The objective of this study was to evaluate the current physical therapy management of patients with LBP in Germany, and to explore guideline adherence to the NVL “Non-specific LBP” recommendations. The results indicate that German physical therapists predominantly provide treatments recommended in the NVL guideline, but also frequently use treatments with low or conflicting evidence for patients with LBP. Even though guideline adherence in the treatment section was high, guideline adherence regarding the physical therapeutic diagnostic process seems deficient. In total, only 38 % of the participants showed guideline-adherent behaviour over both sections indicating deficits in evidence-based management in LBP in German physical therapists. With only 29 % of participants reporting to know the current version of the NVL “Non-specific LBP”, implementation of the NVL into physical therapy practice seems to have failed based on the results of this study.
Regarding the physical diagnostic process, about half of the items were identified by over 80 % of participants as a part of their physical therapeutic examination of patients with non-specific LBP. However, guideline adherence was fairly low (n = 675, 50 %). Screening red flags was performed by only 19 % (n = 253), despite being highly recommended in order to identify signs or symptoms indicating serious pathology requiring further medical diagnostics and different treatment [1, 20, 25]. However, as identified recently, consensus on red flags to be endorsed in guidelines is lacking [26]. Despite the recommendation in guidelines to screen red flags, there is evidence that only a few red flags are useful in clinical practice and the predictive power for serious diseases should be considered with caution. Screening of red flags is considered a necessary competence of physical therapists regarding direct access. Since direct access has not been established in the German health care system, this might partly explain the low guideline adherence in the physical therapeutic diagnostic process. Routinely, physical therapists are restricted to the physicians’ referral and diagnosis, and they lack time and reimbursement for a comprehensive examination of patients in routine care.
In line with the results from Basson et al. [27], mobilisation, heat application and exercise training were among the most frequently applied interventions by German physical therapists. Contrary to the results from previous studies, our results suggest that German physical therapists differentiate between the management of patients with acute and chronic LBP, as recommended in CPG. Notably in contrast to the findings from Zadro et al. [11], German physical therapists rarely use treatments that are not recommended. However, this might be distorted by the interprofessional scope of the NVL, which mentions several interventions less relevant in physical therapy context, hardly known or not feasible to be implemented in daily clinical practice, such as magnetic field therapy or laser therapy. Moreover, the low application rate of electrotherapy modalities, which are consistently not being recommended in the NVL, may be attributed to differences in the health care system of individual countries. While direct access has been implemented in the USA, Great Britain and Ireland, German physical therapists are bound to the physicians who must prescribe electrotherapy separately. German physicians most often prescribe “Krankengymnastik” [28] as the standard physical therapy treatment summarizing active and passive treatment techniques. In this case, physical therapists can apply different treatment modalities including both active and passive treatment approaches apart from special treatments such as electrotherapy. In the treatment of acute LBP, only massage, and in the treatment of both acute and chronic LBP, only Kinesio Taping were applied frequently despite having a negative recommendation.
The overall high guideline adherence in the treatment section (n = 973, 72 %) observed in our study was also found in a recent study of Danish physical therapists [29], where the vast majority of participants was strictly or partly in line with the CPG. In contrast to these results, de Souza et al. [30] stated that among Brazilian physical therapists, only 5–24 % showed full LBP guideline adherence. Ladeira et al. [31] reported 15–30 % adherence rate for physical therapists treating patients with acute LBP in Florida. Differences in reported guideline-adherent behaviour appear to be dependent upon several factors, including study design and the definition of guideline adherence. Husted et al. [29], de Souza et al. [30] and Ladeira et al. [31] evaluated guideline adherence using clinical vignettes. In contrast, participants of the current study ranked their application frequency of treatment modalities as recommended in the NVL and guideline adherence was determined using a scoring system. The benchmark for good adherence was set at ≥ 80 %, following the methods of a Belgian study [22] that measured physical therapists’ adherence to optimal knee osteoarthritis care. However, in our study, the benchmark refers to the point scores of each individual participant, whereas in Spitaels et al. [22] the 80 %-benchmark was used to describe good adherence within each quality indicator regarding the total sample.
In line with previous findings [23], the results of our study indicate greater guideline adherence of physical therapists with academic background (clinical examination: OR 1.71, 95 % CI 1.33–2.19; treatment: OR 1.97, 95 % CI 1.47–2.68; total: OR 1.93, 95 % CI 1.50–2.47). Therapists who deal with scientific literature and have scientific understanding use evidence-based practice (EBP) more frequently [32]. However, due to the exploratory nature of our analyses, ORs should be interpreted with caution.
