ABSTRACT
Background: Clinical Practice Guidelines for low back pain emphasize implementing assessment and addressing of psychosocial context. It is unknown to what extent manual physiotherapists incorporate psychological factors in their diagnostic management of patients with nonspecific low back pain.
Methods: An online survey among Dutch manual physiotherapists was conducted exploring the use of 10 psychological constructs. Frequencies of attention to psychological factors during history-taking and use of questionnaires were calculated. Associations between therapists characteristics and use of psychological questionnaires were analyzed using Spearmans rank correlation coefficient (r s) and logistic regression. In addition, a retrospective patient record review was conducted.
Results: One hundred and twelve manual physiotherapists returned completed surveys. Although respondents indicated psychological factors were assessed, they rarely used psychological questionnaires. Significant but negligible associations were found for age and working hours and the use of specific questionnaires. From 95 patient records reviewed, seven were identified that mentioned one psychological factor each during history taking.
Conclusions: Dutch MPTs, regardless of their age and work characteristics, rarely use psychological questionnaires in patients with LBP, although they report addressing these constructs implicitly during history taking. Educational and implementation strategies are needed to warrant the use of psychological constructs and validated psychological questionnaires at all phases of the clinical reasoning process.
KEYWORDS: Psychology, back pain, history taking, psychological questionnaires, manual physiotherapists, clinical reasoning
Introduction
Low back pain (LBP) is the most disabling musculoskeletal condition worldwide and is influenced by many physical, psychological, and emotional factors increasing the risk of a poor prognosis of recovery and chronic pain [1,2]. Psychological factors are associated with a poor prognosis and development of chronic LBP[3,4,5,6]. These psychological factors likely interact with each other which additionally contributes negatively to pain and long-term disability[7]. Consequently, international Clinical Practice Guidelines (CPGs) for nonspecific LBP commonly recommend focusing on the following psychological factors (in a random sequence): distress, anxiety, depression, somatization, catastrophizing, fear avoidance, illness perceptions, and quality of life. In the Dutch CPG, LBP is classified into three prognostic profiles by assessment of biomedical, psychological, and social factors[8]. In profile three, psychosocial prognostic factors may be causal for a deviated course and can be itemized as a measure of risk. Subsequently, due to the profiles, clinical examination objectives can be formulated on the basis of the prognostic profile to establish health profiles in patients with LBP. However, recommendations for construct-related psychological questionnaires are not provided [1,3,5,9]. Psychological contributors to chronic LBP can be incorporated in a multimodal treatment approach, consisting of pain education, avoiding (bed)rest, continuing physical activities, manual physiotherapy, and NSAIDs when pain inhibits these activities, with the extra benefit of decreasing the negative impact of these factors [10,11]. In chronic LBP, CPGs additionally recommend the use of a combined program of a physical and psychological intervention including a cognitive-behavioral approach[4]. Manual physiotherapy in patients with chronic LBP is, in particular, recommended within such a multidimensional approach [10,11,12].
Evaluating the risk of a poor prognosis as well as deciding on psychologically oriented treatment options are important reasons for manual physiotherapists (MPTs) to identify psychological factors. From a 2015 study in the Netherlands, it is known that psychological factors are insufficiently and inadequately deployed in the four phases of clinical reasoning (diagnostics, treatment plan, treatment, and evaluation) by MPTs in patients with LBP in particular during history taking as part of the diagnostic phase [13]. Therefore, the aims of this study, using a self-reported online survey and secondary data analyses by review of Electronic Health Records (EHR), were (1) to assess type and frequency of use of psychological assessments, including questionnaires, by MPTs during their clinical reasoning process in patients with LBP and (2) to estimate associations between psychological assessments and demographic and professional characteristics of MPTs.
Methods
Design
The design of this study was a cross-sectional online survey among Dutch MTPs. Secondary data were retrospectively evaluated by review of EHRs of patients with LBP.
Online survey
The survey instrument comprised 13 items, all composed on a 5-point Likert scale ranging from ‘never’ to ‘always’, concerning attention to psychological items during history taking (one item), frequency of use of psychological questionnaires (two items), and attention to psychological aspects during the four phases of clinical reasoning (diagnostics, treatment plan, treatment, and evaluation) (four items). Psychological factors evaluated comprised: anxiety, depression, distress, catastrophizing, somatization, fear-avoidance, quality of life, kinesiophobia, and illness perceptions. The remaining six items focused on demographic and work characteristics of the participating MPTs (age, work experience, number of work hours per week overall, number of work hours per week in patients with LBP, and work setting). The content of the treatment modalities was not documented. To safeguard the validity of the survey, the SURGE and CHERRIES checklists were used as guidance to report the survey and to prevent bias, incorrect use, and false interpretation[14].
