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Physical Therapist vs. Family Practitioner Knowledge of Simple Low Back Pain Management in the U.S. Air Force Maj Michaei D. Ross, USAF BSC (Ret.)*; Lt Col John D. Childs, USAF BSCf; Ma] Cory Middel, USAF BSCf; CPT Julie Kujawa, SP USAf; CPT Daniel Brown, SP USAf; CPT Molly Corrigan, SP USAf; CPT Nate Parsons, SP USAf ABSTRACT The purpose of this study was to compare knowledge in managing low back pain (LBP) between physical therapists and family practice physicians. Fifty-four physical therapists and 130 family practice physicians currently serving in the U.S. Air Force completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and rnanagement strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t tests. Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. However, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; relative risk: 1.24 [95% confidence interval: 1.06-1.46]) and believe that patient encouragement and explanation is important (75.9% vs. 56.2%; relative risk: 1.35 [95% confidence interval: 1.09-1.67]). In addition, physical therapists showed significantly greater knowledge regarding optimal management strategies for patients with LBP compared to family practice physicians. The results of this study may have implications for health policy decisions regarding the utilization of physical therapists to provide care for patients with LBP without a referral.
INTRODUCTION Low back pain (LBP) is one of the leading causes of musculoskeletal complaints in the United States and accounts for 25% of patient complaints in a primary care setting.' Health care for patients with LBP is costly, accounting for approximately $86 billion in health care expenditures in the United States in 2005.^ In the U.S. military, musculoskeletal pain, and especially LBP, adversely affects military preparedness and is a common reason for medical evacuation from ongoing conflicts with return to duty often being uncertain.^'^ Furthermore, LBP is a common reason for long-term military service-member disability.'^ Eamily practice physicians have traditionally served as the primary entry point into the health care system for patients with LBP, as well as a primary referral source for physical therapists. However, these physician referral episodes of care have been shown to increase costs compared to episodes of care when patients have directly accessed a physical therapist without physician referral.'''^ Considerable evidence also supports the benefits of early access to a physical therapist.^"'"* The military health care system has long supported the benefits of early access to a physical therapist, as they have been credentialed as direct access providers since 1973.'** However, little evidence exists to confirm that physical therapists in the military have the necessary knowledge in managing patients with LBP in a direct access manner.
*Department of Physical Therapy, University of Scranton. 800 Linden Street, Scranton, PA 18510. tDoctoral Program in Physical Therapy, US Army-Baylor University, ATTN: MCCS-HMT, 3151 Scott Road, Suite 1230, Fort Sam Houston, TX 78234. doi: 10.7205/MILMED-D-I3-00099
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Knowledge in managing LBP can be assessed by many methods. Previously described standardized written examinations by Buchbinder et al'^ and Einestone et al'^ assessed physician knowledge in the management of patients with LBP. These examinations would seem to serve as a pragmatic reference standard for the initial assessment of physical therapist knowledge in managing patients with LBP. If physical therapists could show equal or higher levels of knowledge than their physician counterparts, this would provide at least some level of evidence to suggest that physical therapists have adequate knowledge in providing direct access care for patients with LBP. Therefore, the purpose of this study was to compare knowledge in managing LBP between physical therapists and family practice physicians. We hypothesized that physical therapists would show knowledge levels that were higher than or equal to those of family practice physicians with respect to optimal patient management strategies and beliefs about LBP. This hypothesis was based on previous research that suggested physical therapists in the uniformed services showed higher levels of knowledge in managing musculoskeletal conditions than all physician specialties except for orthopedic surgeons.''''^ In addition, physical therapists in the uniformed services have extensive additional training in managing patients with neuromusculoskeletal conditions without physician referral, as they are often credentialed to order necessary diagnostic studies such as radiographs and magnetic resonance imaging (IVIRI) and to prescribe commonly used nonsteroidal anti-inflammatory medications.'^ METHODS This study used a quasi-experimental, cross-sectional casecontrol design to explore differences in knowledge and
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain TABLE I.
Knowledge, Attitudes, and Guideline Statements With Correct Responses Regarding the Management of Patients With LBP" Statements
Correct Responses
Knowledge Patients with acute LBP should be prescribed complete bed rest until the pain goes away Patients should not return to work until they are almost pain free X-rays of the lumbar spine are useful in the workup of patients with acute LBP Encouragement of physical activity is important in the recovery of LBP Interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP Attitudes 1 am likely to order X-rays for LBP because patients so often expect me to do so There is nothing physically wrong with many patients with chronic back pain Well-tnotivated patients are unlikely to have long-term problems with LBP I have no difficulty in assessing the motivation of my LBP patients Guidelines Practice guidelines are useful to help doctors in the management of medical conditions I would find practice guidelines helpful in the management of LBP
Disagree, Strongly Disagree Disagree, Strongly Disagree Disagree, Strongly Disagree Agree, Strongly Agree Agree, Strongly Agree
Disagree, Strongly Disagree Agree, Strongly Agree Agree, Strongly Agree Agree, Strongly Agree Agree, Strongly Agree Agree, Strongly Agree
Participants were asked to select among the following responses for each statement: strongly agree, agree, uncenain, disagree, and strongly disagree.
beliefs about the management of LBP among physical therapists and family practice physicians currently practicing in the U.S. Air Force. Before subject recruitment and data collection, the study was approved by the institutional review board at Wilford Hall Medical Center in San Antonio, Texas. All subjects provided informed consent before participation. Participants completed the same examinations developed by Buchbinder et al'^^ and Finestone et al'^ that originally assessed knowledge, attitudes, the u.sefulness of clinical practice guidelines, and management strategies of physicians for patients with LBP (Tables I and II). The examination developed by Buchbinder et al'^ consisted of 11 questions (Table I). Five questions assessed participant knowledge about the management of LBP, 4 questions assessed attitudes toward patients with LBP, and 2 questions assessed the usefulness of clinical practice guidelines. The questions were phrased as statements and responses were on a 5-point Likert scale that included "strongly agree," "agree," "uncertain," "disagree," and "strongly disagree" (Table I). For questions on knowledge, the "correct" responses were based on the most recent systematic reviews of the evidence for treatment of patients with LBP."^"^ The percentage of respondents who answered knowledge questions correctly were TABLE M.
