Monday, December 10, 2018 Study: PTs, Family Physicians Similar in Knowledge of LBP Management The numbers were small and the participants limited to certain groups, but results of a recent survey seem to point to yet another reason to increase direct access to physical therapist (PT) services: namely, when it comes to management of low back pain (LBP), PTs know just as much—and sometimes more—than the family practice physicians (FPPs) who often are sought for primary care. Authors believe the results point to the need for further study of the potential for PTs in primary care settings, an issue that APTA is exploring. In a study published in the Journal of Manual & Manipulative Therapy (abstract only available for free), researchers provided results of a survey of 73 PTs and 30 FPPs regarding their knowledge of optimal management strategies for LBP as well as their attitudes toward and use of clinical practice guidelines for the condition. Authors of the study used 2 survey instruments that were developed for earlier studies: an 11-item review of LBP knowledge, attitudes, and guideline statements, and a modified 8-question survey on management interventions. APTA members Michael Ross, PT, DHS; Travis Enser, PT; Allyson Muehlemann, PT, DPT; and Ron Schenk, PT, PhD, were among authors of the study. Participants were asked to respond using a 5-point Likert scale that reflected their level of agreement with various statements on LBP (the 11-question review) or their belief in the importance of various approaches to LBP treatment (the 8-question survey). Answers were classified as correct or incorrect based on what authors describe as "the most recent reviews of the evidence." In the end, 73 PT members of the APTA Private Practice Section (PPS) and 30 members of the American Academy of Family Physicians (AAFP) provided useable responses. The bottom line: the PTs and FPPs achieved similar scores on nearly every item in the surveys. Both groups strongly rejected statements such as "patients should not return to work until they are almost pain free" and "X-rays of the lumbar spine are useful in the work-up of patients with acute LBP," and broadly supported the statements "encouragement of physical activity is important in the recovery of LBP" and "there is nothing physically wrong with many patients with chronic [LBP]." When it came to statements related to optimal management of LBP, PTs and FPPs reported equally strong levels of support for the importance of physical therapy, patient encouragement, and manual manipulation; and were equally emphatic in their disapproval of surgery. Not all scores were close, however. Researchers found that compared with the FPP group, PTs generally had more confidence in their ability to gauge the motivation of their patients, and tended to more consistently reject the idea that "interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP." Other areas of more modest disagreement included support for the statement "I would find clinical practice guidelines helpful in the management of LBP" (agreed with or strongly agreed with by 58.9% of PTs compared with 76% of FPPs) and disagreement with the idea that bed rest is important in recovery from LBP—83.3% of FPPs said bed rest was "not recommended" or "of minor importance," compared with 69.9% of PTs rating bed rest in a similar way. Authors characterized these differences as nonsignificant. As for the PTs' confidence in their ability to assess patient motivation, authors believe that the nature of the PT-patient relationship may be at work. "Assessing patient motivation levels is a time-consuming process," authors write. "The duration of a typical patient visit is longer with the [PT] than a[n] [FPP] and the [PT] typically sees patients on a serial basis for a period of time. This increased patient interaction may play a part in [PTs] having less difficulty in assessing patient motivation." Authors also cited the presence of what they describe as "guideline-discordant care" among notable percentages of both PTs and FPPs, including an inability to choose the drug treatment most preferable for patients with LBP (26% of PTs and 35% of FPPs answered incorrectly by choosing drugs other than acetominophin and nonsteroidal anti-inflammatories), a preference for imaging (18% of PTs and 10% of FPPs), and a belief that bed rest for patients with LBP was of "some importance" (30% of PTs and 17% of FPPs). The numbers indicate that "continued educational efforts in the management of LBP are indicated and represent an area of potential cost savings for the health care system while also improving the quality of care and patient outcomes," authors write. The study has its share of limitations, according to its authors: response rates were small, and the use of members of the APTA PPS and the AAFP may mean that results may not be generalizable. Additionally, authors write, respondents tended to describe themselves as having a "special interest in musculoskeletal medicine," which may affect the "representativeness of the results." Authors believe that, despite those issues, at the very least their study merits further research into the knowledge levels of PTs and what that could mean for patient care. "These results may have implications for health policy decisions regarding the utilization of [PTs] to provide care for patients with LBP without a referral," authors write, "including the potential placement of [PTs] in primary care clinics to initially manage patient with musculoskeletal conditions." [Editor's note: What's the latest on the role of PTs in primary care? Check out this feature article from the December-January issue of PT in Motion magazine for an in-depth look at where things stand, and what APTA is doing, and learn about the basis for the association's efforts in this paper on exploring the roles of PTs in primary care teams.] Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.