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Manual Therapy 18 (2013) 438e442

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Manual Therapy

journal homepage: www.elsevier .com/math

Professional issue

Complexity in the physiotherapy management of low back disorders:Clinical and research implications

Jon Joseph Ford*, Andrew John Hahne 1

Low Back Research Team, Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria 3085, Australia

a r t i c l e i n f o

Article history:Received 20 November 2012Received in revised form17 January 2013Accepted 18 January 2013

Keywords:Back painTreatmentClassificationRandomised controlled trial

* Corresponding author. Tel.: þ61 3 5989 6331; faxE-mail addresses: j.ford@latrobe.edu.au (J.J. Fo

(A.J. Hahne).1 Tel.: þ61 3 9479 5801; fax: þ61 3 9479 5768.

1356-689X/$ e see front matter � 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.math.2013.01.007

a b s t r a c t

Over the past decade a wide variety of approaches for the management of low back disorders (LBD) havebeen developed and evaluated in clinical trials. As a consequence physiotherapists and researchersinterested in LBD are faced with a range of issues to do with complexity. These issues will be exploredand suggestions made to improve the delivery of high quality research evidence and better patientoutcomes.

� 2013 Elsevier Ltd. All rights reserved.

1. Introduction

Physiotherapists are an important service provider in themanagement of LBD. Presumably physiotherapists have a beliefthat their treatment is effective but this contention is not stronglysupported by the research literature (Koes et al., 2010). This paperaims to explore the impact of complexity on the physiotherapymanagement of LBD from a clinical and research perspective.

2. Complexity in clinical and research practice

Inherent in the large repository of clinical knowledge andassociated methods for managing LBD (Koes et al., 2010; Delittoet al., 2012) is complexity. For example, 122 hours of post-graduate training is recommended to attain proficiency in theMcKenzie method (The McKenzie Institute Australia, 2012). Basicapplication of the Maitland style of manual therapy (Jones andRivett, 2004; Maitland et al., 2005) is also a complex task requiring:

� A conceptual understanding and ability to practically applyhypothetico-deductive reasoning

� Knowledge and practical skills to perform a large number ofclinical techniques

: þ61 3 9479 5768.rd), a.hahne@latrobe.edu.au

All rights reserved.

� An understanding of complex concepts such as movement di-agrams and grades of motion

� An ability to identify the relationship between symptomswhendifferent techniques are applied

� A significant degree of measurement rigour in reassessing theeffect of treatment

Physiotherapists who use methods such as the McKenzie andMaitland approaches (Foster et al., 1999; Jackson, 2001; Li andBombardier, 2001; Gracey et al., 2002; Byrne et al., 2005) facefurther complexity when considering the influence of a range ofadditional relevant factors. To this end pathoanatomical, impair-ment, psychosocial, neurophysiological and genetic factors (Fordet al., 2007; O’Sullivan, 2012) as well as the patient’s perspective(Jones and Rivett, 2004) all need consideration.

Given this complexity it is not surprising that a large number ofvariable and somewhat mutually exclusive management methodsfor LBD have been developed. Recent reviews of the classificationliterature show over 80 different subgrouping systems (Ford et al.,2007; Fairbank et al., 2011; Karayannis et al., 2012). There are somecommonalities between the classification approaches of McKenzieand May (2003), Petersen et al. (2003) and the author’s group (Fordet al., 2011a) as well as between the methods of O’Sullivan (2005)and Sahrmann (2002). However, there is less overlap betweenmany other classification approaches including recent recommen-dations from Fritz et al. (2007), the Start Back group (Hill et al., 2011)and psychological based classifications (Bergstrom et al., 2012). Anevenwider arrayof treatment approacheshavebeendescribed in the

J.J. Ford, A.J. Hahne / Manual Therapy 18 (2013) 438e442 439

RCT literature. In the author’s recently published systematic reviews41 conservative treatment types attempting to specifically targeta LBD subgroupwere identified (Hahne et al., 2010; Slater et al., 2012;Surkitt et al., 2012; Richards et al., in press). The number of treatmenttypes in randomised controlled trials (RCT) investigating non-specific treatment is likely to be far greater.

