Elsevier

Physiotherapy

Volume 89, Issue 2, February 2003, Pages 82-96
Physiotherapy

Guidelines
Dutch Physiotherapy Guidelines for Low Back Pain

https://doi.org/10.1016/S0031-9406(05)60579-2Get rights and content

Summary

Many guidelines for the management of low back pain in primary care have been published during recent years, but guidelines for physiotherapy do not yet exist. Therefore, physiotherapy guidelines have been developed, reflecting the consequences of the current state of knowledge of effective and appropriate physiotherapy for low back pain. They aim to improve the efficiency and effectiveness of physiotherapeutic care for patients with low back pain.

The guidelines were constructed on the basis of the phases of the physiotherapy process, using the Dutch method of developing physiotherapy guidelines. Scientific evidence of systematic reviews was used as the basis for the recommendations. A computerised literature search of Medline, Cinahl, the Cochrane Database of Systematic Reviews and the Database of the Dutch National Institute of Allied Health Professions was conducted to identify relevant systematic reviews. If no evidence was available, consensus between experts was obtained.

The guidelines were pilot tested among one hundred physiotherapists and reviewed by an external multi-disciplinary panel.

The guidelines recommend that the diagnostic process should focus on disability and participation problems resulting from back pain. The treatment should consist of an active approach, in which the patients learn to take control over their back pain. For patients with a normal course, where activities and participation gradually increase, reassurance, adequate information and advice to stay active are the most important recommendations. For patients with an abnormal course, where activities and participation do not increase, exercise therapy should also be provided, with a behavioural approach if necessary.

These are the first national physiotherapy guidelines for low back pain. The recommendations are largely in line with other primary care guidelines for low back pain. Implementation will be a major challenge for the near future.

Introduction

Evidence-based healthcare has received increased attention during the last decade and is important to monitor and improve quality of care. Guidelines are useful tools in this process aiming at changing behaviour of healthcare professionals, if needed. Low back pain is a good example of a field where evidence has been pro-vided by many randomised trials and summarised in many systematic reviews. At least 12 guidelines for low back pain in primary care have been published, but none of them specifically for physio-therapy (Koes et al, 2001). However, physiotherapy management of low back pain also needs to move forward in the mainstream of evidence-based healthcare. The need for an evidence-based and more uniform approach is signalled by the variation in treatment of low back pain, both nationally (van der Valk et al, 1995) and internationally (Foster et al, 1999; Li and Bombardier, 2001) and the lack of evidence-based guiding principles.

The Dutch physiotherapy guidelines for low back pain presented in this paper embody the physiotherapeutic diagnostic and therapeutic process in patients with low back pain. Manual therapy is not included in these guidelines because these techniques demand specific know-ledge and skills. For this reason, separate guidelines for manual therapy are being developed in the Netherlands.

In the Netherlands, patients do not have open access to a physiotherapist; they need a referral from a general practitioner or another physician. Consequently, these guidelines focus on patients with low back pain who are referred for physiotherapy.

Their aim is to improve the efficiency and effectiveness of physiotherapy man-agement in patients with low back pain by translating research findings into clinically relevant recommendations, by explicitly describing the role of physio-therapists in the care for patients with low back pain, and by improving collab-oration with other primary care providers.

The concept of ‘low back pain’ in these guidelines refers to ‘non-specific low back pain’, defined as low back pain without a specified physical cause, eg nerve root compression (radicular syndrome), trauma, infection or tumour. In an estimated 90% of patients with low back pain no specific medical diagnosis is made (Nachemson, 1992). Recurrent back pain is defined as several episodes of back pain within one year, the total duration of which amounts to less than six months (Von Korff, 1994). The duration of a low back pain episode can be classified as acute (0-6 weeks), sub-acute (7-12 weeks) or chronic (longer than 12 weeks).

Of the total population, 60% to 90% will experience an episode of low back pain at some time, the annual incidence of being 5% (Frymoyer, 1988). For physiothera-pists in the Netherlands, low back pain is a common referral diagnosis; 27% of all patients referred to a physiotherapist have low back pain (Van Ravensberg et al, 1995).

Physiotherapists describe the health problems of patients with low back pain in terms of impairments, disabilities and participation difficulties.

  • Impairments are manifestations of a disorder referring to body structure or physiological and psychological function, for example decreased muscle strength, pain, sensory impairments or fear of movement.

  • Disabilities refer to problems in the performance of activities such as bending, reaching or walking.

  • Participation problems refer to problems an individual may have in relation to his social life, for example work.

These concepts are derived from the International Classification of Human Functioning, Disability and Health (WHO, 2001). Their use is meant to promote uniformity in the rehabilitation professions.

In the traditional (biomedical) model pain is a direct consequence of under-lying pathology. The symptoms will dim-inish if the pathology is removed. This model cannot easily explain chronic complaints, like chronic low back pain, because there is no clear correlation bet-ween symptoms and pathology. There-fore, the current approach to chronic low back pain tends to be increasingly inspired by the bio-psychosocial per-spective. In this perspective (low back) pain is the result of the interaction between biological, psychological and social factors (Waddell, 1987, Waddell, 1992, Waddell, 1998). Psychosocial factors in particular are supposed to become more important in the transition from acute to chronic and in chronic low back pain.

