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Bart W Koes
Maastricht University
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82
Key Words
Low back pain, physiotherapy,
clinical guidelines, evidencebased healthcare.
Dutch Physiotherapy
Guidelines for Low Back
Pain
by G E Bekkering
H J M Hendriks
B W Koes
R A B Oostendorp
R W J G Ostelo
J M C Thomassen
M W van Tulder
Introduction
Evidence-based healthcare has received
increased attention during the last decade
and is important to monitor and improve
quality of care. Guidelines are useful
tools in this process aiming at changing
behaviour of healthcare professionals, if
needed. Low back pain is a good example
of a field where evidence has been provided by many randomised trials and
summarised in many systematic reviews.
At least 12 guidelines for low back pain in
primary care have been published, but
none of them specifically for physiotherapy (Koes et al, 2001). However,
physiotherapy management of low back
pain also needs to move forward in the
mainstream of evidence-based healthcare.
The need for an evidence-based and more
uniform approach is signalled by the
variation in treatment of low back pain,
both nationally (van der Valk et al, 1995)
and internationally (Foster et al, 1999; Li
and Bombardier, 2001) and the lack of
evidence-based guiding principles.
The Dutch physiotherapy guidelines for
low back pain presented in this paper
embody the physiotherapeutic diagnostic
and therapeutic process in patients with
low back pain. Manual therapy is not
included in these guidelines because
these techniques demand specific knowledge and skills. For this reason, separate
guidelines for manual therapy are being
developed in the Netherlands.
In the Netherlands, patients do not
have open access to a physiotherapist;
they need a referral from a general
practitioner or another physician.
Consequently, these guidelines focus on
patients with low back pain who are
referred for physiotherapy.
Their aim is to improve the efficiency
and effectiveness of physiotherapy management in patients with low back pain
Guidelines
83
Bekkering, G E,
Hendriks, H J M,
Koes, B W,
Oostendorp, R A B,
Ostelo, R W J G,
Thomassen, J M C
and van Tulder, M W
(2003). Dutch
physiotherapy
guidelines for low
back pain,
Physiotherapy, 89,
2, 82-96.
84
Authors
G E Bekkering MSc is
a researcher at the
Dutch National
Institute of Allied
Health Professions,
Amersfoort, and the
Institute for Research
in Extramural
Medicine, VU
University Medical
Centre, Amsterdam.
H J M Hendriks PhD
PT is leader of the
physiotherapy
guidelines
programme at the
Dutch National
Institute of Allied
Health Professions,
Amersfoort. He is
employed by the
Department of
Epidemiology,
Maastricht University.
B W Koes PhD is
professor of general
practice, at Erasmus
University, Rotterdam.
RAB Oostendorp PhD
PT MT is a professor
at the University
Medical Centre,
Centre of Quality of
Care Research,
Nijmegen, and at the
Faculty of Medicine
and Pharmacology,
Postgraduate
Education Manual
Therapy, Free
University of Brussels,
Belgium, and director
of the Dutch National
Institute of Allied
Health Professions,
Amersfoort.
R W J G Ostelo PhD
PT is a researcher at
the Institute for
Research in
Extramural Medicine,
VU University Medical
Centre, Amsterdam.
J M C Thomassen PT
is a physiotherapist at
the Institute for
Rehabilitation and
Rehabilitation
Research,
Hoensbroek,
The Netherlands.
Patient Characteristics
The significance which people attach to
symptoms is based on the subjective
perception and interpretation of stimuli.
If significance does not seem to correspond with an objective reality, a logical
error is being made. A common logical
error is to catastrophise, which means
that the pain, and the situation in which
the pain presents, are being considered a
serious threat, a catastrophe.
The extent to which patients feel that
they have control over the pain is
also important. They may feel that their
health is mainly controlled by themselves
(internal locus of control), or by other
people or circumstances (external locus
of control: patients give other people, for
example physiotherapists, control over
their health -- Hrkp et al, 1996). An
internal locus of control is often related
to active coping and, subsequently, to a
better way of dealing with the pain
(Jensen et al, 1991).