The survey was developed, refined, and checked for consistency, completeness, and technical functionality by first testing the survey among a group of experienced MPTs. Subsequently, potential respondents were recruited via online mailing lists to 928 MTPs who were graduated since 2013 from the master’s program in manual physiotherapy at Stichting Opleidingen Musculoskeletale Therapie (SOMT University of Physiotherapy, Amersfoort, the Netherlands). Additionally, a digital newsletter was posted via the Dutch Association for Manual Therapy (NVMT) in June 2018, including a short explanation of the purpose of the study. Potential respondents received a reminder two weeks after the initial invitation. After written and oral consent, participation was completely voluntary. Complete anonymity was ensured, and all information was kept confidential and anonymized on computer servers of the Vrije Universiteit Brussel (Brussels, Belgium). The survey instrument was developed and distributed using QuestionPro software between May 16 and 4 July 2018.
EHR review
Retrospective EHR reviews were performed to extract routinely collected data on location in five randomly selected and invited primary care manual physiotherapy practices in the province of Zeeland in the Netherlands. Extraction of data was conducted by one author (LvZ) who had complete access to the EHR systems. All records were approved by the practitioner who had database authority to remove all personally identifiable data beforehand. Data collection was restricted to patients complying with diagnostic criteria for nonspecific LBP who had been treated in the previous six months. Patients with specific LBP (e.g., post-surgery, fractures, radicular pain) were excluded. After oral agreement about anonymity and confidentiality about the use of the selected data, records were divided into patients with less than 12 weeks (acute) LBP and those experiencing (chronic) LBP longer than 12 weeks.
Descriptions of psychological constructs were screened on key terms for anxiety, depression, distress, catastrophizing, somatization, fear-avoidance, quality of life, kinesiophobia, and illness perceptions, and counted as absolute frequencies. Attention to psychological aspects during history taking, treatment plan, treatment, and evaluation was recorded separately for patients with acute and chronic LBP. Finally, the use of 11 specific questionnaires for psychological constructs was recorded: Distress/depression/anxiety/somatization: Four-Dimensional Symptoms Questionnaire (4DSQ), Anxiety: Pain Anxiety Symptom Scale (PASS), Depression/anxiety: Hospital Anxiety Depression Scale (HADS), Catastrophizing: Pain Catastrophizing Scale (PCS), Fear-avoidance: Fear-Avoidance Beliefs Questionnaire (FABQ), Kinesiophobia: TAMPA Scale for Kinesiophobia (TSK), Illness perceptions: Illness Perception Questionnaire-B (IPQ-B), Quality of Life: Quality of Life Short Form-36 (SF-36), Quality of Life: EuroQol 5-D (EQ-5D), Psychosocial factors: Acute Low Back Pain Screening Questionnaire (ALBPSQ), and Psychological factors: StarT Back Screening Tool (SBST).
Data analysis
Characteristics of responding MPTs including age, year of graduation, years of experience, weekly working hours in general and with patients with LBP, and work setting were described as means with standard deviations (SD) in case of normally distributed data and with their median and minimum-maximum values where normality was not met. Participants’ working setting (in service, owner, management, or freelance) was described as absolute and relative frequencies. Frequencies of use and types of psychological questionnaires were recorded. Descriptive variables were calculated as medians and interquartile range (IQR) for ordinal variables. In addition, absolute numbers and proportions on the use of questionnaires were calculated.
Correlation coefficients for associations between age, work experience, and working hours of the participating MPTs on the one hand, and the use of questionnaires on the other hand were analyzed by calculating Spearman’s rank correlation coefficient (rs), for which rs < 0.30 was considered as ‘negligible’, 0.30–0.50 as ‘low’, 0.51–0.70 as ‘moderate’, 0.71–0.90 as ‘high’, and 0.91–1.00 as ‘very high’[15]. A binary logistic regression was performed for exploring associations, expressed as odds ratio’s (OR), between age and working hours of the participating MPTs and the use of psychological questionnaires.
Data obtained in QuestionPro were automatically transported and analyzed using IBM SPSS Statistics version 26.0.