determined by adding those who answered either "agree" and "strongly agree" or "disagree" and "strongly disagree" depending on the wording of the question. A response of "uncertain" was coded as being incorrect. For questions concerning attitudes and guidelines, a response of either "agree" or "strongly agree" was considered to be correct, and the percentage of correct responses was determined in the same way. Con'ect responses were graded in the same manner as described by Buchbinder et al.'^ The examination developed by Finestone et al"' consisted of 5 questions about the management strategies for patients with LBP (Table II). Each correct answer was given a score of 20 points, with a maximum overall score on the examination of 100 points with higher scores indicating higher knowledge levels regarding optimal management strategies and beliefs about LBP. Two of the questions were multiple choice (preferred drug treatments and imaging recommendations), whereas the other 3 questions on the importance of bed rest, patient encouragement and explanation, and the use of spinal manipulation were phrased as statements with responses on a 5-point Likert scale that included "not recommended," "of minor importance," "important," "very important," and "extremely important" (Table II). Correct responses were
Questions, Possible Responses, and Correct Responses Regarding the Optimal Management of Patients With LBP'' Questions
What drug treatment is preferable for patients with acute LBP, defined as pain lasting up to 1 week, without sciatica? What imaging studies would you recommend for patients with acute LBP, defined as pain lasting up to 1 week, without sciatica? Rate the importance of bed rest for the effectiveness of simple back pain treatment Rate the importance of patient encouragement and explanation for the effectiveness of simple back pain treatment Rate the importance of manipulation for the effectiveness of simple back pain treatment
Possible Responses Acetaminophin", NSAIDs", COX-2 selective NSAIDs, opioids X-ray of the lumbar spine, ultrasound of the kidneys, CT of the lumbar spine, bone scan, MRI. none of the above" Not recommended", of minor importance, important, very important, extremely important Not recommended, of minor importance, important, very important, extremely important" Not recommended, of minor importance", important", very important", extremely important"
NSAIDs, nonsteroidal anti-inflammatory drugs; CT, computed tomography. "Correct responses are noted.
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain
graded in the same manner as of those Finestone et al'^ with the exception of the question pertaining to the importance of spinal manipulation from the Finestone et al'^ examination. In the original publication, the correct answer to this question was that manipulation was not recommended based on LBP guidelines published in 1996."'* More current guidelines have recommended spinal manipulation in the treatment of patients with LBP."'' Therefore, an answer of "of minor importance," "important," "very important," or "extremely important" was deemed correct for the manipulation question. The LBP examination was administered via an online program entitled SurveyMonkey. No time limit was imposed on the examination. All physical therapists and family practice physicians currently practicing in the U.S. Air Force were invited to participate in this study through electronic mail. Individuals were contacted based on current provider electronic mail distribution lists that were generated by the U.S. Air Force Associate Chiefs for physical therapy and family practice. Subject confidentiality was strictly maintained through assignment of a unique computer-generated code. Before taking the LBP examination, subjects completed a demographic survey that assessed educational preparation and experience in different practice settings. Respondents were also asked if they were familiar with the articles by Buchbinder et al'"' and Finestone et al."' Data frotn any participants familiar with the studies by Buchbinder et al'"' and Finestone et al'^ were excluded because the examination and answer keys were published in those papers. To maximize participation, participants were not asked to complete the examination in a proctored setting. However, participants were asked to complete the study without the help of outside resources (e.g., textbooks, information available on the Internet, or personal communication). All participants were queried at the end of the examination regarding whether they used any outside resources to assist them in the completion of the examination. Data from any participants who used outside resources were excluded. The results of the demographic survey and the content of the examination were stored in a secure, passwordprotected, centralized database for subsequent analysis.
Data Analysis Beliefs of physical therapists and family practice physicians regarding knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP were compared using relative risks (RRs) and 95% confidence intervals (CIs). For each of the 11 questions in the Buchbiner et al'^ examination, an RR > 1 indicates that a higher percentage of physical therapists agreed with the knowledge, attitude, or guideline statement compared with family practice physicians, an RR < 1 indicates that a lower percentage of physical therapists agree, whereas an RR = 1 indicates that there is no difference in belief between physical therapists and family practice physicians. This method of
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analysis was consistent with that of Buchbinder et al'"^ in assessing responses to these same questions. For each of the questions in the Finestone et al"" examination, an RR > 1 indicates that a higher percentage of physical therapists were correct in answering questions regarding management strategies for patients with LBP compared to family practice physicians, an RR < 1 indicates that a lower percentage of physical therapists were correct, whereas an RR = 1 indicates that there is no difference in the correct responses between physical therapists and family practice physicians. An independent t test was also used to compare overall examination scores between physical therapists and family practice physicians, which was consistent with the method of analysis by Finestone et al'* in assessing responses to these same questions. The values for a were established a priori at 0.05. RESULTS 127 physical therapists and 374 family practice physicians were invited to participate in this study. Fifty-four physical therapists (response rate = 43%) and 130 family practice physicians (response rate = 35%) completed the examinations. The characteristics of the participants are shown in Table III. No participant reported receiving assistance from outside resources. Twenty-four physical therapists and 6 family practice physicians reported being familiar with the examinations by Buchbinder et al'^^ and Finestone et al'*, thus these data were not included in the analysis. For the Buchbinder et al''' examination, physical therapists were tnore likely than family practice physicians to have no difficulty assessing the motivation of patients with LBP (63.6% vs. 36.2%; RR: 1.76 [95% Cl: 1.30-2.38]). Besides the results from the "motivation" question, responses were generally comparable for the rest of the Buchbinder et al'"" examination between physical therapists and family practice physicians (Table IV). TABLE III. Characteristics of Clinical Experience and Training for Physical Therapists (/? = 54) and Family Practice Physicians (n = 130) Characteristics Male (;i, %) Age (Mean, Range) Years of Clinical Practice (Mean, Range) Residency Trained (n, %) Fellowship Trained (n, %) Special interest in MSK medicine (;j, %) LBP (H, %) CME for LBP in past 2 years (n, %) 0 hours 1—20 hours 20+ hours
Physical Therapists
Physicians
39 (72.2) 84 (64.6) 40 (28-53) 38 (29-59) U (2-23) 8.3 (0-30) 3 (5.6) 128(98.5) 0(0) 12 (9.2) 48 (88.9) 38 (70.4)
62 (47.7) 30(23.1)
5(9) 27 (50) 22(41)
17(13) 99 (76) 14(11)
MSK, musculoskeletal: CME. continuing medical education; LBP, low back pain.
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain TABLE IV.