Our results indicate that the utility of the NVL “Non-specific LBP” as a CPG for German physical therapists should be discussed. Even though the NVL intends to be a decision-making aid for both physicians and non-medical professionals, the guideline contains little specific information for physical therapists. While this may partly be attributable to a lack of scientific evidence, guidelines specific to physical therapy do exist in other countries such as the US [33] or the Netherlands [20]. Obviously, factors such as the involvement of disciplines and authors, the guideline topic, or the health policy of the respective country can influence the contents and recommendations of CPGs [21, 34]. Although physical therapy representatives were involved in the German NVL development, the percentage from physical therapist in relation to all stakeholders was low.
More than half of participants reported to include guideline recommendations within clinical practice, but only 29 % of the therapists (n = 400) responded that they knew the current version of the NVL “non-specific LBP”. Of those therapists who did not yet follow evidence-based recommendations, 63 % (n = 304) stated that they had a general interest in using guidelines. Thus, improving implementation strategies for guidelines into physical therapy practice seems to offer vast potential. An important prerequisite for improving implementation strategies is the identification of barriers in the application of guideline recommendations [35].
In line with previous studies [13, 36,37,38], survey participants reported inapplicability of guideline recommendations to individual patients (n = 259, 54 %), time restrictions (n = 180, 37 %) and lack of research skills (n = 121, 25 %) as the most important factors inhibiting the use of guidelines in clinical practice. In a Danish study [29], the authors assumed an association between increased guideline adherence and more time spend on the first consultation (60 min or more). A typical physical therapy session in Germany lasts about 15–20 min for patients with musculoskeletal disorders, which poses an important structural barrier. Therapists may need to treat about 20 patients a day, which makes it nearly impossible to search and critically appraise the current evidence [39].
Extensive EBP implementation interventions with frequent contacts have been shown to be more successful in changing the clinical behaviour of health care practitioners and improving patient outcomes than single or one-off interventions [40]. There is still no established approach or framework for transferring EBP into the German health care system [41]. Attitudes and beliefs towards EBP may heavily influence the clinical practice of therapists [42]. Thus, in addition to the removal of existing structural barriers, a successful implementation of research findings may require a change in the attitude and behaviour of physical therapists [25]. This may be a very challenging and ambitious goal, but better adherence to guideline recommendations may considerably improve patient outcomes and reduce health care costs in patients with LBP [12, 43]. Greater utilization of EBP should be of interest to all stakeholders.
Limitations
Although we tried to distribute the survey to a broad number of physical therapists using the snowball sampling approach, the number of study participants (n = 1361) was low compared to the total number of approximately 199,000 physical therapists [44] working in Germany. However, because the exact number of physical therapists remains unclear and there is no information on how many physical therapists manage patients with LBP, no exact response rate could be calculated. The targeted sample size of at least 1000 participants was achieved, but physical therapists with an academic education (25 %) were overrepresented in our sample compared to their assumed number in Germany (3 %) [24].
Using an online survey may have introduced bias by possibly excluding physical therapists without internet access or online content proficiency. Furthermore, it could not be definitively ascertained whether the participants actually met the inclusion criteria, or whether they had participated more than once, as the survey was anonymous and accessible without legitimation. Participants may have looked up the guideline after completing the questionnaire for the first time, which may have influenced our findings towards higher guideline adherence with their second participation. Duplicate responses could have been prevented using a cookie- or IP-based duplicate protection, but this would also have limited study participation via shared devices (for example used in physical therapy facilities) and would have reduced the number of participants.
The data reflect what participants reported, as opposed to how they actually perform their examination and treatment of patients with non-specific LBP. Our study results may be influenced towards higher guideline adherence, as due to social desirability, recommended behaviour is usually being over-reported, and behaviour contrary to guideline recommendations under-reported. In a systematic review, Adams et al. [45] determined that guideline adherence assessed through self-report measures was over-estimated by about 27 % compared to objective methods. Further, sampling bias due to the overrepresentation of physical therapists with an academic background and volunteer bias must be assumed. Therapists with a personal interest in LBP might have participated more readily and might have better knowledge of LBP management than non-respondents.
No firm conclusions on the actual quality of physical therapy management can be drawn. For example, the intensity, frequency and duration of strength training may determine its effectiveness, but the NVL lacks any such information. Thus, these aspects were not evaluated in this study.
Although advice and education are internationally stated to be important aspects of physical therapy management in LBP [27], these interventions were not evaluated in our study, because advice and education should primarily be provided by physicians in Germany. Advice/education is not addressed in the German catalogue of therapies [10] and physical therapists are not formally educated accordingly. However, as time per patient is also limited for physicians, it seems reasonable to assume that physical therapists provide advice and education. Future studies should therefore evaluate the current clinical practice regarding advice/education as well as the content of possible recommendations provided by physical therapists in the management of LBP.