Results
Online survey
Of 928 MPTs invited, one invitation appeared unsubscribed, and 48 invitations were bounced. Consequently, 879 questionnaires were actually received of which 96 (11%) were completed and returned. From the NVMT newsletter, 16 MPTs additionally responded. In total, 112 completed surveys were analyzed. The completion time of the survey was 5–7 minutes. Characteristics of participating MPTs are presented in Table 1.
Table 1.
Characteristics of participating manual physiotherapists (n = 112)
| Age (years), mean (SD) | 33.4 (6.8) |
|---|---|
| Year of graduation in manual therapy, median | 2016 |
| Year of graduation in physiotherapy, median | 2009 |
| Experience in manual physiotherapy (years), mean (SD) | 4.1 (4.8) |
| Experience in physiotherapy (years), mean (SD) | 10 (6.3) |
| Weekly work (hours), mean (SD) | 34.0 (8.2) |
| Weekly work (hours) with patients with LBP, mean (SD) | 13.8 (6.5) |
Work setting, n (%)
|
82 (73) |
|
20 (18) |
|
9 (8%) |
|
1 (0.8) |
Legend: yrs. = years; SD = standard deviation; hrs. = hours; LBP = Llow ack pain.
Psychological factors during four phases of clinical reasoning
Respondents’ self-reported attention to psychological factors during the diagnostic process, treatment plan, treatment, and evaluation in patients with LBP is presented in Table 2. Seventy-five (67%) and 98 (87%) of respondents indicated to ‘often’ or ‘always’ pay attention to psychological factors during the diagnostic phase in patients with LBP, respectively. For treatment plan, treatment, and evaluation, these frequencies were n = 59 (53%), n = 94 (83%) and n = 26 (23%) in patients with acute LBP, and n = 72 (64%), n = 46 (41%). and n = 78 (69%) in patients with chronic LBP.
Table 2.
Attention to psychological factors during the phases of clinical reasoning in patients with low back pain (n = 112)
| Diagnostics | Treatment plan | Treatment | Treatment evaluation | |
|---|---|---|---|---|
| Never n (%) | 1 (1) | 0 (0) | 11 (5) | 5 (3) |
| Rarely n (%) | 17 (8) | 21 (9) | 42 (19) | 24 (11) |
| Sometimes n (%) | 33 (15) | 50 (23) | 73 (33) | 71 (32) |
| Often n (%) | 100 (45) | 97 (43) | 67 (30) | 89 (40) |
| Always n (%) | 63 (33) | 56 (25) | 31 (14) | 35 (16) |
| Median; IQR | 4.0; 3.5,5.0 | 4.0; 3.0,4.0 | 3.0; 3.0;4.0 | 4.0; 4.0;4.5 |
Legend: IQR = interquartile range; LBP = low back pain.
Psychological factors during history taking
Frequencies of assessing psychological factors during history taking in patients with LBP are presented in Table 3. Respondents indicated to ‘often’ or ‘always’ pay attention to psychological factors during history taking with highest frequencies for distress n = 93 (82%), kinesiophobia n = 78 (70%), and anxiety n = 69 (61%). Catastrophizing was the least assessed factor during history taking.
Table 3.
Frequencies of assessing psychological factors during history taking (n = 112)
| Distress | Anxiety | Depression | Somatisation | Catastrophising | Kinesiophobia | |
|---|---|---|---|---|---|---|
| Never n (%) | 2 (2) | 1 (1) | 1 (1) | 3 (3) | 2 (2) | 0 (0) |
| Rarely n (%) | 1 (1) | 8 (7) | 16 (14) | 12 (11) | 20 (18) | 8 (7) |
| Sometimes n (%) | 16 (14) | 34 (30) | 50 (44) | 36 (32) | 29 (26) | 26 (23) |
| Often n (%) | 53 (47) | 44 (39) | 28 (25) | 40 (35) | 40 (35) | 48 (43) |
| Always n (%) | 40 (35) | 25 (22) | 17 (15) | 21 (19) | 21 (19) | 30 (27) |
| Median; IQR | 4.0; 4.0,5.0 | 4.0; 3.0,4.0 | 3.0; 3.0,4.0 | 4.0; 3.0,4.0 | 4.0; 3.0,4.0 | 4.0; 3.0,5.0 |
Legend: IQR = interquartile range; LBP = low back pain.