Both the significance attached to the
pain and the perceived sense of control
may determine movement behaviour. For
instance, when pain is considered as a
signal of possible injury (catastrophe), the
chances will be high that this will result in
fear of movement. Fear of movement is
the fear that movement will result in
(new) pain or (re)injury, which will, in
turn, lead to avoidance (Vlaeyen et al,
1995). Also when, based on previous
experiences, patients expect certain
activities to increase the pain and that
they have no control over this (low level
of control), the chances are that this
situation will be avoided.
Interaction between Patient and
Surroundings
The interaction between patients and
their environment (social factors) also
plays a role in their coping strategy. Very
protective partners, but also contradictory
information and recommendations by
different healthcare providers, may
frighten patients and influence their
coping strategy negatively. Physiotherapists attitudes may also play a role,
for example paying too much attention to
pain and not encouraging patients
independence may affect the course in a
negative way.
Guidelines
85
Description
Strong
Consistent findings in
several high quality
randomised controlled
trials
Moderate
No randomised controlled
trials
86
History Taking
The physiotherapist tries to get a clear
picture of the patients health problem.
What does the patient expect and prefer,
what is the most important complaint,
what are the consequences of this
complaint on daily life, which factors
increase, decrease or maintain the
complaint, and how does the patient feel
about his complaint and its consequences? (Hendriks et al, 2000a).
Key points of history taking are listed in
table 2. In cases of recurrent low back
pain, the physiotherapist specifically
examines possible causes for these
repeated episodes (eg changes in work
load or activities), the total duration of
the complaints and the time between
episodes of low back pain. The physiotherapist will also ask about the use of
ergonomic adjustments and compliance.
These guidelines recommend the use of
two instruments to assess and evaluate
functional status. The first instrument is
for the patient-specific complaints to
assess the patients functional status
(Beurskens et al, 1996). To date, there
are no studies on the reliability of this
instrument, although the questionnaire
has proved to be useful for patients with
Guidelines
87
Analysis
Based on the systematic process of collecting patient data, patients health
problems will be defined. The physiotherapist describes the most important disabilities and participation
problems, the relevant impairments
(which are related to the patients
disabilities or participation problems),
and whether the back pain follows
a normal or an abnormal course.
Indications for an abnormal course are,
for example, the number of daily periods
of rest increase, the use of analgesics
persists or increases, no return to activities
or participation. These indications are
related to the duration of three weeks and
to the patients level of activities.
If the course is abnormal, the physiotherapist describes the present physical,
psychological and social factors maintaining or aggravating the complaints. This
includes co-morbid problems. Finally the
physiotherapist decides whether the
health problem could be improved by
physiotherapy.
If the physiotherapist determines that
physiotherapeutic intervention is likely
to be effective, the physiotherapist sets a
treatment plan.
If there is no indication for physiotherapy, patients are referred back to the
physician. Physiotherapists should contact
the referring physician if they think
that bio-psychosocial factors and/or impairment, disability and participation
problems cannot be treated by physiotherapy (only).
Physiotherapy February 2003/vol 89/no 2
88
Limited/moderate
evidence of effectiveness
Effectiveness unclear
Behavioural therapy
Ultrasound,
electrotherapy, laser,
transcutaneous electrical
nerve stimulation,
massage
Ultrasound,
electrotherapy, laser,
transcutaneous
electrical nerve
stimulation, massage
Moderate evidence
of ineffectiveness
Specific exercises,
traction
Biofeedback
Strong evidence
of ineffectiveness
Traction
Treatment Plan
The main objective of the treatment for
low back pain is a return to the highest
(or desired) level of activities and participation and the prevention of chronic
complaints and recurrences.
As most patients with a normal course
will return to their normal level of activities and participation, irrespective of
treatment, one or two treatment sessions
to coach these patients will often be
enough. The main intervention is patient
education, aimed at patients continuing
their self-management.
