Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Low back pain (LBP) is the leading cause of disability, affecting over 630 million people worldwide [1], and results in significant burden and high cost to society [2]. LBP is associated with a wide range of physical, psychological, and social influences on patients’ lives including functional disability, depression, work absence, poor productivity, poor quality of life, and increased healthcare utilization [3‐8]. Out of 328 medical conditions, LBP was found to be the top contributor to global disability in the 2016 global burden of disease study [9]. In the U.S., the direct and indirect costs of LBP are estimated to exceed $100 billion per year [10, 11], while in Canada, the estimates of the healthcare cost of LBP range between $6 and $12 billion annually [12].

Non-specific LBP is a broad diagnostic term referring to pain that cannot be attributed to any specific cause or pathology [13]. Approximately 90% of all LBP cases presenting to primary care are non-specific in nature [14]. However, a cross-sectional study in Australia of six health disciplines including physiotherapists and doctors of chiropractic suggested that 93% of the clinicians did not view acute non-specific LBP as a single entity [15]. A majority (74%) of respondents thought it is possible to recognize subgroups among non-specific LBP patients.

In spite of significant research efforts to better understand the causes of non-specific LBP, identifying the exact source of “pain generators” remains challenging. It has been argued that in the absence of a clear diagnosis, appropriate treatment plans and care can be difficult to prescribe [16]. This has led to a large body of literature evaluating “one-size-fits-all” approach to treat patients in this category, despite their widely recognized heterogeneity [17]. Some argue that this “one-size-fits-all” approach can lead to diagnosis-treatment mismatch [18].

To improve the diagnosis-treatment process, various stratified care approaches, also known as classification systems, have been proposed to improve patient care and reduce levels of disability for non-specific LBP [19‐23]. These stratified care approaches recommend different ways of assessing and treating non-specific LBP by attempting to classify patients into clinically relevant sub-groups who can then receive targeted interventions [24]. One of the first stratified care approaches was developed by Robin McKenzie in 1981 [25] where patients are sub-grouped based on three clinical presentations: postural syndrome, dysfunction and derangement. Since then many more stratified care approaches have emerged, with Billis et al. [19] identifying 39 stratified care approaches from nine countries, and a number of additional stratified care approaches have been proposed since [21‐23]. Fairbank et al. (2011) [21] identified 28 stratified care approaches (16 diagnostic, 7 prognostic, and 5 treatment-based) specifically for the management of chronic non-specific LBP, while three clinical practice guidelines on the management of LBP suggested the use of the stratified care approaches to subgroup non-specific LBP patients [24, 26, 27]. However, no particular stratified care approach is suggested as being superior over others.

Despite the potential usefulness of stratified care approaches for managing non-specific LBP, many physiotherapists continue to be divided on the use of such approaches [28]. Some choose to continue managing non-specific LBP patients using interventions with limited or no evidence of effectiveness [29], even though patients fail to show any improvement after 3 months [30]. In one study in Quebec, about one third of physiotherapists indicated using the McKenzie subgrouping approach [29] and those physiotherapists were recent graduates or regularly attended postgraduate clinical education [29]. While the uptake of stratified care approaches in chiropractic practice is currently unknown, it is unlikely to be higher considering that stratified care approaches were mostly developed by physiotherapists.

Understanding the varying uptake of stratified care approaches in clinical practice could inform the design of more effective implementation strategies. Among the stratified care approaches recommended by clinical practice guidelines, some focus on diagnostic, prognostic, or treatment stratification. However, there is no cut evidence that one approach is superior over other. For instance, the STarT Back Screening Tool has a level Ia (high quality) evidence for its clinical- and cost-effectiveness [31]. STarT Back provides a systematic method of assessing the biopsychosocial prognostic factors of delayed recovery and matching certain intervention accordingly [32]. On the other hand, a recent meta-analysis [33] concluded that in patients with chronic LBP, McKenzie Method of Mechanical Diagnosis and Therapy is superior to other rehabilitation interventions; however this is dependent on the other kind of intervention being compared to. McKenzie Method was not superior to other rehabilitation interventions for acute LBP. In summary, none of the stratified care approached has shown superiority for all cases of LBP and their focus varies. Furthermore, clinicians’ exposure to any particular stratified care approaches during their training or after graduation is highly variable. For these reasons, we did not limit the behaviour of interest to any one approach. To date, no study has assessed individual barriers and facilitators to using stratified care approaches for managing non-specific LBP among Canadian physiotherapists and chiropractors. Our aim was to explore the determinants of using any of these approaches among physiotherapists and chiropractors. We used the theoretical domains framework (TDF) [34, 35] to explore clinicians’ beliefs and attitudes about, and barriers to, the use of stratified care approaches. The TDF was developed to assess factors likely to impede or enable the uptake of clinical practice guidelines and best practices, and to “simplify and integrate a plethora of behaviour change theories and make theory more accessible to, and usable by, other disciplines” (p. 2) [34]. The TDF has been used across various healthcare settings, health disciplines and clinical conditions to provide in-depth understanding of the underlying behavioural problem and to suggest interventions to increase the likelihood of successful implementation [36‐42]. A three-step validation of this framework resulted in a revised version of the TDF which contains 14 domains [34].