Frequency of using questionnaires
Table 4 shows how often MTPs reported to use psychological questionnaires. Median scores were ‘never’ for the HADS, PASS, PCS, IPQ, ALBPSQ, and EuroQol and ‘rarely’ for the remaining questionnaires. Lower limits of the interquartile ranges were at ‘never’ for all questionnaires while the upper limit reached ‘often’ for the StarT Back Screening Tool.
Table 4.
Frequencies of use of psychological questionnaires (n = 112)
| 4DSQ | HADS | PASS | PCS | FABQ | IPQ-B | TAMPA | QOL SF36 | EQ-5D | ALBPSQ | SBST | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Never n (%) | 47 (42) | 94 (83) | 106 (94) | 89 (79) | 43 (38) | 75 (66) | 40 (35) | 76 (67) | 108 (96) | 89 (79) | 43 (38) |
| Rarely n (%) | 37 (33) | 11 (10) | 4 (4) | 11 (10) | 37 (33) | 20 (18) | 29 (26) | 21 (19) | 3 (3) | 12 (11) | 18 (16) |
| Sometimes n (%) | 22 (20) | 5 (4) | 2 (2 | 7 (6) | 27 (24) | 16 (14) | 33 (29) | 12 (11) | 1 (1) | 11 (10) | 16 (14) |
| Often n (%) | 5 (4) | 2 (2) | 0 (0) | 5 (4) | 4 (4) | 1 (1) | 9 (8) | 3 (3) | 0 (0) | 0 (0) | 23 (20) |
| Always n (%) | 1 (1) | 0 (0) | 0 (0) | 0 (0) | 1 (1) | 0 (0) | 1 (1) | 0 (0) | 0 (0) | 0 (0) | 12 (11) |
| Median; IQR | 2; 1.0,2.75 | 1.0; 1.0,1.0 | 1.0; 1.0,1.0 | 1.0; 1.0,1.0 | 2.0; 1.0,3.0 | 1.0; 1.0,2.0 | 2.0; 1.0,3.0 | 1.0; 1.0,2.0 | 1.0; 1.0,1.0 | 1.0; 1.0,1.0 | 2.0; 1.0,4.0 |
Legend: IQR = interquartile range; 4DSQ = Four-Dimensional Symptom Questionnaire; HADS: Hospital Anxiety Depression Scale; PASS = Pain Anxiety Symptom Scale; PCS = Pain Catastrophizing Scale; FABQ = Fear-Avoidance Beliefs Questionnaire; IPQ-B = Illness Perception Questionnaire-Brief; TAMPA: TAMPA Scale for Kinesiophobia; Quality of Life SF-36 = Short Form-36; EQ5-D = EuroQol Five Dimensions Health Questionnaire; ALBPSQ = Acute Low Back Pain Screening Questionnaire; SBST = StarT Back Screening Tool.
Supplementary questionnaires
The following supplementary questionnaires (n = 8) were cited by the respondents of the survey: Beck Depression Inventory (n = 1), Central Sensitization Inventory (n = 3), Bournemouth Questionnaire (n = 1), the Depression Anxiety and Stress Scale (n = 1), Center for Epidemiologic Studies Depression scale (n = 1), Falls Efficacy Scale (n = 1), Pain Coping List (n = 6), and Pain Coping Inventory (n = 11).
Associations between MPTs characteristics and the use of questionnaires
Significant but negligible Spearman’s correlation coefficients were found between age of MPTs and the use of questionnaires for distress, anxiety, and depression. Work experience was negligibly correlated with using questionnaires for depression and catastrophizing and weekly working hours negligibly correlated with distress and depression. Logistic regression analyses showed significant associations between age and using questionnaires for depression and between weekly working hours and using questionnaires for catastrophizing (Table 5)
Table 5.
Associations between respondents’ characteristics and the use of questionnaires during history taking
| Correlation | Spearman’s ρ | 95% CI | P-value |
|---|---|---|---|
| Age MPT | |||
| Distress | 0.19 | 0.00 to 0.35 | 0.048 |
| Anxiety | 0.20 | 0.02 to 0.39 | 0.03 |
| Depression | 0.28 | 0.11 to 0.45 | 0.00 |
| Work experience | |||
| Depression | 0.25 | 0.07 to 0.41 | 0.01 |
| Catastrophising | 0.20 | 0.02 to 0.38 | 0.03 |
| Weekly working hours | |||
| Distress | −0.20 | −0.39 to −0.01 | 0.03 |
| Depression | 0.27 | 0.08 to 0.44 | 0.00 |
| Factor | Odds Ratio | 95% CI | P-value |
| Age MPT | |||
| Depression | 1.1 | 1.0 to 1.2 | 0.046 |
| Weekly working hours | |||
| Catastrophising | 1.1 | 1.0 to 1.3 | 0.03 |
Legend: Spearman’s ρ = Spearman’s rho; CI = Confidence Interval; P-value = 0.05.