In patients with an abnormal course the
sub-goals of the treatment are to increase
their knowledge and understanding and
change inadequate behaviour, if needed;
gradually to increase activities and participation; to improve relevant functions
(eg muscle strength, flexibility, stability);
to promote an adequate coping style;
and to influence any other physical
or psychosocial factors which may be
associated with chronic low back pain and
which are within the scope of physiotherapy. The main treatment interventions are systematic patient education and
exercise therapy aimed at functioning.
The physiotherapist will pursue an
active policy, in which patients also take
responsibility for the results of the
treatment.
Treatment
Evidence from Systematic Reviews
First the findings of the systematic reviews
are summarised (table 3), followed by a
description of the therapeutic process.
This is based on the distinction between
patients with low back pain with a normal
and those with an abnormal course.
Advice to Stay Active
It is useful to advise (sub)acute patients
with low back pain to stay active.
Guidelines
89
90
Massage
Electrotherapy
Laser
It is unknown whether or not laser is
useful in low back pain.
Guidelines
91
Promoting Adherence
To bring about a beneficial effect on the
complaints, it is important that patients
adhere to the treatment. Various factors
may decrease adherence:
1. Problems which patients experience
in their attempts to adhere to the
exercises and instructions given by
the physiotherapist,
2. Lack of positive feedback.
3. Degree of 'helplessness' (if patients
think that exercise will not help).
4. Bad prognosis.
5. Not feeling much hindered by the
disorder (Sluijs, 1991).
Physiotherapists should explore carefully the extent to which patients are able
to adhere to the prescribed exercises and
Physiotherapy February 2003/vol 89/no 2
92
Guidelines
Evaluation
The physiotherapist evaluates the treatment results regularly and systematically
by setting them against the treatment
objectives. On the basis of this evaluation, the treatment plan may be modified. The physiotherapist may use
the measuring instruments mentioned
previously in the diagnostic process. To
evaluate the outcomes of the information
and advice given, the physiotherapist
should ask: Does the patient know what
he needs to know? and Does the patient
cope the way he should? If the treatment
does not improve a patients functioning
within three weeks, the physiotherapist
should contact the referring physician.
Treatment Conclusion and Report
At the end of the treatment the effects
of the intervention should be evaluated
and reported to the referring physician.
The written report should include the
treatment objectives, the improvements in
functioning, perceived quality of life and
the reason for concluding the treatment
(Hendriks et al, 2000a).
Discussion
In the Netherlands seeking care for low
back pain usually starts with consulting
a general practitioner (primary care
physician), who decides if and which
treatment is necessary. The Dutch general
practice guidelines favour a wait-and-see
policy in acute patients with low back pain
and do not recommend a referral to
physiotherapy within the first six weeks
(Faas et al, 1996). In practice, however,
general practitioners refer patients within
six weeks (Schers et al, 2001).
The physiotherapy guidelines are
largely in line with the general practice
guidelines; if the course of symptoms is
normal the physiotherapist supports the
wait-and-see policy. Patients with an
abnormal course, who do not increase
activities and participation within three
weeks, may be at risk of developing chronic complaints. Therefore intervention is
necessary in order to prevent transition to
the chronic stage.
The guidelines recommend adequate
education and exercise therapy for these
patients, although they may still be in the
acute stage of their back pain, in which
there is no evidence for the effectiveness
of exercise therapy. However, based on
principles of early activation which is
93
94
Acknowledgement
These guidelines were issued by the Royal
Dutch Society for Physiotherapy and
funded by the Government Department of
Public Health, Sciences and Sports.
For the production of these guidelines,
special words of gratitude to the multidisciplinary working committee are in
order. Many thanks to (in alphabetical
order): P F van Akkerveeken PhD
(orthopaedic surgeon, Back Advice Centre
Nederland), R M Bakker-Rens MSc
(occupational physician, Dutch Society for
Occupational Practice), A J Engers PT MSc
(psychologist / human movement scientist,
Centre of Care Research, Medical Centre
St Radboud, Nijmegen), L Geken PhD
(rehabilitation physician, Dutch Society for
Rehabilitation Physicians), J Mens MSc
(orthopaedic surgeon, Spine and Joint
Guidelines
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