1 INTRODUCTION

Low back pain (LBP) is a leading cause of disability worldwide (Buchbinder et al., 2018). In the UK, LBP is the largest single cause of disability accounting for 11% of disability. It is estimated that LBP is responsible for 37% of all chronic pain in men and 44% in women, with the total cost to the UK economy estimated to be over £12 billion per year (NICE, 2016). The prevalence of LBP is thought to be increasing due to an increasing and ageing population (Buchbinder et al., 2018).

Most LBP is termed non-specific low back pain (NSLBP) because the pathoanatomical cause for pain cannot be determined (Maher et al., 2017). National clinical guidelines recommend a biopsychosocial approach to the management of people with NSLBP (Foster et al., 2018). The implementation of effective treatment in line with current guidelines is an international healthcare priority (Buchbinder et al., 2018). In the UK, National Institute for Health and Care Excellence (NICE) (2016) guidelines provide evidence-based recommendations to guide clinical practice for the assessment and treatment of people with LBP with/without sciatica (NICE, 2016). They recommend the provision of information and advice to support a person's ability to self-manage and to consider offering exercise, manual therapy (as part of a treatment package including exercise, combined physical and psychological programs) and psychological therapies (only as part of package including exercise, with or without manual therapy). The use of acupuncture, electrotherapy (percutaneous electrical nerve stimulation or transcutaneous electrical nerve stimulation, interferential), tractions, orthotics, belts and corsets is not recommended.

The updated NICE guidelines (NICE, 2016) were intended to overcome inconsistencies in the commissioning of back pain pathways and pain management programs as well as improving implementation of the guidelines due to clinicians' beliefs that previous recommendations were constraining (Slade et al., 2015). More generally, guidelines have been developed to assist practitioners' decisions about appropriate healthcare, thereby decreasing the gap between research and practice thus reducing variability in practice. Despite the progress made by developing and updating evidence-based guidelines, evidence exists to suggest that the implementation of current guidelines is not yet optimal. The overall extent to which physiotherapists choose recommended, not recommended and treatment with no recommendation for various musculoskeletal (MSK) conditions including LBP has been documented in a systematic review (Zadro et al., 2019). This included studies from across the world highlighting that many physiotherapists did not seem to follow guidelines when managing MSK conditions. According to the review, 35% (25%–76%) of physiotherapists treating patients with LBP provided (or would provide) treatments that were recommended, 44% (34%–61%) provided treatments that were not recommended and 72% (49%–96%) provided treatment that had no recommendation (Zadro et al., 2019).

The guidelines are based on reviews of contemporary research. However, evidence-based practice is more complex and nuanced, incorporating this evidence with clinical expertise and patient preference when making shared-decisions alongside patients. Contemporary debates recognise the benefits of guidelines in helping clinicians who need information regarding the evidence, but also acknowledge them as hegemonic force of consensus and conformity that miss the nuances needed for treating individual persons (Copeland, 2020). A review synthesising results from qualitative and quantitative studies from outpatient settings concluded that physiotherapy treatment decisions in LBP are usually based on facilitating the relationship with the patient and expected patient engagement with treatment and/or self-management (Gardner et al., 2017). Whilst factors influencing decision making processes of an individualised treatment approach have been documented (Widerström et al., 2019), the complexities of such individualised approaches have not been recognised in recent LBP recommendations (Foster et al., 2018). Qualitative research conducted in a primary healthcare setting has provided a clinical perspective on the complexity of individualised treatment approaches that is not recognised in LBP guidelines. Specific characteristics of the patient, the assessment as well as the practitioners working environment, personal convictions, constraints and emotions have been shown to influence decisions for individualised care of patients with LBP (Widerström et al., 2019). Further, qualitative research has recently described how practitioners have combined treatments as well as applied treatments for atypical purposes in order to enhance treatment effectiveness, reach out to patients, facilitate the handling of complex situations and overcome personal shortcomings (Widerström et al., 2019). As a result, it is important to examine the combinations of treatments provided in practice to provide insight into the complexities of clinical decision making within this context.

Whilst the extent to which physiotherapists adhere to guidelines for LBP has been documented (Zadro et al., 2019), no study has examined the combinations of treatment offered. Such understanding will enable us to ascertain the extent to which patients receive treatment that is solely in line with the recommendations; the extent to which patients receive recommended treatment that is being provided alongside other treatments that are not recommended or have no recommendation; and the extent to which patients receive only treatments that are not recommended or have no recommendation. This is significant given the context in which clinical decision making occurs and in which clinicians balance patient expectation and preference with clinical guidelines to facilitate the patient-practitioner relationship and engages the patient in treatment and/or self-management.