In this section, we present the specific beliefs and corresponding themes underpinning two key theoretical domains shared by both physiotherapists and chiropractors (Environmental Context and Resources and Social Influences), followed by the key domains for each discipline.

The perceived benefits of using stratified care approaches to manage non-specific LBP for both the chiropractic and physiotherapy disciplines included empowering patients to self-manage, addressing psychosocial issues, better health outcomes, a more accurate prognosis, implementing EBP and a more uniform practice between clinicians. The lesser reluctance of physiotherapists to routinely use stratified care approaches in clinical practice may be attributed to formal stratified care approaches of undergraduate or postgraduate training compared to chiropractors. Factors perceived as strongly influencing the use of stratified care approaches clustered around three theoretical domains (Environmental Context and Resources; Social Influences; and Goals) for physiotherapists and seven key domains (Environmental Context and Resources; Beliefs about Capabilities; Social Influences; Intentions; Knowledge; Behavioural Regulation; and Beliefs about Consequences) for chiropractors. Interestingly, the two domains shared by both disciplines (Environmental Context and Resources and Social Influences) were frequently reported in a review of exploratory studies underpinned by the TDF among different health disciplines across a range of behaviours [53]. For instance, barriers observed in our study such as lack of time, cost, and other colleagues in the same practice who are unfamiliar with stratified care approaches (Environmental Context and Resources) were also concerns raised by UK physiotherapists [54]. Our findings are also consistent with other studies showing that across different professions, clinicians are generally more receptive to evidence communicated by their peers (Social Influences) than research evidence and clinical practice guidelines [13, 15, 39, 55‐73]. Nonetheless, about one third of our participants from both disciplines indicated that they would not consider consulting more experienced peers, and most chiropractors indicated that the views of researchers would likely influence their decision to manage patients using stratified care approaches. Interestingly, the decision of physiotherapists to manage acute/chronic LBP patients in apparent distress using the stratified care approaches appeared to be easier (less influenced) than for chiropractors, possibly because physiotherapists receive more undergraduate training in using psychological interventions [55].

For the majority of participating physiotherapists, the goal of managing non-specific LBP patients with stratified care approaches (Goals domain) may be incompatible with dealing with others’ goals such as: the clinic owner wishing keep the patients for longer time, patients’ beliefs or attitudes (resistance to using stratified care approaches and fear of movement) and clinical presentation (pain level and psychological overlay). This may be explained by the fact that physiotherapists tend to work in group practices and need to adhere to specific rules set by the clinic owner [74]. In contrast, half of chiropractors in Canada work as solo practitioners [75, 76], possibly explaining why none of the interviewed chiropractors mentioned that incompatibility of stratified care approaches was an issue.

On the other hand, five additional theoretical domains (Beliefs about Capabilities; Intentions; Knowledge; Behavioural Regulation; and Beliefs about Consequences) were deemed important for chiropractors. While two-thirds of chiropractors felt confident in assessing non-specific LBP patients using stratified care approaches and matching the targeted treatments (Beliefs about Capabilities) others considered that their experience was more important in identifying the most appropriate treatment than using stratified care approaches. This is in line with previous findings where a small percentage of chiropractors admitted they preferred relying on their personal experience to guide treatment for neck pain [52].

Chiropractors expressed high Intentions of managing non-specific LBP patients using stratified care approaches. However, about one third of chiropractors said they would not use stratified care approaches to manage non-specific LBP patients, with some concerns raised regarding certain stratified care approaches such as STarT Back Tool [32] because chiropractors were not involved in the original research, unlike the physiotherapy profession [77]. This is in line with a systematic review of the determinants of professionals’ intentions and behaviours which concluded that professional role and identity is an essential determinant of intention [78]. Another review showed that there are few studies regarding the use of stratified care approaches like Start Back Tool in chiropractic patients [79].

Chiropractors expressed their awareness and understanding of stratified care approaches in terms of Knowledge. However, about half of the chiropractors either did not use stratified care approaches or did not know how to apply them in the management of non-specific LBP patients. This might explain why one-third of chiropractors were not confident in using stratified care approaches and considered their experience to be more important than using stratified care approaches. Previous work showed that chiropractors usually appreciated researchers’ efforts but felt it was not applicable to their daily clinical practice [80‐82].

About two-thirds of chiropractors mentioned that they have a clear plan under what circumstances they will use stratified care approaches in their practice (Behavioural Regulation domain). Statements relating to Beliefs about Consequences shed some light on some of the perceived disadvantages of using stratified care approaches in chiropractic practice, including: stratified care approaches mistakenly identify patients and lead to overtreatment, limited patient assessment, are too simplistic, do not cover lifestyle factors, are more focused on yellow flags (i.e., risk of delayed recovery), are not widely used, and do not speed up recovery.

The findings of this study indicate that both physiotherapists and chiropractors were aware of the existence of different stratified care approaches. Different barriers and facilitators were identified for each discipline. These determinants reflect the nature and type of practices, as well the prior training. Nonetheless, participants from both disciplines generally agreed about the benefits of stratified care approaches for managing non-specific LBP. These included empowering patients to self-manage, implementing EBP, considering psychosocial risk factors, a more uniform practice between clinicians, and better health outcomes. Determinants identified may inform the design of a theory-based KT intervention to increase the use of selected stratified care approaches to manage non-specific LBP patients.