"How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?"

BACKGROUND: Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. OBJECTIVE: The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. DESIGN: This was an exploratory interview study using inductive content analysis. METHOD: Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS: Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). CONCLUSION: This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.

Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare.

BACKGROUND: It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed. OBJECTIVE: The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare. DESIGN: This was an explorative study using qualitative content analysis. METHOD: Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS: Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities). CONCLUSION: This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.

Feasibility of the subgroup criteria included in the treatment-strategy-based (TREST) classification system (CS) for patients with non-specific low back pain (NSLBP).

BACKGROUND: The new treatment-strategy based (TREST) classification system (CS) is in its exploratory phase with potential to impact clinical decision-making in the management of non-specific low back pain (NSLBP). OBJECTIVE: To evaluate the feasibility of subgroup criteria included in TREST subgroups: pain modulation, stabilization exercise, mobilization, and training. METHODS: An observational cross-sectional investigation involving a secondary analysis of data from 128 examinations of NSLBP patients, categorized individually by four examiners into one of the TREST subgroups. Four separate multivariate logistic regression analyses in two models were applied to identify how examiners applied judgments on pain intensity, disability and predetermined signs and symptoms to categorize patients into subgroups. RESULTS: Associations were found between the presence of "neurological signs and symptoms" (OR 5.5, 95% CI 1.9-16), "irritability" (OR 3.0, 95% CI 3.2-20) and disability (ODI) >30 (OR 8.5, 95% CI 3-20) and the subgroup pain modulation; between the presence of "bilateral spinal signs" (OR 5.6, 95% CI 1.1-29) and the subgroup stabilization exercise; between the presence of "specific segmental signs" (OR 4.0, 95% CI 1.2-14) and ODI ≤30 (OR 0.2, 95% CI 0.1-0.6) and the subgroup mobilization; between the presence of "neurological signs and symptoms" (OR 0.2, 95% CI 0.1-0.4) and the subgroup training. CONCLUSIONS: Findings preliminary support feasibility of TREST subgroup criteria: neurological deficits, irritability, bilateral spinal signs, segmental signs and disability in the categorization of NSLBP patients. Further validation of the TREST classification system is required to establish its value in clinical reasoning and impact on patient outcomes.

Inter-examiner reliability of a proposed decision-making treatment based classification system for low back pain patients.

Evolving evidence has shown increased clinical outcomes, when low back pain (LBP) patients are classified and receive matched physical treatment. The present study aimed to examine the inter-examiner reliability of a proposed new decision-making classification system for non-specific LBP patients, using a mixed simultaneous and independent examiner design. With minimal familiarization, two pairs of experienced physiotherapists trained in Orthopedic Manual Therapy (OMT) at two different out-patient clinics in primary care, examined and classified 64 consenting consecutive patients. Further, inter-examiner reliability on five examination items was examined. The agreement between examiners was expressed by percentage of agreement (%) and by the un-weighted (κ) or weighted (κ(w)) kappa coefficient. The overall % agreement, categorizing patients into one of four classifications was 80% and κ = 0.72. For each classification, pain modulation, stabilization exercise, mobilization and training, agreement was 90%, 83%, 58% and 89% (κ = 0.77, 0.67, 0.11 and 0.75), respectively. Agreement on five individual examination items was; irritability 82% (κ(w) = 0.41), specific movement pattern 68% (κ = 0.38), specific segmental signs 67% (κ = 0.28), uni- or bilateral signs 62% (κ = 0.42), and neurological signs and symptoms 92% (κ = 0.84). This study demonstrated that this new classification system had substantial inter-examiner reliability when used by clinically experienced OMT-trained physiotherapists. Agreement within classification was substantial, except for mobilization which was poor. Inter-examiner reliability for the individual examination items varied from fair to almost perfect. Further studies are needed to investigate utility and validity of this new classification system.