Percentages of Physical Therapists and Family Practice Physicians Agreeing With Knowledge, Attitudes, and Guideline Statements for the Management of Pattents With LBP'' Percent Agreement Physical Therapists
Statements Knowledge Patients with acute LBP should be prescribed complete bed rest until the pain goes away Patients shoukl not return to work until they are almost pain free X-rays of Ihe lumbar spine are useful in the workup of patients with acute LBP Encouragement of physical activity is important in the recovery of LBP Interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP Attitudes I am likely to order X-rays for LBP because patients so often expect me to do so There is nothing physically wrong with many patients with chronic back pain Well-motivated patients are unlikely to have long-tenn problems with LBP I have no difficulty in assessing the motivation of my LBP patients Guidelines Practice guidelines are useful to help doctors in the management of medical conditions I would find practice guidelines helpful in the management of LBP
For the Finestone et al examination, the percentage of physical therapists and family practice physicians were comparable who had correct answers regarding imaging and the importance of bed rest and manipulation (Table V). However, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; RR: 1.24 [95% CI: 1.06-1.46]) and to believe that patient encouragement and explanation is "extremely important" (75.9% vs. 56.2%; RR: 1.35 [95% CI: 1.09-1.67]). The mean .score on the Finestone et al"^ examination (maximum overall score = 100) was 87.0 ± 17.4 points (95% CI: 82.3-91.8) for physical therapists vs. 80.5 ± 18.2 points (95% CI: 77.3-83.6) for family practice physicians (p < 0.05). DISCUSSION The purpose of this study was to compare knowledge in managing LBP between physical therapists and family practice physicians. We hypothesized that physical therapists would show knowledge levels that were higher than or equal to those of family practice physicians with respect to optimal patient management strategies and beliefs about TABLE V..
0 2.8 18.2 94.5 18.2
3.6 12.7 63.6 63.6 78.2 81.8
Phy.sicians
RR (95% CI)
0
2.34(0.05-116.43) 7.02(0.29-169.66) 0.82(0.43-1.55) 0.98(0.78-1.23) 0.61 (0.34-1.13)
0 22.3 99.2 30
36.2
0.28(0.07-1.16) 0.72 (0.33-1.58) 1.27 (0.98-1.66) 1.76(1.30-2.38)
87.7 80.8
0.89 (0.76-1.04) 1.01 (0.87-1.18)
13.1 17.7
50
LBP. This hypothesis was based on previous research that suggested physical therapists in the uniformed services showed higher levels of knowledge in managing musculoskeletal conditions than all physician specialties except for orthopedic surgeons.''''** In addition, physical therapists in the uniformed services have extensive additional training in managing patients with neuromusculoskeletal conditions without physician referral, as they are often credentialed to order necessary diagnostic studies such as radiographs and MRI and to prescribe cotnmonly used nonsteroidal antiinfiarnmatory medications.''* In this study, physical therapists showed significantly improved knowledge regarding optimal management strategies for patients with LBP cotnpared to family practice physicians. In addition, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; RR: 1.24 [95% CI: 1.06-1.46]) and believe that patient encouragement and explanation is important (75.9% vs. 56.2%; RR: 1.35 [95% CI: 1.09-1.67]). Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were similar between the groups. Thus, our hypothesis was supported.
Percentages of Physical Therapists and Family Practice Physicians Who Correctly Answered Questions on the Optimal Management of Patients With LBP'* Percent Correct Questions
Physical Therapists
Physicians
RR (95% CI)
What drug treatment is preferable for patients with acute LBP, defined as pain lasting up to 1 week, without sciatica? What imaging studies would you recommend for patients with acute LBP. defined as pain lasting up to 1 week, without sciatica? Importance of bed rest Importance of patient encouragement and explanation Importance of manipulation
85.2
68.5
1.24(1.06-1.46)
90.7
90.8
0.99(0.90-1.11)
87 75.9 96.3
89.2 56.2 97.7
0.98(0.87-1.10) 1.35(1.09-1.67) 0.99(0.93-1.05)
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Fhysical Therapist vs. Family Fractitioner Knowledge of Low Back Fain
Participants in our study completed the same examination developed by Finestone et al,"' which consisted of 5 questions about the management strategies for patients with LBP (Table II), Each correct answer was given a score of 20 points, with a maximum overall score on the examination of 100 points, with higher scores indicating higher knowledge levels regarding optimal management strategies and beliefs about LBP. One of the questions in this examination developed by Finestone et al'^ dealt with the importance of manipulation in the treatment of patients with LBP. In the original Finestone et al'^ article, a correct response for this question was that manipulation for the treatment of patients with LBP was "not recommended," based on guidelines for the treatment of LBP published in 1996.^"* Based on more current guidelines,^'' which support the use of manipulation in the treatment of patients with LBP, we changed the correct response for the importance of manipulation for the treatment of patients with LBP to "of minor importance," "important," "very important," or "extremely important." Therefore, direct comparisons between our results and those of Finestone et al'^ are difficult given the differences in scoring the manipulation question. However, if we scored the manipulation question as "not recommended," the mean scores of physical therapists and family practice physicians were 68,5 and 61.4, respectively. In the Finestone et al'^ study, the mean scores of family practitioners and orthopedists were 69,7 and 44.3, respectively. These results suggest that the participants in our study showed knowledge levels that were higher than or equal to the participants in the Finestone et al'^ study. Current management guidelines for patients with LBP include recommendations for patients to stay active, which is more effective than resting in bed."^ Although none of the participants in our study agreed that patients with acute LBP should be prescribed complete bed rest until the pain goes away, 13% of physical therapists and 11% of family practice physicians incorrectly recommended some form of bed rest for patients with LBP (Table V). In the study by Buchbinder et al,'"' between 9% and 18% of physicians agreed that patients with acute LBP should be prescribed complete bed rest until the pain goes away. Furthermore, in the study by Finestone et al,'^ 67% of orthopedists and 46% of family practitioners incorrectly recommended some form of bed rest. Although the participants in our study seemed to rely less on bed rest in the management of patients with LBP than physicians in the Buchbinder et al ^ and Finestone et al, t 6 studies, the data from our study suggest that bed rest is still used in the management of patients with LBP, despite no proof of its effectiveness. In the Finestone et al"' study, only 8% of family practitioners but 53% of orthopedists incorrectly recommended cyclooxygenase-2 (COX-2) selective nonsteroidal antiinflammatory medications in the treatment of patients with LBP. Interestingly, a greater number of physical therapists (85.2%) than family practitioners (68,5%) in our study
