42 SA JournAl of PhySiotherAPy 2012 Vol 68 no 1 Research Article Physiotherapy Modalities used in the Management of chronic low Back Pain Corresponding Author: Vaneshveri Naidoo Physiotherapy Department Faculty of Health Sciences University of the Witwatersrand 7 York Road, Parktown Johannesburg 2193 E­mail: Vaneshveri.naidoo@wits.ac.za. AbSTrAcT: Chronic low back pain (CLBP) is a costly and common medical problem accounting for 75-90% of compensation costs as a result of repeated treatments, long term work absenteeism and social support-unemployment compensation. Physiotherapy treatment modalities are commonly used in the management of CLBP. data on the management of CLBP by physiotherapists in low income countries are scarce. A cross-sectional survey was used to investigate the manage- ment of CLBP by physiotherapists in kwazulu-natal (kZn). The objectives of the study were to establish: the commonly used physio- therapy modalities; reasons; and the evidence base used for their choice. Six hundred and eighty-five self-administered questionnaires were posted to all registered physiotherapists in kZn. of 213 returned questionnaires, 141 (20.6%) met the inclusion criteria as they managed patients with CLBP. General exercises (30%); spinal mobilisation (28%); myofascial release (18%), education (12%) and training of local stabili sers (12%) were the commonly used treatment modalities. key reasons for the selection of the treatment modalities were undergraduate education received; own clinical experience and the attendance of postgraduate courses/ physiotherapy conferences. From the reasons specified for the selection of treatment modalities, the use of written current available literature through reading of journal articles was sparsely utilized. Key wordS: CHRoniC LoW BACk PAin (CLBP); PHySioTHERAPy modALiTiES; PSyCHoSoCiAL FACToRS; EvidEnCE-BASEd PRACTiCE Naidoo V, MSc (Physiotherapy),1 Mudzi W, PhD (Physiotherapy),1 Ntsiea V, MPH,1 Becker PJ, PhD.2 1 Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand. 2 Biostatistics Unit, Medical Research Council of South Africa. (Van Vuuren et al., 2006). Several authors report that a small number of the population (3­10%) will develop chronic low back pain (CLBP) (Diamond and Borenstein, 2006; Ferreira et al., 2006; Koes et al., 2006; Cassidy et al., 2005) however, it can be as much as 40% (O’ Sullivan 2005). The main consequences of back problems are: pain, disability, limited function (including activities of daily living) and decreased productivity (including work loss) (Kendall et al., 1997). Pain is defined as chronic if the pain persists for three months or longer (Koes et al., 2006). CLBP presents as a persistent, disabling condition and has a profound effect on quality of life (Staal et al., 2005; Kendall et al., 1997). The prognosis is less favourable and it results in considerable socioeconomic costs as a result of repeated treatments, long term work absenteeism and social support (unemployment compensation) (Koes et al., 2006; Ferreira et al., 2006). INTRODUCTION It is extensively documented that low back pain (LBP) is one of the most common and costly pandemic medical conditions affecting up to 80% of people world­wide in their lifetime (Guzman et al., 2007; Diamond and Borenstein, 2006; Cairns et al., 2006). Statistics on chronic back pain in the general popu­ lation from low income countries are scarce (Omokhodion and Sanya, 2003). Thirty­thousand South African’s suffer from neck and back problems on a daily basis, 10% of which will become chronic Disability due to chronic low back pain is increasing faster than any other form of incapacity. Physiotherapy intervention is a com­ mon form of conservative management for CLBP (Goldby et al., 2006; Cairns et al., 2006). Physiotherapy intervention consists of manual therapy (manipulation and mobilisation), exercise, advice and education as well as multidisciplinary group rehabilitation which includes the psychosocial aspect of CLBP (Guzman et al., 2007; Goldby et al., 2006; Cairns et al., 2006). The literature advocates multidisciplinary treatment, behavioural treatment (all types: operant, cognitive and respondent) and exercise therapy in the management of CLBP (van Middelkoop et al., 2011). There are also many other treatment modalities (trac­ tion, massage, tens, interferential ther­ apy and low level laser therapy) which lack scientific evidence regarding their efficacy in the treatment of CLBP (van Middelkoop et al., 2011) 43 SA JournAl of PhySiotherAPy 2012 Vol 68 