The aim of this research was therefore to summarise the combination of treatments provided for patients with LBP within private practice in the UK and the extent to which these combinations of treatments are in agreement with evidence-based guidelines.

2 METHODS 2.1 Study design

A cross-sectional study was performed through an online standardised data collection (SDC) system, full details of which are reported by Moore et al. (2012). The SDC system recorded information on patient details, diagnosis, referral information, body site and symptoms, treatment details and discharge information (i.e., outcome of referral and goal achievement). The use of an SDC system ensures data is collected in a systematic and agreed format, therefore improving data quality.

2.2 Sampling and recruitment

All registered MSK physiotherapists in private practice in the UK who are Physio First members (the trade Organisation for Chartered Physiotherapists in Private Practice) were invited to participate in SDC, named the Data for Impact project. Practitioners were recruited through advertisements via Physio First in-house communication, email networks and at national physiotherapy conferences. Practitioners were asked to input data on all new MSK patients via the online SDC system.

2.3 Data collection

The online SDC was administered through Filemaker Pro. Practitioners recruited to the study were provided with instructions concerning how to access and enter data onto the online SDC. Patient records submitted via the online system between January 2017 and January 2020 were included in the analyses. Practitioners commenced data collection following their recruitment to the study.

2.4 Classification of treatments

Practitioners were able to report up to six initial treatment modalities. Treatments were classified according to the NICE guidelines (NICE, 2016) as ‘recommended’, ‘not recommended’ and those that had ‘no recommendation’ (i.e., treatments that were not specified in the guidelines). In accordance with the NICE guidelines (NICE, 2016), treatments that were ‘recommended’ were further characterised into those that ‘must be provided’, which were information and advice, and those that ‘should be considered’, which included exercise (both group and individual) and manual therapy (specifically spinal manipulation and mobilisation or soft tissue techniques such as massage) but only when combined with exercise.

2.5 Statistical analysis

All analyses were performed using SPSS version 24 (IBM Corp.). The percentage of patients who received each of the treatment modalities and the percentage of patients who received a treatment that is ‘recommended’, ‘not recommended’ or has ‘no recommendation’ were calculated. Following this, all combinations of treatments (provided to >1.0% of patients) were reported. These combinations are listed within the group they fall, for example, combinations that included ‘recommended’ forms of treatment only, combinations that included ‘recommended’ treatment and treatment that was ‘not recommended’ only.

3 RESULTS 3.1 Patient characteristics

A total of 8003 patients were recorded as having attended physiotherapy treatment for a condition in the lumbar spine with/without referred pain. Data were collected from 391 practitioners.

The mean age of patients was 54.02 years (SD = 16.6). Patient characteristics are reported in Table 1.

TABLE 1. Characteristics of patients with LBP n % Gender Male 4042 50.5% Female 3939 49.2% Not reported 22 0.3% Duration of symptoms Acute (6 weeks or less) 4902 61.3% Subacute (7–12 weeks) 980 12.2% Chronic (more than 12 weeks) 2108 26.3% Not reported 13 0.2% Previous episodes No previous episodes 2964 37.0% One previous episode 1489 18.6% Two previous episodes 647 8.1% Three previous episodes 257 3.2% Many previous episodes 2628 32.8% Not reported 18 0.2% Mechanism Leisure activity 1363 17.0% RTA or trauma 536 6.7% Spontaneous 3921 49.0% Sport 765 9.6% Work 783 9.8% Other 609 7.6% Not reported 26 0.3% Body site Lumbar spine only 2771 34.6% Lumbar spine and referral to buttock 1879 23.5% Lumbar spine and referral to mid-thigh 800 10.0% Lumbar spine and referral to knee 721 9.0% Lumbar spine and referral to mid-calf 583 7.3% Lumbar spine and referral to heel 503 6.3% Lumbar spine and referral to foot and toes 746 9.3% Abbreviation: LBP, low back pain. 3.2 Overall treatment choices

The results summarising the percentages of patients receiving treatments that are ‘recommended’, ‘not recommended’ and have ‘no recommendation’ is shown in Table 2. Almost all patients were provided with a ‘recommended’ treatment (95.0%), 31.9% of patents were provided with a treatment that is ‘not recommended’ and 33.8% of patients were provided with a treatment that has ‘no recommendation’. 82.3% of patients were provided information and advice. Manual therapy treatment (i.e., manipulation, mobilisation or soft tissue techniques such as massage) is recommended when combined with exercise, and this combination was provided to 62.3% of patients. The most frequently reported treatments that are specifically ‘not recommended’ included ultrasound, provided to 13.9% of patients and interferential, provided to 12.6% of patients. The most frequently reported treatments that had ‘no recommendations’ included manual therapy treatments (manipulation, mobilisation or soft tissue techniques such as massage) when provided without exercises (13.4%), cold therapy (5.8%), other forms of manual therapy (i.e., other than those specified in the guidelines) (5.5%) and other electrotherapy treatment (5.2%).