In an open population the prognosis is usually favourable; in an estimated 75% to 90% of patients back pain disappears spontaneously within four to six weeks (Waddell, 1998). In patients visiting a general practitioner because of their back pain, the prognosis is a little less fav-ourable; 65% are free of symptoms after 12 weeks (Van de Hoogen et al, 1998).

Low back pain often recurs; 75% of patients who seek help from their general practitioner suffer at least one relapse within the year (Van de Hoogen et al, 1998). The persistence of back pain does not necessarily indicate a less favourable prognosis. There is growing consensus that the extent of disability is the most important predictor of outcome in low back pain (Von Korff and Saunders, 1996).

Linton (2000) performed a systematic review regarding the relationship between psychological factors and neck and back pain. The review included 36 prospective studies. Based on several clinically rel-evant and methodologically sound studies, Linton concluded that psychological factors are strongly associated with the change from acute to chronic pain, and with disability. Also, it becomes clear that psychosocial factors generally have a bigger impact on disabilities than biomedical and biomechanical factors. Aspects such as attitudes and emotions of the patient are important: passive coping strategies, perceptions about pain, and emotions such as depression or fear are highly associated with pain and disabilities. Also, there is moderate to strong evidence that these psychosocial factors may, in the long term, predict pain and disabilities.

Waddell and Waddell (2000) conducted a systematic review on the influence of social factors on back and neck pain. They conclude that the studies investigated are of poor methodological quality, although there are many indic-ations that social factors may be related to back and neck pain.

The only social factors which show consistent findings, in either one syst-ematic review or in more than two meth-odologically sound studies, are lower social class, and lower work satisfaction. The authors emphasise that social factors are not a risk factor for the development of back or neck pain, but that they may well influence it, and also the way in which patients cope with their complaints.

Patients may cope with their complaints either adequately or inadequately. This is called ‘active or passive coping' (Folkman and Lazarus, 1980).

Active coping means that people under-take actions by themselves to control the pain (for example by looking for dis-traction, or by moving). Low back pain patients who manage to adjust their act-ivities appropriately have an active (or adequate) coping strategy. Passive coping refers to the adoption of a passive attitude (resting or using medication), or depend-ing on others as a way of controlling pain (Jensen et al, 1991). Patients who restrict their movements because of low back pain, who persist in avoiding certain activities or rest a lot to relieve the pain, have passive (or inadequate) coping strategies. Active coping is associated with better functioning, while passive coping is associated with worse functioning (Jensen et al, 1991).

The way in which a person copes with his complaints will be determined by patient characteristics (significance and sense of control), as well as by the interactions between the person and his personal environment.

The significance which people attach to symptoms is based on the subjective perception and interpretation of stimuli. If significance does not seem to cor-respond with an objective reality, a logical error is being made. A common logical error is ‘to catastrophise', which means that the pain, and the situation in which the pain presents, are being considered a serious threat, ‘a catastrophe'.

The extent to which patients feel that they have control over the pain is also important. They may feel that their health is mainly controlled by themselves (‘internal locus of control'), or by other people or circumstances (‘external locus of control': patients give other people, for example physiotherapists, control over their health – Härkäpää et al, 1996). An internal locus of control is often related to active coping and, subsequently, to a better way of dealing with the pain (Jensen et al, 1991).

Both the significance attached to the pain and the perceived sense of control may determine movement behaviour. For instance, when pain is considered as a signal of possible injury (catastrophe), the chances will be high that this will result in fear of movement. Fear of movement is the fear that movement will result in (new) pain or (re)injury, which will, in turn, lead to avoidance (Vlaeyen et al, 1995). Also when, based on previous experiences, patients expect certain activities to increase the pain and that they have no control over this (low level of control), the chances are that this situation will be avoided.

The interaction between patients and their environment (social factors) also plays a role in their coping strategy. Very protective partners, but also contradictory information and recommendations by different healthcare providers, may frighten patients and influence their coping strategy negatively. Physio-therapists' attitudes may also play a role, for example paying too much attention to pain and not encouraging patients' independence may affect the course in a negative way.

Section snippets

Method of Guideline Development

These guidelines are systematically developed according to the method of Physiotherapy Guidelines Development in the Netherlands (Hendriks et al, 2000b).

The members of the working group (authors) of the Low Back Pain Guide-lines are all either experienced phys-iotherapists in low back pain or re-searchers in physiotherapy and low back pain. An external group of ten experts from relevant disciplines (a general practitioner, an occupational physician, a rehabilitation physician, an orthopaedic

Treatment of Patients with Low Back Pain with a Normal Course

The starting point is that patients cope adequately with their symptoms. One treatment session in which the physiotherapist gives education and exercise therapy, if needed, should therefore be sufficient. If necessary, a second app-ointment may be made, in order to evaluate the course of disability and participation problems.

Discussion

In the Netherlands seeking care for low back pain usually starts with consulting a general practitioner (primary care physician), who decides if and which treatment is necessary. The Dutch general practice guidelines favour a wait-and-see policy in acute patients with low back pain and do not recommend a referral to physiotherapy within the first six weeks (Faas et al, 1996). In practice, however, general practitioners refer patients within six weeks (Schers et al, 2001).

The physiotherapy

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