Background: Physiotherapy scope of practice includes treatments for low back pain (LBP) that are recommended in guidelines, as well as some that are not recommended. At present it is unclear to what extent physiotherapy treatment choices for LBP align with the evidence.
Objective: To determine what percentage of physiotherapy treatment choices for LBP are high-value, low-value or of unknown value.
Design: Systematic review
Methods: We performed searches in several databases combining terms synonymous with “practice patterns” and “physiotherapy” from the earliest record to April 2018. We included studies that quantified physiotherapy treatment choices for LBP through surveys, audits of clinical notes, and other methods. Treatments recommended in guidelines or systematic reviews were considered ‘high-value’ and those recommended against were considered ‘low-value’. Treatments were ‘unknown-value’ if evidence was inconclusive. We summarised the percentage of physiotherapists who chose treatments that were high-value, low-value, or of unknown value using medians and interquartile ranges.
Results: We included 48 studies. As assessed by surveys completed by physiotherapists, the median percentage of treatment choices that were high-value, low-value, and of unknown value for LBP was 35%, 44% and 72%. For example, for acute LBP, the most frequently provided high-value treatment was advice to stay active (32%); the most frequently provided low-value treatments were paracetamol (39%) and electrotherapy (34%). As assessed by audits of clinical notes, these percentages were 50%, 18% and 43%, respectively. For example, for chronic LBP, the most frequently provided high-value treatment was exercise (64%); the most frequently provided low-value treatments were electrotherapy (18%) and traction (6%).
Conclusion: Between 35-50% of physiotherapists provide high-value care for LBP, while between 18-44% provide low-value care and most provide care of unknown value (43-72%). This highlights an urgent need to develop and test strategies to help physiotherapists replace low-value or untested treatments for LBP with high-value care.