acute LBP (ALBP) 35.6%; n=32: chronic LBP (CLBP) 17%; n=16), and abdominal exercise (ALBP 11.1%; n=10: CLBP 9.6%; n=9).

The most popular forms of exercise therapy used by outpatient physiotherapists in acute hospital settings in Ireland lack support from evidence-based clinical guidelines, and further large-scale high quality randomized controlled trials of these approaches are warranted. Further research should also establish the use of exercise therapy and attitudes to clinical guidelines of physiotherapists in other countries and healthcare settings.

Introduction

At the beginning of the 21st century low back pain (LBP) continues to exact a huge toll in terms of suffering and costs (Waddell, 2004). The lifetime and 1-year prevalence of LBP are approximately 60–80% (Torstensen et al., 1998), and 34% (Croft et al., 1999), respectively. While the majority of acute episodes resolve within 12 weeks, the recurrence rate is high; in a large-scale prospective cohort study one third of subjects reported persistent, disabling LBP 12 months after initial medical consultation (Thomas et al., 1999). In the Republic of Ireland (ROI) the treatment of LBP costs the Exchequer over €32 million per annum, and represents 27% of disability payments at a cost of €500 M (Leech, 2004).

While the ROI Health Strategy (2001) proposed the primary care setting as the central focus for the delivery of health and personal social services for the majority of patients’ in Ireland through the development of numerous inter-disciplinary community-based primary care teams that included physiotherapy, there have been significant delays in its implementation. Consequently, current physiotherapy services for publicly funded LBP patients are largely provided within the secondary care acute hospital setting (Moore and Hurley, 2004). In the current economic climate of limited resources for health care spending and growing waiting lists for physiotherapy, it is important to establish if the treatment provided to patients with LBP is supported by the current evidence base.

Nonetheless, the evidence base is conflicting in terms of its support for exercise therapy in acute and chronic LBP (CLBP) conditions. Recent systematic reviews have concluded that exercise is a safe and effective therapy for improving flexibility, strength and function, and reducing pain in CLBP patients compared to usual care (van Tulder et al., 2000; Liddle et al., 2004; Rainville et al., 2004; van Tulder and Koes, 2004a). Available CLBP clinical guidelines advocate some form of exercise therapy, but the type and intensity of the exercise varies from a general active approach (Netherlands, Denmark), to intense exercises (Finland) and multimodal exercises (Germany; Koes et al., 2001). Conversely, systematic reviews of acute LBP (ALBP) have found the effects of back exercises either equivocal or more harmful than other conservative or inactive treatments (van Tulder et al., 2000; van Tulder and Koes, 2004b). Clinical guideline recommendations for ALBP show some variation; the recently developed European clinical guideline (van Tulder et al., 2002), and several national guidelines (i.e. Netherlands, UK, New Zealand, Australia, Sweden) only advocate exercise in the form of advice to stay active and do not support specific strengthening, flexibility, flexion or extension exercises (Koes et al., 2001). The American and Swiss guidelines state that low-stress aerobic exercises are a therapeutic option in ALBP, while the Danish guideline specifically mentions McKenzie exercises (Manniche, 1999). There is a broader consensus among guidelines recommending the use of physical reconditioning programmes for subALBP of at least 6 weeks duration (Koes et al., 2001; van Tulder et al., 2002). The inconsistency between both systematic reviews and clinical guidelines are partly related to differences in the definitions of ALBP and CLBP, as well as variation in the composition and methodology of review and guideline committees, and disparity in the availability and interpretation of the most recently published randomized controlled trials in the area. Furthermore, the development, reporting and content of primary care guidelines for LBP are not of uniform high quality (van Tulder et al., 2004), and the characteristics of guideline developers cannot be used as a reliable proxy for guideline quality (Eccles and Grimshaw, 2004).