Large survey’s show that this variability in classification andtreatment methods observed in the research literature is alsopresent in clinical practice (Jackson, 2001; Kent and Keating, 2005;Spoto and Collins, 2008; Liddle et al., 2009). In theory clinicalreasoning is a strategy of value in interpreting and processing largeamounts of theoretical and clinical information into effectivetreatment planning (Jones and Rivett, 2004). However, a range ofclinical reasoning approaches are used by physiotherapists (Jonesand Rivett, 2004) which are in themselves complex to apply andchallenging to learn, particularly for novice practitioners (Gobetand Borg, 2011; Davies and Howell, 2012).

3. Physiotherapy for low back disorders e craft or profession?

The authors propose that complexity has had an impact onexternal perceptions and internal realities regarding the nature ofphysiotherapy and in particular manual therapy for LBD. Sections ofthe medical community (Bogduk, 1996; Buchbinder, 2009) havedescribed physiotherapists practicing manual therapy as a “craft”group defined as an occupation “involving skill in making things (inthis case treating patients) by hand” (Oxford Dictionaries, 2012). Thisview contrasts starkly with common descriptions of physiotherapy asa professional group founded on evidence-based principles (AmericanPhysical Therapy Association, 2001; Herbert et al., 2005; Delitto et al.,2012; Little and Davenport, 2012). An evidence-based approach en-compasses integration of the best available evidence, clinical expertiseand patient values with regards to clinical decision making (Sackettet al., 2000). Within the context of complexity, the question of phys-iotherapy as a craft or professional group warrants exploration.

Physiotherapists are potentially unique in their capacity tomanage LBD by combining high level theoretical knowledge andmanual skills within a biopsychosocial context (American PhysicalTherapy Association, 2001). However there is large variability inmanual therapy standards in clinical practice (Boissonnault andBryan, 2005; Sizer et al., 2007; Davies and Howell, 2012) despiteefforts to develop recognised minimal competency levels(International Federation of Orthopaedic Manipulative PhysicalTherapists, 2008). Some developers of methods for managing LBDhave demonstrated a selective engagement with the evidence base.An example of this is the recent trend of excluding pathoanatomicalfactors from clinical protocols for LBD (Sahrmann, 2002; Fritz et al.,2007; Macedo et al., 2010) despite a likelihood that concepts suchas tissue healing are important for developing effective treatment(Adams et al., 2010; Hancock et al., 2011; Ford and Hahne, 2012).Similar themes are evident in classification systems not accountingfor psychosocial and/or neurophysiological factors (Ford et al.,

Fig. 1. The continuum between craft

2007; Fersum et al., 2010). Others have expressed strong reserva-tions on the value of randomised controlled trials for evaluatingeffectiveness of treatments (Clemence, 1998; Downing and Hunter,2003; Milanese, 2011). These examples, in addition to the variableand poorly integrated knowledge base already described, areincongruent with professional group status as depicted in Fig. 1.

Such considerations may not sit comfortably for many physio-therapists who pride themselves on providing the highest quality ofcare. Indeed, these comments on craft group status cannot bebroadly applied as different physiotherapists from different juris-dictions are likely to rate differently on the craft versus professionalgroup continuum (Boissonnault and Bryan, 2005; Sizer et al., 2007).However, physiotherapists should be aware of the potential impactof certain behaviours on shaping the external perception and in-ternal reality of the profession (Jette, 2012).

It is the authors’ view that behaviours by some physiotherapistsand researchers tending towards craft group status are stronglydriven by the complexity of LBD. Predominantly this appears torelate to the difficulties in systematically identifying, interpretingand integrating all relevant research and clinical knowledge as wellas a disconnect between clinicians and researchers around theworld. Therefore, a major challenge for the profession is to respondin a coherent and integrated manner to positively deal with theissue of LBD complexity.