TABLE 2. Number and percentage of treatments provided that involved treatments that were ‘recommended’, ‘not recommended’ or had ‘no recommendation’ according to NICE guidelines 2016 (n = 8003)   n % ‘Recommended’ Must be provided Information and advice 6629 82.8% Should be considered Exercise 6467 80.8% Manual therapya, and exerciseb 4989  62.3%  Total patients provided a ‘recommended' treatment 7602 95.0% ‘Not recommended’ Orthotics 49 0.6% Traction 584 7.3% Ultrasound 1109 13.9% TENS 41 0.5% IF 1005 12.6% Acupuncture 553 6.9% Total patients provided a ‘not recommended’ treatment 2556 31.9% ‘No recommendation’ Manual therapya (without exerciseb) 1072 13.4% Cold therapy 464 5.8% Other manual therapy treatments 440 5.5% Other electrotherapy treatments 417 5.2% Local heat/heat therapy 244 3.1% Other treatments (not specified) 213 2.7% Other external support 177 2.2% Biofeedback 14 0.2% Total patients provided a treatment with ‘no recommendation’ 2707 33.8% Abbreviation: NICE, National Institute for Health and Care Excellence. 3.3 Combinations of ‘recommended’ treatments, ‘not recommended’ treatments and treatments with ‘no recommendation’

The percentage of patients that received only ‘recommended’ treatments, only ‘not recommended’ treatments, only treatments with ‘no recommendation’ and other combinations of treatments is summarised in Figure 1. Most patients (95.0%) received a recommended treatment, with 46.3% of patients also receiving a treatment that is ‘not recommended’ and/or a treatment that has ‘no recommendation’ alongside the ‘recommended’ treatment. A small percentage of patients received treatments that are ‘not recommended’ (0.3%), only treatment that has ‘no recommendation’ (2.4%), or a combination of treatment that is ‘not recommended’ and treatment that has ‘no recommendation’ (1.8%) (see Figure 1).

Number and percentage of patients receiving treatments that are ‘recommended’, ‘not recommended’ or have ‘no recommendation’

The combination of ‘recommended’ treatments for all patients (i.e., regardless of other treatment ‘not recommended’ or with ‘no recommendation’ they may have received) is provided in Figure 2. Patients (51.2%) received a combination of information and advice, manual therapy and exercise; 17.4% of patients received information and advice alongside exercise; 9.6% received information and advice alongside manual therapy.

Number and percentage of patients receiving ‘recommended’ treatment

Details of the treatments provided for each combination is summarised in Table 3. For patients who received only ‘recommended’ treatment, the majority were provided information, advice and exercise with/without manual therapy (65.7%). Patients (11.6%) received only ‘recommended’ treatments (i.e., exercise with/without manual therapy) but, contrary to the guidelines did not specify that they provided information and advice.

TABLE 3. Combinations of treatment provided for patients with LBP Treatment Combinations n % Overall % ‘Recommended’ only Information and advice specified Information and advice, manual therapya and exercise 2562 65.7% 32.0% Information and advice and exercise 792 20.3% 9.9% Information and advice only 89 2.3% 1.1% Information and advice not specified Manual therapya and exercise 414 10.6% 5.2% Exercise only 40 1.0% 0.5% Total ‘recommended’ only 3897 100.0% 48.7% ‘Recommended’ and ‘no recommendation’ Information and advice specified Information and advice and manual therapya (without exercise) 351 26.5% 4.4% Information and advice, manual therapya and exercise and other manual therapy treatments 157 11.8% 2.0% Information and advice, manual therapya and exercise, and local heat 108 8.1% 1.3% Information and advice, manual therapya and exercise, and other electrotherapy treatments 84 6.3% 1.0% Other combinations of treatmentb 398 30.0% 5.0% Information and advice not specified Manual therapya, exercise and other electrotherapy treatments 92 6.9% 1.1% Other combinations of treatmentb 137 10.3% 1.7% Total ‘recommended’ and ‘no recommendation’ 1327 100.0% 16.6% ‘Recommended’ and ‘not recommended’ forms Information and advice specified Information and advice, manual therapy, exercise and acupuncture 121 9.0% 1.5% Information and advice, manual therapy, exercise and ultrasound 422 31.5% 5.3% Information and advice, manual therapy, exercise and interferential 145 10.8% 1.8% Other combinations of treatmentb 317 23.7% 4.0% Information and advice not specified Manual therapy, exercise, and ultrasound 84 6.3% 1.0% Other combinations of treatmentb 251 18.7% 3.1% Total ‘recommended’ and ‘not recommended’ 1340 100.0% 16.7% ‘Recommended’, ‘not recommended’, and ‘no recommendation’ Information and advice specified Information and advice, exercise, traction, interferential and cold therapy 195 18.8% 2.4% Information and advice, traction, interferential and cold therapy 146 14.1% 1.8% Information and advice, ultrasound, and manual therapya (without exercise) 95 9.2% 1.2% Other combinations of treatmentb 535 51.5% 6.7% Information and advice not specified Other combinationsb 67 6.5% 0.8% Total 1038 100.0% 13.0% ‘Not recommended’ only b Total ‘not recommended’ only 32 100.0% 0.4% No recommendation only b Total no recommendation only 196 100.0% 2.4% Abbreviation: LBP, low back pain.