Previous postal surveys have established the physiotherapeutic management of patients with LBP in the ROI/Britain (Foster et al., 1999) and Northern Ireland (Gracey et al., 2002). The study by Foster et al. included a sample of physiotherapists working in Health Board and private settings in the ROI (36.3%; n=295), but did not distinguish between the findings for this subgroup and the remaining 64% from Britain. Details of the types of exercise therapy utilized by therapists were limited to the McKenzie approach (46.6% Foster et al., 1999; 71.4% Gracey et al., 2002), abdominal exercise (17.5% Foster et al., 1999), active exercise (26.9% Gracey et al., 2002), and muscle re-education (8.1% Gracey et al., 2002), and failed to discriminate between patients with ALBP and CLBP.

Therefore, the aim of the study was to explore the current use of a range of exercise therapy approaches by outpatient physiotherapists in acute hospital settings in the ROI by means of a postal questionnaire.

Section snippets

Survey instrument

The survey instrument was developed following a literature review to enhance its content validity. A pilot study involving two physiotherapists working in private practice established its face validity and identified the need for minor amendments. The resultant questionnaire comprised three sections (i) ‘therapists’ (i.e. clinical grade, years experience and speciality), (ii) ‘LBP caseload’ (i.e. percentage of patients with LBP on therapists’ caseloads and the ratio of acute [0–3 months LBP] to

Survey response

Of the total of 120 questionnaires distributed, 87 completed questionnaires (72.5% response rate) were returned.

Therapist information

The majority of respondents 58.6% (n=51) worked at the level of Senior Grade, with 35.6% (n=31) working at Basic Grade level and the remaining 5.8% (n=5) working as clinical tutors or managers. The therapists were evenly distributed in terms of years since qualification; approximately 25% (n=22) of respondents were qualified for each of 1–3 years, 4–6 years, 7–10 years and over 10

Discussion

This small-scale survey explored for the first time the use of a range of exercise approaches by outpatient physiotherapists in the acute hospital setting in the ROI for the management of both acute and CLBP. An excellent response rate of 72.5% was achieved, which compares favourably with previous physiotherapy surveys (Foster et al., 1999; Konstantinou et al., 2002). Nonetheless, the study is limited by its sampling method, small sample size and potential non-response bias that should be

Conclusion

The findings of this small-scale study have provided an insight into contemporary exercise therapy practice for LBP among a sample of physiotherapists working in the acute hospital sector in Ireland. Although lacking support from evidence-based clinical guidelines, specific spinal stabilization exercises and the McKenzie approach were the most commonly used forms of exercise therapy.

Acknowledgements

The authors gratefully acknowledge the physiotherapists working in acute public hospitals in the Republic of Ireland who took part in this study.

References (40)

  • D.C. Cherkin et al.

    A comparison of physical therapy, chiropractic manipulation and provision of an educational booklet for the treatment of patients with low back pain

    New England Journal of Medicine

    (1998)
  • P.R. Croft et al.

    Short-term physical risk factors for new episodes of low back pain

    Prospective evidence from the South Manchester Back Pain Study. Spine

    (1999)
  • M.P. Eccles et al.

    Selecting, presenting and delivering clinical guidelines: are there any “magic bullets”?

    Medical Journal of Australia

    (2004)
  • Foster NE, Doughty G. Using clinical guidelines and research evidence in the management of back pain patients: a...
  • N.E. Foster et al.

    Management of non-specific low back pain by physiotherapists in Britain and Ireland

    Spine

    (1999)
  • Golby L, Moore A, Doust J, Trew M. A randomised controlled trial investigating the efficacy of manual therapy,...
  • J.H. Gracey et al.

    Physiotherapy management of low back pain: a survey of current practice in Northern Ireland

    Spine

    (2002)
  • J.M. Grimshaw et al.

    Effectiveness and efficiency of guideline dissemination and implementation strategies

    Health Technology Assessment

    (2004)
  • Quality and fairness—a health system for you

    (2001)
  • J.A. Hides et al.

    Long term effects of specific stabilising exercises for first-episode low back pain

    Spine

    (2001)
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