Contemporary approaches to managing low back pain (LBP) recognize the multi-factorial etiology of the condition and the need to adopt a bio-psychosocial approach to both assessment and management. Current clinical practice guidelines support the use of active interventions primarily based on the bio-psychosocial model.2–3 There is significant evidence for promoting self-management and a healthy lifestyle as a means of restoring and maintaining function while at the same time addressing unhelpful beliefs and attitudes toward pain.4–5 In addition, research has recommended a multidisciplinary rehabilitation approach that incorporates cognitive–behavioural principles.3
Despite the large body of literature supporting the use of a bio-psychosocial approach to managing LBP, many physiotherapists have yet to integrate evidence-based management strategies into their clinical practice. Previous studies conducted in Canada and worldwide have highlighted physiotherapists’ poor adherence to clinical practice guidelines,6 as well as a primarily biomedical orientation to patient care.7 A survey of physiotherapists’ attitudes and beliefs about LBP management conducted in 2001 in Ontario demonstrated a biomedical orientation, poor knowledge of clinical practice guidelines, and the common use of interventions that are not guideline recommended.7 Another study conducted in 2011 in Quebec also demonstrated a strong biomedical orientation, with only a small proportion of physiotherapists being aware of clinical practice guidelines.8
It has been well established that having a biomedical orientation affects clinical decisions and clinical practice.9 There is also evidence to suggest that a relationship exists between orientation as measured using questionnaires and actual clinical practice.10 Thus, physiotherapists need to be aware of their beliefs and how they can influence their clinical practice as well as the language used during a physiotherapy encounter. This is of great importance because previously held beliefs and perceptions are significant barriers to behavioural change and adherence to an evidence-based approach.6
In their study, Benny and Evans conducted a survey of Ontario physiotherapists attitudes towards and beliefs about managing LBP.1 They used the Pain Attitudes and Beliefs Scale for Physiotherapists, which is widely used in the literature and has demonstrated good psychometric properties.2 The questionnaire allows clinicians to evaluate both a biomedical and a bio-psychosocial orientation. Unlike the results of previously published surveys, Benny and Evans’ results demonstrated that Ontario physiotherapists had attitudes and beliefs that aligned with current clinical practice guidelines, including a large bio-psychosocial orientation.1 In addition, the majority of respondents were familiar with clinical practice guidelines and used them to inform their practice. The results of this survey demonstrated that after two decades of research that has increasingly stressed the importance of a bio-psychosocial approach, the beliefs and attitudes of physiotherapists have changed and now align with current evidence.
An important finding that is worth noting is that physiotherapists with less than 10 years of clinical experience had higher biomedical scores than those with more years of experience. A survey of the current state of pain education in Canadian physiotherapy programmes demonstrated that there is considerable variability in the time devoted to, and the scope of, pain education across Canada and that, on average, less than 40% of pain education curriculum content is adequately addressed.11 This survey may explain, in part, why physiotherapists with less experience may be more prone to a biomedical orientation even though many aspects of chronic LBP management such as cognitive–behaviourally informed approaches are included in the chronic pain curriculum. In addition, lack of confidence in delivering educational and psychosocial interventions are significant barriers to its implementation.
Thus, it is possible that experience and exposure may be driving some of the trend toward a more bio-psychosocial orientation to physiotherapy. It has been widely accepted that some physiotherapists lack the skills to deliver bio-psychosocial interventions. Thus, it is important to consider how well prepared physiotherapists are and whether they possess the competencies necessary to deliver an effective bio-psychosocial programme of care. In addition, it is important that physiotherapists develop the skills necessary to recognize when a patient might benefit from a referral to a multidisciplinary clinic.12
References
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