EHR review
From 12 MPTs across the five primary care practices, 274 patient records were analyzed including records from patients with acute LBP n = 173 (63%) and chronic LBP n = 101 (37%). In seven records, descriptions of psychological constructs during history taking were identified concerning kinesiophobia (n = 3), distress (n = 2), and coping behavior (n = 2).
Discussion
Main findings
The results of this study indicate that MPTs rarely use psychological questionnaires, contrary their own report that psychological factors are frequently employed during the process of clinical reasoning and age, work experience and working hours demonstrated negligible associations with the use of questionnaires.
Adherence to clinical practice guidelines
Participating MPTs were relatively recently graduated and their knowledge about the prognostic role of psychological factors from CPGs LBP is assumed present [16,17]. However, our results are consistent with those reported by Singla et al. who found that the application of the biopsychosocial approach is not mastered by MPTs in favor of a biomedical focus [16]. Shifting to a more biopsychosocial approach is necessary to increase adherence to CPGs in LBP [18]. A step-by-step process of deductive and narrative multidimensional clinical reasoning is required to combine validated multidimensional measurements to explicit diagnostic cues and guide in treatment targets and increase adherence to CPGs. Especially the gap between the diagnostic phase and the treatment phase is a point of concern in that perspective. An international consensus-based and measurable model of clinical reasoning based on quality indicators is lacking and educational programs have various and inconsistent approaches[19].
Comparison with existing evidence
Reasons for limited use of psychological questionnaires have been proposed: insufficiently educated, lack of uniform recommendations or inadequate use of CPGs, not suitable for the topic, difficulty in incorporating psychological aspects in the process of clinical reasoning, lack of knowledge about pain neuroscience, and an overall biomedical vision [13,18,20]. We assume that these reasons are, to a certain extent, also applicable to the Dutch population of MPTs. As a consequence, if a more psychological strategy is provided, it will be based more on personal experience and not on an evidence-based approach [21]. From analyzing EHRs, a method that appeals to routinely collected data (RCD) and increased objectivity and representatives, we found that MPTs reported that psychological aspects are assessed during the process of clinical reasoning [22]. Although it has been found that therapists address psychological problems during treatment contacts, they tend to overestimate their ability to recognize psychological factors [13,23]. EHRs show that attention was sometimes given to psychological factors, but these data did not provide insight into whether it actually influenced the applied treatment. A lack of transparency in describing the process of clinical reasoning may be the causative factor here, in addition to the implicit awareness that they feel unprepared to assess and interpret psychological factors as prognostic factors. We assume that transparency and measurability of the clinical reasoning process increase the adherence to CPGs and are imperative to estimate the predictive value of psychological factors[22]. In addition, a recent study found that physical therapists were not able to interpret and identify the presence of psychological factors by using questionnaires and therefore showed low sensitivity [24]. Although MPTs may be implicitly aware of the presence of psychological factors, in clinical practice they seem to rely more on intuition and personal experience instead of using validated measurements to compensate for this low sensitivity.
Implications for practice
To adhere to CPGs and to enhance transparency in clinical reasoning, it is necessary to quantify the outcomes of clinical examination and, in addition to that, of psychological assessments. The selection of which psychological factors fit my patient arises from history-taking and results in the next phase of clinical reasoning, namely formulating objectives of clinical examination. In addition, psychological factors as prognostic factors add to achieve treatment objectives for individual patients. In contrast, however, an approach from a biomedical perspective is expected by patients and is also considered to be more important by MPTs, instead of unraveling psychological interactions from a biopsychosocial perspective that may conflict with patients’ beliefs [25]. MPTs feel unprepared to intervene on psychological factors and therefore their wish to comply with their patients’ expectations of a biomedical intervention may not be a valid excuse [19]. However, MPTs need to be aware that psychological factors influence physical functioning and improving patient’s insight and understanding of their multilevel condition will facilitate the alliance with their patients. A biopsychosocial approach instead of biomedical labeling may additionally improve adherence to CPGs in LBP and in other musculoskeletal pain conditions.