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correctly selected acetaminophen and nonsteroidal antiinflammatory medications as the preferable drug treatment for patients with LBP (RR: 1.24 [95% CI: 1.06-1,46]) (Table V). Although physical therapists in the uniformed services are able to prescribe acetaminophen and nonsteroidal anti-inflammatory medications, they are not able to prescribe COX-2 selective nonsteroidal anti-inflammatory medications and opioids, which may have influenced their medication selection for this question. In addition, physicians may be more likely to be influenced by pharmaceutical companies' marketing campaigns^^ and be informed by pharmaceutical representatives regarding the wide variety of drug classes.' This may explain, in part, the preference of family practice physicians for COX-2 selective nonsteroidal antiinflammatory medications and opioids in the management of patients with LBP, despite no evidence to support this practice over prescribing acetaminophen and nonselective nonsteroidal anti-inflammatory medications. In this study, physical therapists were more likely than family practitioners to not have difficulty assessing the motivation levels of patients with LBP (63.6% vs. 36.2%; RR: 1,76 [95% CI: 1.30-2,38]), In addition, physical therapists were more likely than family practitioners to correctly believe that patient encouragement and explanation is "extremely important" in the management of patients with LBP (75,9% vs. 56.2%; RR: 1.35 [95% CI: 1.09-1.67]). Assessing patient motivation levels and educating patients is a time-consuming process. The duration of a typical patient visit is longer with the physical therapist than a family practice physician and the physical therapist typically sees patients on a serial basis for a period of time. This increased patient interaction may play a part in physical therapists having less difficulty in assessing patient motivation and placing a greater emphasis on patient encouragement and explanation. Clinicians should not routinely obtain diagnostic imaging in patients with nonspecific LBP.^"* Rather, diagnostic imaging for patients with LBP should be reserved for when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.^"* In this study, 9% of physical therapists and family practice physicians would recommend diagnostic imaging for patients with acute LBP without sciatica and 18% of physical therapists and 22% of family practice physicians believe that X-rays of the lumbar spine are useful in the workup of patients with acute LBP. In the study by Buchbinder et al,'^ between 29% and 41% of physicians agreed that X-rays of the lumbar spine are useful in the workup of patients with acute LBP. In the Finestone et al'^ study, 53% of orthopedists and 8% of family practitioners failed to respond that no imaging was necessary for patients with acute LBP without sciatica. These data suggest that diagnostic imaging may be unnecessarily overutilized in the management of patients with simple LBP. This is concerning as there is no evidence that routine conventional radiography in patients with nonspecific LBP is associated
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain
with a greater improvement in patient outcomes.^^ In addition, routine advanced imaging (i.e., computed tomography and IVIRI) is not associated with improved patient outcomes^^ and identifies many abnormalities that are poorly correlated with sytnptoms^''''"'*' but could lead to additional, possibly unnecessary interventions.'^^ There are some limitations that should be considered when evaluating the results of our study. First, these data tnay not be generalizable to other practice settings. Educational programs for physical therapists and physicians do not use standardized curricula and exposure to educational experiences regarding the management of patients with LBP differs. Physical therapists in the uniformed services also have extensive additional orthopedic training in managing patients with neuromusculoskeletal conditions without physician referral.'"* Furthermore, they are often credentialed to order necessary diagnostic studies such as radiographs and IVIRI and to prescribe commonly used nonsteroidal antiinflammatory medications.'"* Therefore, one might expect physical therapists in the uniformed services to show knowledge levels that exceed those without advanced orthopedic training or credentialing. Eurther research could be performed to determine if the results obtained with physical therapists in the uniformed services would be similar to civilian physical therapists. Second, we invited volunteer physical therapists and family practice physicians to participate in this study. With a physical therapist response rate of 43% and a family practice physician response rate of 35%, which is somewhat lower than we expected for a military setting, there is the potential for selection bias. More specifically, the physical therapists and family practice physicians who volunteered to participate in this study may have been more cornfortable witb managing patients with LBP and therefore, more apt to participate in this study. However, physician participants in the studies by Buchbinder et al'^ and Einestone et al'^ were also volunteers, which likely mitigates any potential bias in discussing our results in relation to those studies. Nonetheless, it would be interesting to see if there were any relevant differences between those who volunteered to participate in this study and those that did not in terms of their knowledge in managing patients with LBP. Third, although we assessed knowledge in managing LBP between physical therapists and family practice physicians, we did not assess knowledge pertaining to "red flags" that may be associated with LBP, such as extremity weakness/atrophy, altered reflexes, incontinence, and saddle anesthesia. One reason for an initial evaluation from a physician is to evaluate for "red flags" or emergency situations that require immediate interventions. Future studies should assess "red flag" knowledge in patients with LBP between physical therapists and family practice physicians. In addition, future efforts should be geared toward developing plan of care algorithms that include "red flag" assessment by which uniformed service members could be seen initially by a physical therapist rather than a family practice physi-
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cian. Eourth, it is not completely clear if the subgroups of patients with LBP being seen by physical therapists and family practice physicians are identical. If the physicians are seeing more patients with LBP that is classified as "acute on chronic" or patients with LBP that have multiple comorbidities, this might lead to differences in clinical approaches or at least clinical experiences between the 2 provider groups, which may have influenced the results of this study.
CONCLUSION This study compared knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies of physical therapists and family practice physicians for patients with LBP. Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the 2 groups. However, physical therapists showed knowledge levels that were higher than or equal to those of primary care physicians with respect to optimal management strategies and beliefs about LBP. In addition, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians and believe that patient encouragement and explanation is important. The results of this study may have implications for health policy decisions regarding the utilization of physical therapists to provide care for patients with LBP without a referral including the potential placement of physical therapists in primary care clinics to initially manage patients with musculoskeletal conditions, the development of multidisciplinary clinics including both physical therapists and family practice physicians, and involvement of physical therapists in family practice physician training programs.
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain 8. Childs JD, Fritz JM, Flynn TW, et al: A clinical prediction rule to identify patients with low back pain who will benefit from spinal manipulation: a validation study. Ann Intern Med 2004: 141: 920-8. 9. Ehrmann-Feldman D, Rossignol M, Abenhaim L, Gobeille D: Physician referral to physical therapy in a cohort of workers compensated for low back pain. Phys Ther 1996: 76: 150-6. 10. Elynn T, Fritz J, Whitman J, et al: A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002, 27: 2835-43. 11. Linton SJ, Hellsing AL, Andersson D: A controlled study of the effects of an early intervention on acute musculoskeletal pain problems. Pain 1993: 54: 353-9. 12. Ross MD: Physical therapy and changes in disability for patients with low back pain. Mil Med 2002; 167(8): 662-5. 13. Zigenfus GC, Yin J, Giang GM, Fogarty WT: Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders. J Occup Environ Med 2000; 42: 35-9. 14. Greathouse DG, Schreck RC, Benson CJ: The United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Spoils Phys Ther 1994: 19: 261-6. 15. Buchbinder R, Staples M, Jolley D: Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine 2009; 34: 1218-26. 16. Finestone AS, Raveh A, Mirovsky Y. Lahad A, Milgrom C: Orthopaedists' and family practitioners' knowledge of simple low back pain management. Spine 2009: 34: 1600-3. 17. Childs JD, Whitman JM, Pugia ML, Sizer PS Jr, Flynn TW, Delitto A: Knowledge in managing musculoskeletal conditions and educational preparation of physical therapists in the uniformed services. Mil Med 2007: 172: 440-5. 18. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A: A description of physical therapists' knowledge in managing tnusculoskeletal conditions. BMC Musculoskelet Disord 2005: 6: 32. 19. Hagen K. Hilde G, Jamtvedt G, et al: Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev 2004; 4: CD001254.
