title: Persistent back pain--why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists.
abstract: OBJECTIVE
  (a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving.
  
  
  METHODS
  A mixed methods study, including a questionnaire survey and qualitative analysis of semi-structured interviews. Questionnaire survey; 354/600 (59%) clinicians equally distributed between chiropractic, osteopathy and physiotherapy professions. Interview study; a purposive sample of fourteen clinicians from each profession identified from the survey responses. Methodological techniques ranged from grounded theory analysis to sorting of categories by both the research team and the subjects themselves.
  
  
  RESULTS
  At least 10% of each of the professions reported that they continued to treat patients with low back pain who showed almost no improvement for over three months. There is some indication that this is an underestimate. reasons for continuing unsuccessful management of low back pain were not found to be primarily monetary in nature; rather it appears to have much more to do with the scope of care that extends beyond issues addressed in the current physical therapy guidelines. The interview data showed that clinicians viewed their role as including health education and counselling rather than a 'cure or refer' approach. Additionally, participants raised concerns that discharging patients from their care meant sending them to into a therapeutic void.
  
  
  CONCLUSIONS
  Long-term treatment of patients with low back pain without objective signs of improvement is an established practice in a minority of clinicians studied. This approach contrasts with clinical guidelines that encourage self-management, reassurance, re-activation, and involvement of multidisciplinary teams for patients who do not recover. Some of the rationale provided makes a strong case for ongoing contact. However, the practice is also maintained through poor communication with other professions and mistrust of the healthcare system.
authors.affiliation: Department of Psychology, Royal Holloway, University of London, Egham, Surrey TW20 0EX, UK. t.pincus@rhul.ac.uk
authors.forename: Tamar
authors.initials: T
authors.lastname: Pincus
authors.forename: Steven
authors.initials: S
authors.lastname: Vogel
authors.forename: Alan
authors.initials: A
authors.lastname: Breen
authors.forename: Nadine
authors.initials: N
authors.lastname: Foster
authors.forename: Martin
authors.initials: M
authors.lastname: Underwood
mesh_terms: D000488:Allied Health Personnel / Q000523:psychology*; D001291:Attitude of Health Personnel; D002684:Chiropractic / Q000523:psychology; D002908:Chronic Disease; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D017116:Low Back Pain / Q000628:therapy*; D026761:Physical Therapy Specialty / Q000706:statistics & numerical data*; D011369:Professional-Patient Relations; D011795:Surveys and Questionnaires; D016896:Treatment Outcome