4. Clinical practice implications

The authors believe physiotherapists should be cognizant of theimpact of complexity on clinical practice and resolute in aiming toadhere to professional group standards. Suggestions to assist thisprocess include practitioners:

� Establishing a sound foundation of knowledge and minimumlevel practical skills across the range of commonly used LBDmanagement methods (e.g. Maitland and McKenzie methods)

� Extending this foundation to incorporate the assessment andappropriate management of the multiple dimensions relevantto LBD (e.g. pathoanatomical, impairment, psychosocial, neu-rophysiological and genetic factors) as well as the patient’sperspective

� Appreciating the importance of a systematic approach toorganising complex bodies of knowledge (Jette, 2012) andengagingwith reasonable attempts to do so (Delitto et al., 2012)

� Integrating new innovations for managing LBP with the prac-titioner’s existing knowledge and skill foundation rather thansubstituting “old for new”

� Purposeful endeavour in the clinic to improve clinical reason-ing skills as a means of dealing with complexity (Jones andRivett, 2004; Davies and Howell, 2012)

� Carefully considering the best available evidence (from alltypes of research, not just RCT) in the context of the practi-tioner’s clinical experience and the patient’s perspective

and professional group status.

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In dealing with the complexity of LBD, the experience of theauthors is that practitioners, particularly those with less experi-ence, appreciate and benefit from structured and systematic clinicalmentoring (Ford et al., 2011a, 2011b, 2012a, 2012b). This approachsets a level of minimum competency that can then be furtherdeveloped independently and includes:

� The use of thorough and systematic assessment templates andtools supported by a multi-dimensional classification system

� Detailed clinical protocols outlining the necessary re-quirements of LBD management methods

� Clinical decision making algorithms to assist in tailoring oftreatment to the patient (Helmhout et al., 2008; Foster andDelitto, 2011) thereby avoiding a “one size fits all” approach

� Formal clinical mentoring with regular review of patientprogress and practitioner feedback

Researchhasdemonstrated thedifficulty inengagingpractitionerswith evidence-based practice (Stevenson et al., 2006). The experienceof the authors is that structured clinical mentoring utilising a sys-tematic method of knowledge organisation is an effective method ofchanging practitioner behaviour in accordance with the evidence.

5. Research implications e the importance of classification

The issue of LBD complexity has significant research implica-tions. A pragmatic approach to RCT design favours choices thatmaximise applicability of results to “the real world”. As such min-imal restriction is placed on participant eligibility or prescriptiveoperationalisation of the treatment applied (van der Windt et al.,2008; Zwarenstein et al., 2008). In an ideal world where a prag-matic RCT demonstrates treatment effectiveness, issues of com-plexity can be considered as irrelevant, and broadly applicableclinical recommendations can bemade (van derWindt et al., 2008).Pragmatic designs are commonly used in RCT for LBD but the re-sults have not found evidence supporting the effectiveness ofphysiotherapy (van der Windt et al., 2008).

Many have postulated that the complexity of LBP needs to beaccounted for inRCTby improved subgroupingor classification (Fordet al., 2007; Fairbank et al., 2011; Karayannis et al., 2012). Sampleheterogeneity can diminish the chance of finding a significanttreatment effect due to the reduced proportion of the sample forwhich the treatment is appropriate. Recruiting participants thatbelong to a homogenous subgroupwho receivematched and specifictreatment is more likely to demonstrate effectiveness due in part toa reduction in the clinical complexity the practitioner has to address.

Over the last decade a number of classification based trials havebeen published, although to date the results have been mixed(Slater et al., 2012; Surkitt et al., 2012). Given the number of clas-sification and treatment approaches available for physiotherapists,informed decisionsmust bemade regarding further research in thisarea. Data from a range of surveys suggest that physiotherapistsmost commonly employ manual therapy, the McKenzie approachand motor control retraining when treating LBD (Foster et al., 1999;Jackson, 2001; Li and Bombardier, 2001; Gracey et al., 2002; Byrneet al., 2005). Despite the publication of hundreds of RCT to date,these popular methods of managing LBD have not been adequatelyevaluated for efficacy in a manner consistent with clinical practiceand in accordance with classification principles (Slater et al., 2012;Surkitt et al., 2012; Ford et al., 2012b). An additional considerationis the fact that most clinicians incorporate a variety of methodswhen managing LBD. Clinical trials need to reflect this complexityby evaluating multi-modal management approaches, despite thepotential limitations in not being able to attribute effect to onespecific treatment component (Jull and Moore, 2010). Once

evidence of effectiveness is identified, specific components of themanagement method can be subsequently evaluated in new RCT.