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20. Clarke J, van Tulder M, Blornberg S, et al: Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev 2005: 4: CD003010. 21. Hilde G, Hagen KB, Jamtvedt G, et al: Advice to stay active as a single treatment for low-back pain and sciatica. Cochrane Database Syst Rev 2002; 2: CD003632. 22. Hayden JA, van Tulder M, Malmivaara AV, et al: Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med 2005: 142: 765-75. 23. Eurlan AD, van Tulder MW, Cherkin DC, et al: Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005; 1: CD001351. 24. Koes BW, van Tulder MW, Ostelo R, et al: Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001: 26: 2504-13; discussion 2513-4. 25. Chou R, Qaseem A, Snow V, et al: Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478-91. 26. Fretheim A, Oxman AD: International variations in prescribing antihypertensive drugs: its extent and possible explanations. BMC Health Serv Res 2005; 5: 21. 27. Miller P, Kendrick D, Bentley E, Fielding K: Cost-effectiveness of lumbar spine radiography in primary care patients with low back pain. Spine 2002; 27(20): 2291-7. 28. Jarvik JG. Hollingworth W, Martin B, et al: Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA 2003; 289: 2810-8. 29. Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E: Are first-time episodes of serious LBP associated with new MRI findings? Spine J 2006: 6: 624-35. 30. Jarvik JG. Hollingworth W, Heagerty PJ, Haynor DR. Boyko EJ, Deyo RA: Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and itrtaging risk factors. Spine 2005: 30: 1541-8: discussion 1549.
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Physical Therapist vs. Family Practitioner Knowledge of Simple Low Back Pain Management in the U.S. Air Force Maj Michaei D. Ross, USAF BSC (Ret.)*; Lt Col John D. Childs, USAF BSCf; Ma] Cory Middel, USAF BSCf; CPT Julie Kujawa, SP USAf; CPT Daniel Brown, SP USAf; CPT Molly Corrigan, SP USAf; CPT Nate Parsons, SP USAf ABSTRACT The purpose of this study was to compare knowledge in managing low back pain (LBP) between physical therapists and family practice physicians. Fifty-four physical therapists and 130 family practice physicians currently serving in the U.S. Air Force completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and rnanagement strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t tests. Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. However, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; relative risk: 1.24 [95% confidence interval: 1.06-1.46]) and believe that patient encouragement and explanation is important (75.9% vs. 56.2%; relative risk: 1.35 [95% confidence interval: 1.09-1.67]). In addition, physical therapists showed significantly greater knowledge regarding optimal management strategies for patients with LBP compared to family practice physicians. The results of this study may have implications for health policy decisions regarding the utilization of physical therapists to provide care for patients with LBP without a referral.
INTRODUCTION Low back pain (LBP) is one of the leading causes of musculoskeletal complaints in the United States and accounts for 25% of patient complaints in a primary care setting.' Health care for patients with LBP is costly, accounting for approximately $86 billion in health care expenditures in the United States in 2005.^ In the U.S. military, musculoskeletal pain, and especially LBP, adversely affects military preparedness and is a common reason for medical evacuation from ongoing conflicts with return to duty often being uncertain.^'^ Furthermore, LBP is a common reason for long-term military service-member disability.'^ Eamily practice physicians have traditionally served as the primary entry point into the health care system for patients with LBP, as well as a primary referral source for physical therapists. However, these physician referral episodes of care have been shown to increase costs compared to episodes of care when patients have directly accessed a physical therapist without physician referral.'''^ Considerable evidence also supports the benefits of early access to a physical therapist.^"'"* The military health care system has long supported the benefits of early access to a physical therapist, as they have been credentialed as direct access providers since 1973.'** However, little evidence exists to confirm that physical therapists in the military have the necessary knowledge in managing patients with LBP in a direct access manner.
*Department of Physical Therapy, University of Scranton. 800 Linden Street, Scranton, PA 18510. tDoctoral Program in Physical Therapy, US Army-Baylor University, ATTN: MCCS-HMT, 3151 Scott Road, Suite 1230, Fort Sam Houston, TX 78234. doi: 10.7205/MILMED-D-I3-00099
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Knowledge in managing LBP can be assessed by many methods. Previously described standardized written examinations by Buchbinder et al'^ and Einestone et al'^ assessed physician knowledge in the management of patients with LBP. These examinations would seem to serve as a pragmatic reference standard for the initial assessment of physical therapist knowledge in managing patients with LBP. If physical therapists could show equal or higher levels of knowledge than their physician counterparts, this would provide at least some level of evidence to suggest that physical therapists have adequate knowledge in providing direct access care for patients with LBP. Therefore, the purpose of this study was to compare knowledge in managing LBP between physical therapists and family practice physicians. We hypothesized that physical therapists would show knowledge levels that were higher than or equal to those of family practice physicians with respect to optimal patient management strategies and beliefs about LBP. This hypothesis was based on previous research that suggested physical therapists in the uniformed services showed higher levels of knowledge in managing musculoskeletal conditions than all physician specialties except for orthopedic surgeons.''''^ In addition, physical therapists in the uniformed services have extensive additional training in managing patients with neuromusculoskeletal conditions without physician referral, as they are often credentialed to order necessary diagnostic studies such as radiographs and magnetic resonance imaging (IVIRI) and to prescribe commonly used nonsteroidal anti-inflammatory medications.'^ METHODS This study used a quasi-experimental, cross-sectional casecontrol design to explore differences in knowledge and
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain TABLE I.
Knowledge, Attitudes, and Guideline Statements With Correct Responses Regarding the Management of Patients With LBP" Statements
Correct Responses
Knowledge Patients with acute LBP should be prescribed complete bed rest until the pain goes away Patients should not return to work until they are almost pain free X-rays of the lumbar spine are useful in the workup of patients with acute LBP Encouragement of physical activity is important in the recovery of LBP Interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP Attitudes 1 am likely to order X-rays for LBP because patients so often expect me to do so There is nothing physically wrong with many patients with chronic back pain Well-tnotivated patients are unlikely to have long-term problems with LBP I have no difficulty in assessing the motivation of my LBP patients Guidelines Practice guidelines are useful to help doctors in the management of medical conditions I would find practice guidelines helpful in the management of LBP
Disagree, Strongly Disagree Disagree, Strongly Disagree Disagree, Strongly Disagree Agree, Strongly Agree Agree, Strongly Agree
Disagree, Strongly Disagree Agree, Strongly Agree Agree, Strongly Agree Agree, Strongly Agree Agree, Strongly Agree Agree, Strongly Agree
Participants were asked to select among the following responses for each statement: strongly agree, agree, uncenain, disagree, and strongly disagree.