Patients receiving a combination of ‘recommended’ treatments alongside treatments with ‘no recommendation’ tended to receive information and advice, manual therapy (manipulation, mobilisation and/or soft tissue techniques such as massage and exercise) without exercise.

Patients who received treatments that were ‘not recommended’ alongside ‘recommended’ treatment, received information and advice, manual therapy, exercise and either ultrasound (5.3%), interferential (1.8%) or acupuncture (1.5%).

4 DISCUSSION

The findings of this study provide insight into the self-reported clinical practice of participating physiotherapists and highlight the extent to which they follow the NICE guidelines (NICE, 2016). Almost all patients were provided with a ‘recommended’ treatment (95.0%). Approximately half of these patients were also provided with treatments that were either ‘not recommended’ (16.7%), had ‘no recommendation’ (16.6%) or a combination of both (13.0%). Few patients received only treatments that were ‘not recommended’ and/or had ‘no recommendation’ (4.6%). Practitioners reported using different combinations of treatments across all three recommendation domains. Most practitioners reported multimodal treatment programmes and only a few reported using treatments in isolation. The most highly reported treatment combination was information and advice with manual therapy and exercise (51.2%). This treatment combination is consistent with the guideline recommendations which state that manual therapy should be considered as part of a treatment package with exercise (NICE, 2016).

The highest reported treatment category was ‘information and advice’ with practitioners recording this in 82.8% of their patients. This category can be subsumed by the broader concept of ‘patient education’ which is recommended as a first line treatment for people with LBP (Foster et al., 2018). The NICE (2016) guidelines state that clinicians should provide people with advice and information to facilitate their ability to self-manage. The use of the word ‘provide’, instead of other terms used within the guidelines such as ‘consider’, reinforces the strength of this recommendation. Although a high proportion of patients in this study received education, it is possible that some practitioners did not report provision of information and advice, perhaps not viewing these as ‘treatments’ but rather as a standard part of healthcare. Indeed, patient education is regarded as an integral part of physiotherapy practice (Caladine, 2013). Whilst the data highlight the frequency that information and advice were used during the care of individual patients, it does not provide an in-depth understanding about how the education was used in practice. For example, details about the timing, frequency or duration of the education within the patient's episode of care were not investigated and the pedagogical approach, quality and relevance of the education are also unknown.

The NICE (2016) guidelines have a relatively broad focus on improving the person's ability to manage their LBP. As a result, the information and advice category within this study was underpinned by a broad range of education approaches being grouped under the recommended domain. In contrast, a recent systematic review by Zadro et al. (2019) categorised patient education-related activities across recommended, not recommended and no recommendation domains. The different approach to categorising treatments may be one reason why the reported use of information and advice in this study was higher than those recorded by Zadro and colleagues. For example, Zadro and colleagues categorised posture advice under the no recommendation domain. Although the quality of the posture advice used by participants in this study was unknown, it was categorised under the recommended domain based on an assumption that treatment goals would be directed at improving the patient's ability to self-manage. In practice, posture advice is a wide-ranging concept. Whilst there is no strong evidence to support the provision of advice about maintaining a ‘good’ posture or avoiding particular postures for people with LBP (Swain et al., 2020), contemporary literature recommends clinicians support people to adopt more relaxed postures and challenge unhelpful beliefs and behaviours (Slater et al., 2019). In order to improve our understanding about how patient education is used in practice the SDC system could be adapted to capture further details.

Some practitioners reported provision of treatments which were not recommended (31.9%) or had no recommendations (33.8%) within the guidelines. These findings are consistent with previous research which also found that some physiotherapists in the UK used treatments that were not supported by LBP guidelines (Bishop et al., 2008; Evans et al., 2010; Harte et al., 2005; Parr & May,