This survey study of 85 physiotherapists found that nearly every respondent used one or more (prognostic) screening tool or other patient-reported questionnaire for acute LBP patients, with an average of nearly three instruments. Of these instruments, the STarT Back Screening Tool (SBT) and the Quebec Back Pain Disability Scale (QBPDS) were most frequently used for this patient group. Remarkably, despite physiotherapists’ wide acceptance of the use of (patient-reported) measurement instruments in cases of acute LBP, they reported that these instruments generally do not substantially influence their clinical decision-making.
According to our survey, Dutch physiotherapists most frequently use the QBPDS (used by 64% of physiotherapists, with 32% reporting this to be the most frequently used instrument) and the SBT (61 and 38%, respectively) with LBP patients. The QBPDS [23] is a 20-item questionnaire that is recommended in the current Dutch LBP guideline for physiotherapists [13], so it is no surprise that so many physiotherapists use it. However, the QBPDS was developed and is recommended to be used for treatment effect evaluation rather than as a screening tool. In line with this, our physiotherapists reported that treatment effect evaluation was their most important purpose for using the QBPDS in cases of acute LBP (63% of respondents), whereas only a minority of respondents (19%) used it for prognosis estimation.
Apart from the QBPDS, the SBT was the most frequently used screening tool for acute LBP patients. However, more experienced physiotherapists seem to use the SBT more often than the QBPDS. The SBT [18] is a nine-item screening tool that is widely accepted in daily practice, despite its relative newness (it was introduced in 2008 [29]). The SBT aims to classify patients into one of three risk profiles: the low-risk group should receive minimal care, the medium-risk group should receive ‘average’ physiotherapy treatment, and the high-risk group should receive more complex and intensive psychologically informed physiotherapy treatment [16]. This risk classification with treatment advice appears to correspond with the preferences of our survey respondents, who reported that a risk profile classification was the most preferable outcome for an ‘ideal’ screening tool. On the other hand, physiotherapists have criticised the risk profiles from the SBT. For example, a study by Woods and Gaskell [30] found that physiotherapists reported several perceived barriers to using the SBT, namely a ‘perceived oversimplification of the decision making process’, an ‘impact on professional reputations and professional development’, ‘risks associated with single treatment sessions’, ‘patient satisfaction’ and ‘threats to patient-centered care’. Apparently, physiotherapists have conflicting preferences regarding such screening tools.
Both the SBT and the QBPDS have recently been included in a standard set of measurement instrument for LBP patients that will be implemented in daily physiotherapy practice in the Netherlands [31]. In addition to the SBT and the QBPDS, the set of measurement instruments includes the Patient-Specific Functional Scale (PSFS) and Oswestry Low Back Pain Disability Questionnaire (ODI) (our third and fourth most frequently used instruments), as well as a Numeric Rating Scale (NRS) item for pain intensity and a Global Perceived Effect (GPE) item. According to this standard set, the SBT should be used to distinguish low-risk patients from medium- and high-risk patients. For low-risk patients, only the PSFS and NRS should be used at the start and end of treatment, and the GPE should be used at the end of treatment. For medium- and high-risk patients, all the instruments in this standard set should be used at the start of treatment, every six weeks and at the end of treatment. In addition, the GPE should be used at the end of treatment for those patients. Based on our survey, many physiotherapists are already using these instruments. If this standard set is implemented successfully, its usage will become more standardised and uniform. Ideally, this could be achieved by recommending this set in a physiotherapy guideline for LBP.
We expected that physiotherapists with more work experience might use screening tools and questionnaires less frequently than physiotherapists with less experience, as this first group would rely more on their own expertise. However, we did not find such an association, except for the finding that more experienced physiotherapists tend to choose the SBT rather than the QBPDS as a screening tool for their patients with acute LBP. This decision seems to be in line with the main purpose of the SBT (i.e. prognosis) and QBPDS (i.e. treatment evaluation). Male gender was the only physiotherapist characteristic for which we found an association with using a larger number of instruments for acute LBP, but this findings needs to be interpreted with caution due to the explorative character of this analysis. We do not know why male physiotherapists reported to use more instruments compared to female physiotherapists.
Our findings suggest that physiotherapists are not convinced of the benefits of the currently available (prognostic) measurement instruments for daily physiotherapy practice, because their outcomes did not affect clinical decision-making about most patients. One reason could be that none of the existing instruments (including screening tools) are yet able to adequately predict the course of LBP symptoms, so they do not provide any relevant prognostic information for the physiotherapist. Despite the enormous effort put into prognostic LBP research, LBP screening tools all perform poorly in identifying those patients at higher risk for chronic LBP [32]. Even for the SBT, the accuracy of prediction of outcome of patients with LBP was low [33]. This finding suggests that new research may need to focus on developing a better measurement instrument (e.g., screening tool) that do fits the needs of physiotherapists. In an ongoing study, we aim to develop and subsequently validate such a new screening tool that includes an algorithm that adequately predicts the chance of recovery within three months, in patients with acute LBP. In the development phase of this tool, the (practical) preferences from physiotherapists are considered essential, in order to have large impact on daily practice. A second reason for scepticism about the added value of measurement instruments could be that physiotherapists prefer to rely on their own expertise for their clinical decision-making, although their predictive ability is debateable [33]. A third reason might be that physiotherapists only use measurement instruments because of perceived obligations from external parties, like insurance companies (reported by 24% of respondents) or clinical guidelines (17%). If they only use these tools because external parties require them to, physiotherapists may not intend to use them in treatment decisions. Finally, physiotherapists may generally provide a ‘one-size-fits-all’ treatment for patients with LBP [14], so the outcome of any measurement instrument will not affect their clinical decisions.
Regardless of the underlying reasons for using measurement instruments, our study may suggest that measurement instruments (e.g., screening tools) should be further optimised to have more added value for daily practice. Based on the preferences reported in our survey, such an instrument should be very easy and quick to apply on one hand, but also highly reliable and valid on the other. Furthermore, the instrument’s impact on clinical decision-making might be optimised if it is fully integrated into the electronic health record. Ideally, this would give physiotherapists clear treatment advice in a highly intuitive way, although such treatment advice is quite controversial among some clinicians because it could threaten their professional role. In addition, our study suggests that physiotherapists should be more critical about which instruments to use and for which purpose. It seems that many instruments are being applied standardly, but without integrating the information retrieved from the instrument adequately in their clinical decision making. Thereby, the potential of measurement instruments is not fully utilized.
Our study had some limitations that should be acknowledged. First, our findings are based on the results of a survey with a 13% response rate, without a sample size calculation. Due to our response rate, we cannot be sure that these findings are representative for all physiotherapists working with LBP in the Netherlands. It can be assumed that physiotherapists with an interest in LBP were more willing to participate in our survey study. However, non-response in survey studies does not seem to result in major response bias, even if non-response is non-random (e.g. related to respondents’ interests) [34, 35]. In addition, the general characteristics of our respondents seem to correspond with those of Dutch physiotherapists (i.e. 52% male in our study vs. 41% in the Dutch physiotherapy population; mean age of 39 years in our study vs. 43 years in the Dutch physiotherapy population [36]). Moreover, sample size calculations are not considered essential in survey studies like ours. Second, we initially aimed to provide insight into the use or non-use of prognostic screening tools in particular, but decided to include all patient-reported measurement instruments that are currently being used with LBP patients, most of which are not screening tools. We decided to do that to avoid any misunderstanding, as we expected that physiotherapists may not be aware of the difference between a prognostic screening tool and any other measurement instrument. Thereby, our study results apply to measurement instruments in LBP in general, instead of prognostic instruments specifically.