Prioritising the validation of commonly used classification andspecific treatment methods does not negate the necessity forclinical trials on emerging approaches for LBD. However, it doesprovide a focus that maximises the capacity of the physiotherapyprofession to successfully build upon the existing knowledgefoundation using evidence-based principles.

6. Research implications e treatment integrity

Treatment integrity refers to the degree inwhich an intervention isdelivered as intended. Even with significant training, treatmentintegrity in RCT can vary substantially particularly if the treatment iscomplex to administer (Borrelli et al., 2005;Helmhout et al., 2008; vander Windt et al., 2008). Low treatment integrity increases the risk offalse conclusions being drawn regarding effectiveness due to thetreatment being inadequately applied to participants. A variety ofmethods to improve treatment integrity have been described andshould be carefully considered during RCT planning (Borrelli et al.,2005; van der Windt et al., 2008). These methods, particularly whencombinedwith classification principles, enable complexmanagementmethods to be appropriately evaluated in an RCT setting.

Treatment design considerations necessitate a clearly definedtheoretical model with associated practical detail described inclinical manuals (Craig et al., 2008; Helmhout et al., 2008; Fosterand Delitto, 2011). Expert practitioners should develop these.Algorithmic approaches to clinical decision making should also beused to maximise specificity and adaptability of the clinical pro-tocol to participant presentation (Milanese, 2011). In the authors’recent RCT (Hahne et al., 2011) the use of session by session,structured clinical notes with specific cuing regarding algorithmicassessment and treatment process was a helpful strategy. Detailedinformation sheets were also valuable, as the process of explainingthese resources to the participant reinforced critical treatmentcomponents in the physiotherapist’s own mind.

Training of practitioners is an important component to treatmentintegrity and should be of an appropriate duration for the com-plexity of the intervention being evaluated. For example, the phys-iotherapists in the Start Back trial (Hill et al., 2011) receivedninedaysof training in order to be competent in providing “psychologicallyinformed physiotherapy” to participants at high risk of a poor out-come. The training included teacher lead sessions, group discussion,role play and interviewing of simulated patients (Main et al., 2012).

Delivery of treatment should be an audited process with con-structive feedback provided to the trial physiotherapists. In a trialcompleted by the authors this feedback was provided at weeksthree and seven of a 10 week program and also used monthly tel-ephone hook ups to discuss difficult cases (Hahne et al., 2011).Evaluation of treatment integrity at the participant level can also bea useful strategy (Borrelli et al., 2005).

7. Research benefits of classification and treatment integritymeasures

The issues associated with the complexity of LBD can be sub-stantively ameliorated in RCT that recruit homogenous LBD sub-groups, apply a matched and specific treatment and employadequate treatment integrity measures. In such trials, the likelihoodof the trial demonstrating results favouring physiotherapy treatmentis increased. Robust classification and treatment integrity measuresalso enable other researchers to more precisely replicate trials withpositive findings. A more detailed description of classification andtreatment procedures reduces the risk of systematic reviews erro-neously pooling the results of clinically heterogeneous RCT for the

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purposes ofmeta-analysis. Finally, thesemeasures allowclinicians tomore easily interpret and replicate the management approachthereby improving engagement with evidence-based practice andtranslation of results to the clinical setting. However, despite thesebenefits, few RCT or systematic reviews have adequately addressedclassification and treatment integrity issues (Hahne et al., 2010;Slater et al., 2012; Surkitt et al., 2012; Richards et al., 2012).

8. Conclusion

Physiotherapists working clinically and in research settings aswell as the profession as a whole should be aware of the challengesLBD complexity brings to an evidence-based approach. The rec-ommendations of this paper should assist clinicians and re-searchers in collaboratively working to overcome complexity issuesand deliver high quality research evidence and better patientoutcomes.

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