In patients with LBP, a cognitive-behavioral approach is suggested in which assessment of psychological factors should be included next to manual therapy interventions and active exercises. However, to avoid overuse of such treatments, many of the psychological factors are not directly related to physical dysfunction and they may also not be modifiable, though they influence the pain experience and need to be considered in the chosen intervention [26]. In our study older MPTs may focus more on distress and depression, although they act differently on the other psychological factors. In general, associations between psychological assessments and professional or demographic characteristics were negligible.
Limitations
First, non-respondent bias may have distorted the results of our online survey. [27] Second, including the term ‘survey’ in the subject line of the survey may have led to a decrease in the response rate while a reminder within a shorter time after the invitation could have increased the response [27]. Last, although registering data in EHRs follows mandatory fields, we cannot exclude the possibility that data on psychological constructs and questionnaires were incomplete. Due to regular auditing, we assume that the quality of EHRs in Dutch physiotherapy is adequate which is supported by one study based on quality indicators [28].
Opportunities
Awareness should rise among MPTs that knowledge and cognitive skills fail in assessing psychological factors[29]. Future research in patients with LBP should be directed toward the interpretation of scores of psychological questionnaires most frequently used such as the 4DSQ, PASS, and TAMPA, and how to implement these in the process of clinical reasoning. Education of MPTs in the biopsychosocial model and a more psychologically informed approach should be encouraged including the training of skills for managing these [18,30]. A promising conceptual framework has been presented to improve pain management with the focus on a more psychologically informed practice[31]. Promising treatment options are a cognitive-behavioral approach and pain neuroscience education both as a component of a comprehensive strategy[31,32,33].
Conclusion
Dutch MPTs, regardless of their age and work characteristics, rarely use psychological questionnaires in patients with LBP, although they report addressing these constructs implicitly during history taking. Educational and implementation strategies are needed to warrant the use of psychological constructs and validated psychological questionnaires at all phases of the clinical reasoning process.
Acknowledgments
We thank all the MPTs for participating in the online survey and the MPTs for sharing their data in the EHR review.
Biographies
Hank Hallegraeff received his Bachelor's degree in Physiotherapy at Amsterdam University of Applied Science in 1981. He studied clinical epidemiology at the University of Amsterdam (Master of Science in 2005) and his Ph.D. in Medical Sciences was completed in 2013 at the University of Groningen. Since 2006 he has been a lecturer at SOMT University of Physiotherapy and since 2020 he is also Head of Master Education in Musculoskeletal Ultrasound.
Leonie van Zweden received her Bachelor Physiotherapy at Avans University of Applied Science in Breda, the Netherlands, and her Master of Science degree in Physio- and Manual therapy at Vrije Universiteit Brussel, Brussels, Belgium in 2018. She is currently working at Physiotherapy and Manual Therapy at Fysiotherapie SaFyR Krabbendijke, Krabbendijke, the Netherlands.
Rob Oostendorp was born (1942) in Nijmegen, the Netherlands. He received his Bachelor's degree in Physiotherapy in 1966, his MSc in Rehabilitation Science and Physiotherapy in 1984 at the Vrije Universiteit Brussel, Belgium, and his Ph.D. in Medical Sciences in 1988 at the Radboud University Nijmegen. He was appointed as professor Manual Therapy in 1989 at the Vrije Universiteit Brussel and as professor Allied Health Sciences (particularly physiotherapy) in 2000 at the Radboud University Nijmegen. He retired in 2012. He is officer in de Orde van Oranje Nassau. He is (co-) author of about 200 articles in peer-reviewed journals and supervisor of about 30 Ph.D. studies.
Emiel van Trijffel (1968) is a manual physical therapist with a background in clinical epidemiology. He is a university lecturer at SOMT University of Physiotherapy, The Netherlands, and at Vrije Universiteit Brussels, Belgium. His research focuses on diagnostics, prognostic modeling, and clinical reasoning in manual physical therapy.
Funding Statement
The authors declared that no grants were involved in supporting this work.
Ethical approval
This voluntary practice-based research among Dutch MPTs was performed without interference in usual standard care and patients were not physically involved. To ensure the autonomy and safety of the participants the data is collected and archived anonymously. There were no risks to participation. All MPTs participated voluntarily and had the right to refuse to participate. The study therefore falls outside the scope of the Dutch Medical Research Involving Human Subjects.
Act (https://english.ccmo.nl/).
Disclosure statement
No potential conflict of interest was reported by the author(s).
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