beliefs about the management of LBP among physical therapists and family practice physicians currently practicing in the U.S. Air Force. Before subject recruitment and data collection, the study was approved by the institutional review board at Wilford Hall Medical Center in San Antonio, Texas. All subjects provided informed consent before participation. Participants completed the same examinations developed by Buchbinder et al'^^ and Finestone et al'^ that originally assessed knowledge, attitudes, the u.sefulness of clinical practice guidelines, and management strategies of physicians for patients with LBP (Tables I and II). The examination developed by Buchbinder et al'^ consisted of 11 questions (Table I). Five questions assessed participant knowledge about the management of LBP, 4 questions assessed attitudes toward patients with LBP, and 2 questions assessed the usefulness of clinical practice guidelines. The questions were phrased as statements and responses were on a 5-point Likert scale that included "strongly agree," "agree," "uncertain," "disagree," and "strongly disagree" (Table I). For questions on knowledge, the "correct" responses were based on the most recent systematic reviews of the evidence for treatment of patients with LBP."^"^ The percentage of respondents who answered knowledge questions correctly were TABLE M.
determined by adding those who answered either "agree" and "strongly agree" or "disagree" and "strongly disagree" depending on the wording of the question. A response of "uncertain" was coded as being incorrect. For questions concerning attitudes and guidelines, a response of either "agree" or "strongly agree" was considered to be correct, and the percentage of correct responses was determined in the same way. Con'ect responses were graded in the same manner as described by Buchbinder et al.'^ The examination developed by Finestone et al"' consisted of 5 questions about the management strategies for patients with LBP (Table II). Each correct answer was given a score of 20 points, with a maximum overall score on the examination of 100 points with higher scores indicating higher knowledge levels regarding optimal management strategies and beliefs about LBP. Two of the questions were multiple choice (preferred drug treatments and imaging recommendations), whereas the other 3 questions on the importance of bed rest, patient encouragement and explanation, and the use of spinal manipulation were phrased as statements with responses on a 5-point Likert scale that included "not recommended," "of minor importance," "important," "very important," and "extremely important" (Table II). Correct responses were
Questions, Possible Responses, and Correct Responses Regarding the Optimal Management of Patients With LBP'' Questions
What drug treatment is preferable for patients with acute LBP, defined as pain lasting up to 1 week, without sciatica? What imaging studies would you recommend for patients with acute LBP, defined as pain lasting up to 1 week, without sciatica? Rate the importance of bed rest for the effectiveness of simple back pain treatment Rate the importance of patient encouragement and explanation for the effectiveness of simple back pain treatment Rate the importance of manipulation for the effectiveness of simple back pain treatment
Possible Responses Acetaminophin", NSAIDs", COX-2 selective NSAIDs, opioids X-ray of the lumbar spine, ultrasound of the kidneys, CT of the lumbar spine, bone scan, MRI. none of the above" Not recommended", of minor importance, important, very important, extremely important Not recommended, of minor importance, important, very important, extremely important" Not recommended, of minor importance", important", very important", extremely important"
NSAIDs, nonsteroidal anti-inflammatory drugs; CT, computed tomography. "Correct responses are noted.
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain
graded in the same manner as of those Finestone et al'^ with the exception of the question pertaining to the importance of spinal manipulation from the Finestone et al'^ examination. In the original publication, the correct answer to this question was that manipulation was not recommended based on LBP guidelines published in 1996."'* More current guidelines have recommended spinal manipulation in the treatment of patients with LBP."'' Therefore, an answer of "of minor importance," "important," "very important," or "extremely important" was deemed correct for the manipulation question. The LBP examination was administered via an online program entitled SurveyMonkey. No time limit was imposed on the examination. All physical therapists and family practice physicians currently practicing in the U.S. Air Force were invited to participate in this study through electronic mail. Individuals were contacted based on current provider electronic mail distribution lists that were generated by the U.S. Air Force Associate Chiefs for physical therapy and family practice. Subject confidentiality was strictly maintained through assignment of a unique computer-generated code. Before taking the LBP examination, subjects completed a demographic survey that assessed educational preparation and experience in different practice settings. Respondents were also asked if they were familiar with the articles by Buchbinder et al'"' and Finestone et al."' Data frotn any participants familiar with the studies by Buchbinder et al'"' and Finestone et al'^ were excluded because the examination and answer keys were published in those papers. To maximize participation, participants were not asked to complete the examination in a proctored setting. However, participants were asked to complete the study without the help of outside resources (e.g., textbooks, information available on the Internet, or personal communication). All participants were queried at the end of the examination regarding whether they used any outside resources to assist them in the completion of the examination. Data from any participants who used outside resources were excluded. The results of the demographic survey and the content of the examination were stored in a secure, passwordprotected, centralized database for subsequent analysis.
Data Analysis Beliefs of physical therapists and family practice physicians regarding knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP were compared using relative risks (RRs) and 95% confidence intervals (CIs). For each of the 11 questions in the Buchbiner et al'^ examination, an RR > 1 indicates that a higher percentage of physical therapists agreed with the knowledge, attitude, or guideline statement compared with family practice physicians, an RR < 1 indicates that a lower percentage of physical therapists agree, whereas an RR = 1 indicates that there is no difference in belief between physical therapists and family practice physicians. This method of
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analysis was consistent with that of Buchbinder et al'"^ in assessing responses to these same questions. For each of the questions in the Finestone et al"" examination, an RR > 1 indicates that a higher percentage of physical therapists were correct in answering questions regarding management strategies for patients with LBP compared to family practice physicians, an RR < 1 indicates that a lower percentage of physical therapists were correct, whereas an RR = 1 indicates that there is no difference in the correct responses between physical therapists and family practice physicians. An independent t test was also used to compare overall examination scores between physical therapists and family practice physicians, which was consistent with the method of analysis by Finestone et al'* in assessing responses to these same questions. The values for a were established a priori at 0.05. RESULTS 127 physical therapists and 374 family practice physicians were invited to participate in this study. Fifty-four physical therapists (response rate = 43%) and 130 family practice physicians (response rate = 35%) completed the examinations. The characteristics of the participants are shown in Table III. No participant reported receiving assistance from outside resources. Twenty-four physical therapists and 6 family practice physicians reported being familiar with the examinations by Buchbinder et al'^^ and Finestone et al'*, thus these data were not included in the analysis. For the Buchbinder et al''' examination, physical therapists were tnore likely than family practice physicians to have no difficulty assessing the motivation of patients with LBP (63.6% vs. 36.2%; RR: 1.76 [95% Cl: 1.30-2.38]). Besides the results from the "motivation" question, responses were generally comparable for the rest of the Buchbinder et al'"" examination between physical therapists and family practice physicians (Table IV). TABLE III. Characteristics of Clinical Experience and Training for Physical Therapists (/? = 54) and Family Practice Physicians (n = 130) Characteristics Male (;i, %) Age (Mean, Range) Years of Clinical Practice (Mean, Range) Residency Trained (n, %) Fellowship Trained (n, %) Special interest in MSK medicine (;j, %) LBP (H, %) CME for LBP in past 2 years (n, %) 0 hours 1—20 hours 20+ hours
Physical Therapists
Physicians
39 (72.2) 84 (64.6) 40 (28-53) 38 (29-59) U (2-23) 8.3 (0-30) 3 (5.6) 128(98.5) 0(0) 12 (9.2) 48 (88.9) 38 (70.4)
62 (47.7) 30(23.1)
5(9) 27 (50) 22(41)
17(13) 99 (76) 14(11)
MSK, musculoskeletal: CME. continuing medical education; LBP, low back pain.