no 1 Evidence based practice (EBP) improves the quality and appropriate­ ness of patient care, treatment out­ comes, the efficiency and effectiveness of the medical practitioner and costs involved in the management of patients (Manchikanti, 2008). It represents a shift away from the traditional practice based on clinical experience and knowledge of authorities, toward substantiated data (Bithell, 2000). Information regarding best practice/treatment is continually evolving, hence information becomes outdated and thus it is imperative to stay updated (Research Committee [Victorian Branch] of the Australian Physiotherapy Association [APA] and invited contributors, 1999). No studies have been done in South Africa/Kwazulu­Natal (KZN) investi­ gating the physiotherapy interventions used in the management of patients with CLBP. Thus the aim of this study was to investigate the treatment modalities which are currently being used in the management of chronic low back pain by physiotherapists in KZN. METHODOLOGY This quantitative descriptive cross sectional study was conducted using a self­administered questionnaire with the aim as stated above. Ethical clearance was granted by the Witwatersrand University Human Research Ethics Committee (clearance number: M070908). All (685) practicing physiotherapists in KZN registered with the Health Professions Council of South Africa involved in the management of chronic low back pain were included in the study. A questionnaire was developed for this study with the aid of current literature (Guzman et al., 2007; Taylor et al., 2007; Goldby et al., 2006; Ferreira et al., 2006; Kaapa et al., 2006; Koes et al., 2006; Moseley et al., 2004) and a group of academic and clinical (all of whom are Orthopaedic Manipulative Therapy (OMT) trained and OMT course lecturers) experts involved with the management of CLBP. The questionnaire contained the following sections: – Biographical information (age; gender; qualifications obtained; number of years qualified; type of employment; area of practice and professional body membership); Management of CLBP (involved in the management of patients with CLBP; statistics on the number of CLBP patients treated; modalities used to manage the ability to critique articles; characteristics of a good article and recognition of levels of evidence (Sackett et al., 1998). The test­retest reliability of the ques­ tionnaire was established in the pilot study on ten physiotherapists. There CLBP; three prioritised modalities in CLBP management; postgraduate courses attended; the cause of CLBP; pain mechanism of chronic pain and psychosocial aspects of CLBP) and questions about: the number of journal articles read; the source of the articles; Figure 1: commonly used treatment modalities in the management of clBP (n=141) Table 1: Prioritised treatment modalities used in the management of clBP Treatment Modalities 1st prioritised modality (n =128 ) n(%) 2nd prioritised modality (n =131) n(%) 3rd prioritised modality (n =129) n(%) Spinal mobilisation 40(31) 31(24) 13(10) Myofascial release 17(13) 25(19) 19(15) Education 17(13) 5(4) 2(2) Training local stablisers 12(9) 14(11) 17(12) General Exercises 7(6) 12(9) 29(22) Ergonomics/Kinetic Handling 5(4) 8(6) 12(9) Heat/ice/strapping 9(7) 5(4) 9(7) Dry needling 1(1) 5(4) - Interferential therapy 2(2) 3(2) 6(5) Ultrasound therapy 1(1) 2(1) 3(2) Shortwave therapy 1(1) - 1(1) Cognitive & Behavioral therapy 5(4) 3(2) 4(3) Motor control exercises 3(2) 3(2) 2(2) Stretching exercises 1(1) 4(3) 4(3) Traction - 3(2) 1(1) Neural tissue mobilisation - 4(3) 3(2) Massage 7(6) 4(3) 4(3) 44 SA JournAl of PhySiotherAPy 2012 Vol 68 no 1 were no differences in the answers given between the first round and second round that was conducted one week later. The questionnaire and infor­ mation sheet were both posted and emailed to the subjects. Descriptive sta­ tistics were used to present the data as frequencies and percentages RESULTS A total of 685 questionnaires were dis­ tributed, 213 (31.1%) were returned. One hundred and forty one (20.6%) physiotherapists were involved in the management of chronic low back pain. Eighty­four percent were females, aged between 20–30 years (49%). The majo­ rity had post qualification experience of between three and ten years (87%). Six percent of the study sample had post graduate qualifications and sixty­ five percent of the study sample was employed in private practice. Twenty­eight percent of the study sample treated between 11 and 20 patients with CLBP per month, followed