Are the attitudes and beliefs of Australian exercise-based practitioners associated with their use of treatment modalities for chronic low back pain

Key points

1. 01Most practitioners regularly used guideline-recommended care (education and exercise) with moderate to high confidence
2. 02Higher biomedical beliefs were linked to greater use and confidence in manual therapy and specific exercise
3. 03Higher biopsychosocial beliefs were linked to greater confidence in pain education, general exercise and CBT
4. 04Physiotherapists used specific exercise, manual therapy and combined manual plus exercise more than exercise physiologists, partly reflecting scope of practice
5. 05This was a self-report survey, so it shows associations, not whether changing beliefs changes care

How it was conducted

Design

Online cross-sectional survey (Qualtrics), preregistered on OSF, CHERRIES reporting

Participants

233 Australian practitioners working with chronic low back pain (143 physiotherapists, 90 accredited exercise physiologists), from 317 starts, Dec 2021 to Jul 2023

Measures

Self-reported use of and confidence in 7 treatments, plus biomedical and biopsychosocial beliefs via PABS-PT (10 biomedical, 9 biopsychosocial items)

Analysis

Mann-Whitney U and t-tests to compare disciplines; multiple linear regression for associated factors, p<0.05

What they found

• 233 complete responses (90 exercise physiologists, 143 physiotherapists) from 317 starts
• 97% were at least somewhat confident treating chronic low back pain, with no difference between disciplines
• Exercise physiologists held higher biopsychosocial beliefs than physiotherapists (mean difference 1.79, p=0.002, d=0.41); biomedical beliefs were similar
• Physiotherapists were more likely to use specific exercise, manual therapy and combined manual plus exercise (p<0.001, r=0.40 to 0.70) and pain education (p=0.036, r=0.14)
• Most common treatments were pain education (94.2%) and pain education plus exercise (92.6%); CBT was least common (62.5%)
• Among general exercise users: resistance with load 83.7%, bodyweight 82.7%, aerobic 81.2%, flexibility 80.7%
• Specific exercise types: motor control and movement impairment 67.6% each, core stability 63.2%, Pilates 39.4%; manual therapy: joint mobilisation 79.2%, massage 77.6%
• 79% identified physical activity guidelines correctly (89% of exercise physiologists vs 73% of physiotherapists); 53% used guidelines to inform prescription
• Regression coefficients were small with low variance explained: higher biomedical orientation linked positively to specific exercise, manual therapy and combined exercise plus manual therapy, and negatively to general exercise use and combined exercise plus pain education; higher biopsychosocial orientation linked positively to confidence in general exercise, CBT, pain education and combined exercise plus pain education, and negatively to confidence in manual therapy

Limitations

• Convenience sample recruited via social media and professional lists, with possible non-response bias
• Cross-sectional self-report of use and confidence, not observed practice or patient outcomes
• Treatments were assessed individually rather than ranked by preference, and use and confidence were high across most modalities, limiting discrimination
• A planned high versus low belief subgroup analysis was dropped because only 26 participants met criteria

Why it matters

For patients

The exercise or hands-on treatment your therapist recommends for back pain may reflect their underlying beliefs as much as the evidence, so it is reasonable to ask why a given approach was chosen.

For clinicians

Your attitudes and beliefs about back pain appear to influence your treatment choices and confidence, so reflecting on a biopsychosocial versus biomedical orientation may help align care with guidelines.

For readers

Practitioner beliefs are associated with treatment patterns for chronic low back pain, but this survey cannot show that shifting beliefs would improve care.