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain TABLE IV.
Percentages of Physical Therapists and Family Practice Physicians Agreeing With Knowledge, Attitudes, and Guideline Statements for the Management of Pattents With LBP'' Percent Agreement Physical Therapists
Statements Knowledge Patients with acute LBP should be prescribed complete bed rest until the pain goes away Patients shoukl not return to work until they are almost pain free X-rays of Ihe lumbar spine are useful in the workup of patients with acute LBP Encouragement of physical activity is important in the recovery of LBP Interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP Attitudes I am likely to order X-rays for LBP because patients so often expect me to do so There is nothing physically wrong with many patients with chronic back pain Well-motivated patients are unlikely to have long-tenn problems with LBP I have no difficulty in assessing the motivation of my LBP patients Guidelines Practice guidelines are useful to help doctors in the management of medical conditions I would find practice guidelines helpful in the management of LBP
For the Finestone et al examination, the percentage of physical therapists and family practice physicians were comparable who had correct answers regarding imaging and the importance of bed rest and manipulation (Table V). However, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; RR: 1.24 [95% CI: 1.06-1.46]) and to believe that patient encouragement and explanation is "extremely important" (75.9% vs. 56.2%; RR: 1.35 [95% CI: 1.09-1.67]). The mean .score on the Finestone et al"^ examination (maximum overall score = 100) was 87.0 ± 17.4 points (95% CI: 82.3-91.8) for physical therapists vs. 80.5 ± 18.2 points (95% CI: 77.3-83.6) for family practice physicians (p < 0.05). DISCUSSION The purpose of this study was to compare knowledge in managing LBP between physical therapists and family practice physicians. We hypothesized that physical therapists would show knowledge levels that were higher than or equal to those of family practice physicians with respect to optimal patient management strategies and beliefs about TABLE V..
0 2.8 18.2 94.5 18.2
3.6 12.7 63.6 63.6 78.2 81.8
Phy.sicians
RR (95% CI)
0
2.34(0.05-116.43) 7.02(0.29-169.66) 0.82(0.43-1.55) 0.98(0.78-1.23) 0.61 (0.34-1.13)
0 22.3 99.2 30
36.2
0.28(0.07-1.16) 0.72 (0.33-1.58) 1.27 (0.98-1.66) 1.76(1.30-2.38)
87.7 80.8
0.89 (0.76-1.04) 1.01 (0.87-1.18)
13.1 17.7
50
LBP. This hypothesis was based on previous research that suggested physical therapists in the uniformed services showed higher levels of knowledge in managing musculoskeletal conditions than all physician specialties except for orthopedic surgeons.''''** In addition, physical therapists in the uniformed services have extensive additional training in managing patients with neuromusculoskeletal conditions without physician referral, as they are often credentialed to order necessary diagnostic studies such as radiographs and MRI and to prescribe cotnmonly used nonsteroidal antiinfiarnmatory medications.''* In this study, physical therapists showed significantly improved knowledge regarding optimal management strategies for patients with LBP cotnpared to family practice physicians. In addition, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; RR: 1.24 [95% CI: 1.06-1.46]) and believe that patient encouragement and explanation is important (75.9% vs. 56.2%; RR: 1.35 [95% CI: 1.09-1.67]). Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were similar between the groups. Thus, our hypothesis was supported.
Percentages of Physical Therapists and Family Practice Physicians Who Correctly Answered Questions on the Optimal Management of Patients With LBP'* Percent Correct Questions
Physical Therapists
Physicians
RR (95% CI)
What drug treatment is preferable for patients with acute LBP, defined as pain lasting up to 1 week, without sciatica? What imaging studies would you recommend for patients with acute LBP. defined as pain lasting up to 1 week, without sciatica? Importance of bed rest Importance of patient encouragement and explanation Importance of manipulation
85.2
68.5
1.24(1.06-1.46)
90.7
90.8
0.99(0.90-1.11)
87 75.9 96.3
89.2 56.2 97.7
0.98(0.87-1.10) 1.35(1.09-1.67) 0.99(0.93-1.05)
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Fhysical Therapist vs. Family Fractitioner Knowledge of Low Back Fain
Participants in our study completed the same examination developed by Finestone et al,"' which consisted of 5 questions about the management strategies for patients with LBP (Table II), Each correct answer was given a score of 20 points, with a maximum overall score on the examination of 100 points, with higher scores indicating higher knowledge levels regarding optimal management strategies and beliefs about LBP. One of the questions in this examination developed by Finestone et al'^ dealt with the importance of manipulation in the treatment of patients with LBP. In the original Finestone et al'^ article, a correct response for this question was that manipulation for the treatment of patients with LBP was "not recommended," based on guidelines for the treatment of LBP published in 1996.^"* Based on more current guidelines,^'' which support the use of manipulation in the treatment of patients with LBP, we changed the correct response for the importance of manipulation for the treatment of patients with LBP to "of minor importance," "important," "very important," or "extremely important." Therefore, direct comparisons between our results and those of Finestone et al'^ are difficult given the differences in scoring the manipulation question. However, if we scored the manipulation question as "not recommended," the mean scores of physical therapists and family practice physicians were 68,5 and 61.4, respectively. In the Finestone et al'^ study, the mean scores of family practitioners and orthopedists were 69,7 and 44.3, respectively. These results suggest that the participants in our study showed knowledge levels that were higher than or equal to the participants in the Finestone et al'^ study. Current management guidelines for patients with LBP include recommendations for patients to stay active, which is more effective than resting in bed."^ Although none of the participants in our study agreed that patients with acute LBP should be prescribed complete bed rest until the pain goes away, 13% of physical therapists and 11% of family practice physicians incorrectly recommended some form of bed rest for patients with LBP (Table V). In the study by Buchbinder et al,'"' between 9% and 18% of physicians agreed that patients with acute LBP should be prescribed complete bed rest until the pain goes away. Furthermore, in the study by Finestone et al,'^ 67% of orthopedists and 46% of family practitioners incorrectly recommended some form of bed rest. Although the participants in our study seemed to rely less on bed rest in the management of patients with LBP than physicians in the Buchbinder et al ^ and Finestone et al, t 6 studies, the data from our study suggest that bed rest is still used in the management of patients with LBP, despite no proof of its effectiveness. In the Finestone et al"' study, only 8% of family practitioners but 53% of orthopedists incorrectly recommended cyclooxygenase-2 (COX-2) selective nonsteroidal antiinflammatory medications in the treatment of patients with LBP. Interestingly, a greater number of physical therapists (85.2%) than family practitioners (68,5%) in our study