closely by 25% of the sample who treated more than 20 patients per month. A general exercise program (30%) and spinal mobilisation (28%) were the most commonly used physiotherapy treatment modalities for CLBP, followed by myofascial release (MFR) (18%), education (12%) and training of local stabilisers (12%), (see Figure 1). The first and second prioritised treat­ ment modalities happened to be the same (spinal mobilisation) followed thirdly by general exercise. These results are illu­ strated in Table 1. The most frequently selected reasons for the chosen moda­ lities included undergraduate education and clinical experience, (see Table 2). Seventy­three percent of the respon­ dents were unaware that CLBP stemmed from simple mechanical backache rather than serious spinal pathology or nerve root pain. Eighty­one percent of the study sample did not recognise the pain mechanism (central sensitisation) associated with chronic pain compared to nociception, peripheral sensitisation, central phenomenon and general sensi­ tisation, (see figure 2) Ninety­four percent of the study sample assessed for yellow flags in patients with CLBP, but none of the respondents were able to identify all these psychosocial factors. They only identified between three and five out of Figure 2: Knowledge of the pain mechanism involved in clBP (n=141) Table 2: The most frequently selected Reasons for the chosen modalities (n=141) Modality Reason Number / (%) Spinal mobilisation Undergraduate education 65 (46) Clinical experience proves effectiveness of the modality 25 (18) Pathophysiological basis 13 (9) Postgraduate courses / Physiotherapy conferences 12 (9) General exercise Program Undergraduate education 42 (30) Clinical experience proves effectiveness of the modality 22 (16) Motivates the patient 10 (7) Postgraduate courses / Physiotherapy conferences 8 (6) Myofascial release Undergraduate education 35 (25) Clinical experience proves effectiveness of the modality 35 (25) Postgraduate courses / Physiotherapy conferences 29 (21) Pathophysiological basis 21 (15) Education Undergraduate education 49 (35) Motivates the patient 29 (21) Clinical experience proves effectiveness of the modality 17 (12) Postgraduate courses / Physiotherapy conferences 16 (11) Training local stabilisers Undergraduate education 38 (27) Postgraduate courses / Physiotherapy conferences 26 (18) Clinical experience proves effectiveness of the modality 23 (16) Evidenced based literature 15 (11) 45 SA JournAl of PhySiotherAPy 2012 Vol 68 no 1 nine factors that should be investigated. Forty­seven percent read between 1­5 articles per year while 16% percent of the study sample did not read any articles. Forty­two percent critiqued the journal articles they read. When criti­ cally reviewing an article only three of the accepted characteristics of a good article could be identified by the study sample. No more than 9% was able to correctly identify the levels of evidence of journal articles. DISCUSSION Spinal mobilisation was the overwhelm­ ing modality of choice by the study sample. Chiradejnant et al. (2003)’s study confirmed that spinal mobilisation assists with pain relief and improves mobility of the spine and that mobilisa­ tion of the lumbar spine has an imme­ diate effect in relieving low back pain (Bokarius and Bokarius, 2010). Hence probably a reason why therapists would choose a modality which produces an immediate positive effect, as patients expect to obtain some pain relief after having received treatment (Goosens et al., 2005). Despite this treatment modality finding favour among the study sample, the efficacy of spinal mobilisation in the treatment of CLBP is unpersuasive and many studies have found that spinal mobilisation does not produce significant reductions in pain and disability (Rubenstein et al., 2011; Mohensi­Bandpei et al., 2006; Bronfort et al., 2004; Avery and O’Driscoll, 2004). Bokarius and Bokarius, 2010 also report a high recurrence rate of back pain one year post treatment following spinal mobilization. A general exercise program (30%) was also commonly used to manage patients with CLBP. Exercises (irrespective of the type of exercise) are most efficacious in the management of patients with CLBP (Lewis et al., 2008). There is increas­ ing evidence proving that rehabilitation which involves exercise therapy is the most effective in reducing pain, disabi­ lity and the recurrence of LBP (Smith and Grimmer­Sommers 2010; Taylor et al., 2007; Ferreira et al., 2006). Education about CLBP and train­ ing of the local stabiliser muscles was used by 12% of the physiotherapists in this study. Educating patients as well as training of the local stabiliser muscles is often time consuming and requires sound knowledge of the educator/therapist (De Jong et al., 2005; Lorimar et al., 2004). Training of local stabilisers also requires a high level of skill of the thera­ pist (O’ Sullivan, 2000). Education con­ cerning CLBP is effective in the short term only regarding pain relief; return to work and function in general, but it has the ability to change attitudes, beliefs and behaviour which is integral in the management of chronic pain (de Jong et al., 2005; Moseley et al., 2004;). Eighteen percent of the study sample used myofascial release in the manage­ ment of CLBP. Evidence regarding MFR in CLBP is lacking; however the ben­ eficial effects of MFR are seen in both pelvic asymmetry (Barnes et al., 2011) and fibromyalgia (Castro­Sanchez et al., 2011). The most popular reasons cited for the choice of treatment modality chosen were: undergraduate education, clini­ cal experience, and knowledge gained through postgraduate courses / physio­ therapy conferences. Undergraduate institutions play an important role regarding the attitudes of graduates with regard to evidence based practice (EBP), (Research Committee [Victorian Branch] of the APA and invited contributors, 1999). Furthermore, Louw and Morris (2010) state that through EBP educa­ tional requirements for physiotherapists regarding the management of LBP, and hence CLBP as well, can be assessed, consequently contributing to the vital impact of undergraduate education in patient management. Chronic pain and disability due to back pain is associated with psycho­social factors (Bokarius VA and Bokarius V, 2010; Kaapa et al., 2006; Koes et al., 2006). Ninety­four percent of the study sample assessed the psychosocial aspects of CLBP, but none of the respondents were cognisant of all the psycho­social factors that need to be assessed. The cause of CLBP is “multi­ factorial” in nature (Kaapa et al., 2006; O’ Sullivan, 2005) and needs to be considered within a “biopsychosocial framework” (O’ Sullivan, 2005). The biopsychosocial model of chronic low back pain and disability comprises of: “pain; attitudes and beliefs; psycho­ logical distress; illness behaviour and social environment” (Waddell, 1999). The interaction of these factors contri butes to the CLBP disorder and disability (O’ Sullivan, 2005; Waddell, 1999). For effective treatment of this disorder, the main “driving mecha­ nism” of the pain must be identified. If psychosocial factors are disregarded, chronic pain and disability perpetuates, thereby forfeiting ‘reasonable’ quality of life. This study sample treated a considerable number of patients with CLBP per month (about 20 patients per month); therefore it is imperative that physio therapists are cognisant of all psychosocial factors or ‘yellow flags’ to ensure the successful management of these patients. Physiotherapists in this study did not use evidence from literature when selecting treatment modalities for the management of CLBP. Forty­seven per­ cent read between one and five articles per year, whilst 16% did not read any articles. Berger (2007) is of the opin­ ion that the available evidence provides little guidance to clinicians who need to decide which interventions to implement for chronic low back pain. Conversely, Koes et al. (2006) presented clear guidelines regarding the manage ment of patients with CLBP which could be used by physiotherapists. Interpretation of results in journal articles can at times be difficult if one is not well versed with the statistics that were used, something that was alluded to by the respondents in this study. The language used in arti­ cles is sometimes intricate and can be a deterrent to reading of articles. This could be why physiotherapists do not use the current available written evidence in clinical practice (Smith and Grimmer­ Somers 2010), although they may get information on EBP from CPD courses and congresses. Eighty­seven percent of the respon­ dents were unable to correctly identify the levels of evidence of journal articles. Evaluating evidence requires critical appraisal skills (Research Committee of the Victorian Branch of the APA and invited contributors) and if lacking it would be difficult to recognise and imple­ ment evidence. Forty­two percent of the study sample reported that they critique articles that they read. 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