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correctly selected acetaminophen and nonsteroidal antiinflammatory medications as the preferable drug treatment for patients with LBP (RR: 1.24 [95% CI: 1.06-1,46]) (Table V). Although physical therapists in the uniformed services are able to prescribe acetaminophen and nonsteroidal anti-inflammatory medications, they are not able to prescribe COX-2 selective nonsteroidal anti-inflammatory medications and opioids, which may have influenced their medication selection for this question. In addition, physicians may be more likely to be influenced by pharmaceutical companies' marketing campaigns^^ and be informed by pharmaceutical representatives regarding the wide variety of drug classes.' This may explain, in part, the preference of family practice physicians for COX-2 selective nonsteroidal antiinflammatory medications and opioids in the management of patients with LBP, despite no evidence to support this practice over prescribing acetaminophen and nonselective nonsteroidal anti-inflammatory medications. In this study, physical therapists were more likely than family practitioners to not have difficulty assessing the motivation levels of patients with LBP (63.6% vs. 36.2%; RR: 1,76 [95% CI: 1.30-2,38]), In addition, physical therapists were more likely than family practitioners to correctly believe that patient encouragement and explanation is "extremely important" in the management of patients with LBP (75,9% vs. 56.2%; RR: 1.35 [95% CI: 1.09-1.67]). Assessing patient motivation levels and educating patients is a time-consuming process. The duration of a typical patient visit is longer with the physical therapist than a family practice physician and the physical therapist typically sees patients on a serial basis for a period of time. This increased patient interaction may play a part in physical therapists having less difficulty in assessing patient motivation and placing a greater emphasis on patient encouragement and explanation. Clinicians should not routinely obtain diagnostic imaging in patients with nonspecific LBP.^"* Rather, diagnostic imaging for patients with LBP should be reserved for when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.^"* In this study, 9% of physical therapists and family practice physicians would recommend diagnostic imaging for patients with acute LBP without sciatica and 18% of physical therapists and 22% of family practice physicians believe that X-rays of the lumbar spine are useful in the workup of patients with acute LBP. In the study by Buchbinder et al,'^ between 29% and 41% of physicians agreed that X-rays of the lumbar spine are useful in the workup of patients with acute LBP. In the Finestone et al'^ study, 53% of orthopedists and 8% of family practitioners failed to respond that no imaging was necessary for patients with acute LBP without sciatica. These data suggest that diagnostic imaging may be unnecessarily overutilized in the management of patients with simple LBP. This is concerning as there is no evidence that routine conventional radiography in patients with nonspecific LBP is associated
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Physical Therapist vs. Family Practitioner Knowledge of Low Back Pain
with a greater improvement in patient outcomes.^^ In addition, routine advanced imaging (i.e., computed tomography and IVIRI) is not associated with improved patient outcomes^^ and identifies many abnormalities that are poorly correlated with sytnptoms^''''"'*' but could lead to additional, possibly unnecessary interventions.'^^ There are some limitations that should be considered when evaluating the results of our study. First, these data tnay not be generalizable to other practice settings. Educational programs for physical therapists and physicians do not use standardized curricula and exposure to educational experiences regarding the management of patients with LBP differs. Physical therapists in the uniformed services also have extensive additional orthopedic training in managing patients with neuromusculoskeletal conditions without physician referral.'"* Furthermore, they are often credentialed to order necessary diagnostic studies such as radiographs and IVIRI and to prescribe commonly used nonsteroidal antiinflammatory medications.'"* Therefore, one might expect physical therapists in the uniformed services to show knowledge levels that exceed those without advanced orthopedic training or credentialing. Eurther research could be performed to determine if the results obtained with physical therapists in the uniformed services would be similar to civilian physical therapists. Second, we invited volunteer physical therapists and family practice physicians to participate in this study. With a physical therapist response rate of 43% and a family practice physician response rate of 35%, which is somewhat lower than we expected for a military setting, there is the potential for selection bias. More specifically, the physical therapists and family practice physicians who volunteered to participate in this study may have been more cornfortable witb managing patients with LBP and therefore, more apt to participate in this study. However, physician participants in the studies by Buchbinder et al'^ and Einestone et al'^ were also volunteers, which likely mitigates any potential bias in discussing our results in relation to those studies. Nonetheless, it would be interesting to see if there were any relevant differences between those who volunteered to participate in this study and those that did not in terms of their knowledge in managing patients with LBP. Third, although we assessed knowledge in managing LBP between physical therapists and family practice physicians, we did not assess knowledge pertaining to "red flags" that may be associated with LBP, such as extremity weakness/atrophy, altered reflexes, incontinence, and saddle anesthesia. One reason for an initial evaluation from a physician is to evaluate for "red flags" or emergency situations that require immediate interventions. Future studies should assess "red flag" knowledge in patients with LBP between physical therapists and family practice physicians. In addition, future efforts should be geared toward developing plan of care algorithms that include "red flag" assessment by which uniformed service members could be seen initially by a physical therapist rather than a family practice physi-
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cian. Eourth, it is not completely clear if the subgroups of patients with LBP being seen by physical therapists and family practice physicians are identical. If the physicians are seeing more patients with LBP that is classified as "acute on chronic" or patients with LBP that have multiple comorbidities, this might lead to differences in clinical approaches or at least clinical experiences between the 2 provider groups, which may have influenced the results of this study.
CONCLUSION This study compared knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies of physical therapists and family practice physicians for patients with LBP. Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the 2 groups. However, physical therapists showed knowledge levels that were higher than or equal to those of primary care physicians with respect to optimal management strategies and beliefs about LBP. In addition, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians and believe that patient encouragement and explanation is important. The results of this study may have implications for health policy decisions regarding the utilization of physical therapists to provide care for patients with LBP without a referral including the potential placement of physical therapists in primary care clinics to initially manage patients with musculoskeletal conditions, the development of multidisciplinary clinics including both physical therapists and family practice physicians, and involvement of physical therapists in family practice physician training programs.
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MILITARY MEDICINE, Vol. 179, February 2014
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