title: Advising people with back pain to take time off work: a survey examining the role of private musculoskeletal practitioners in the UK.
abstract: Research has demonstrated that health care practitioners' adherence to guidelines for managing low back pain (LBP) remain suboptimal in recommending work absence, but specific beliefs about their role in maintaining patients at work have not been adequately researched. We examined private musculoskeletal practitioners' (chiropractors, osteopaths, and physiotherapists) beliefs and reported clinical behaviours in reference to patients' work. A cross-sectional postal questionnaire of 900 musculoskeletal practitioners included the Attitudes to Back pain in musculoskeletal practitioners questionnaires, reported frequency of four work-related behaviours, and a new measure of practitioners' work-related beliefs. Data from 337 respondents (37%) were analysed. Eighty percent of respondents reported recommending work absence to patients with LBP sometimes, and 14% recommended a work absence often or always. Seventy percent of practitioners never visit the patient's workplace. Most practitioners report that they prescribe exercises that can be carried out at work. Physiotherapists visited the workplace more frequently and gave less sick leave certification than either of the other groups. They also regarded work as more beneficial and less of a threat to exacerbate patients' LBP. There were small but significant correlations between work-related beliefs and reported behaviours. Our study confirms that, in contrast to current guidelines, many practitioners believe that LBP necessitates work absence. Overall, practitioners perceived their role in returning patients to work as limited, and believed that direct contact with employers was beyond their remit. In the UK, physiotherapists appear to be better placed to liaise with work in terms of both their beliefs and activities.
authors.affiliation: Department of Psychology, Royal Holloway, University of London, Egham, UK.
authors.forename: Tamar
authors.initials: T
authors.lastname: Pincus
authors.forename: Leona
authors.initials: L
authors.lastname: Greenwood
authors.forename: Emma
authors.initials: E
authors.lastname: McHarg
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002684:Chiropractic / Q000523:psychology / Q000639:trends; D003430:Cross-Sectional Studies; D005260:Female; D019983:Guideline Adherence / Q000639:trends*; D006282:Health Personnel / Q000523:psychology / Q000639:trends*; D006801:Humans; D017116:Low Back Pain / Q000191:economics / Q000523:psychology / Q000534:rehabilitation*; D008297:Male; D008875:Middle Aged; D055360:Osteopathic Physicians / Q000523:psychology / Q000639:trends; D010353:Patient Education as Topic / Q000639:trends*; D059825:Physical Therapists / Q000523:psychology / Q000639:trends; D018582:Sick Leave / Q000639:trends*; D011795:Surveys and Questionnaires; D006113:United Kingdom; D017132:Workplace / Q000592:standards
references.citation: Bishop A, Foster NE, Thomas E, Hay EM. How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Pain. 2008;135:187-195.
references.citation: Buchbinder R, Jolley D, Wyatt M. Volvo award winner in clinical studies: effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine (Phila Pa 1976). 2001;26:2535-2542.
references.citation: Cattell RB. The scree test for the number of factors. Multivariate Behav Res. 1966;1:245-276.
references.citation: Coole C, Watson PJ, Drummond A. Work problems due to low back pain: what do GPs do? A questionnaire survey. Fam Pract. 2010;27:31-37.
references.citation: Corbett M, Foster N, Ong BN. GP attitudes and self-reported behaviour in primary care consultations for low back pain. Fam Pract. 2009;26:359-364.
references.citation: Coudeyre E, Rannou F, Tubach F, Baron G, Coriat F, Brin S, Revel M, Poiraudeau S. General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain. 2006;124:330-337.
references.citation: Evans DW, Breen AC, Pincus T, Sim J, Underwood M, Vogel S, Foster NE. The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) randomized trial. Spine (Phila Pa 1976). 2010;35:858-866.
references.citation: Hlobil H, Staal J, Spoelstra M, Ariëns GA, Smid T, Van Mechelen W. Effectiveness of a return-to-work intervention for subacute low-back pain. Scand J Work Environ Health. 2005;31:249-257.
references.citation: Houben RM, Ostelo RW, Vlaeyen JW, Wolters PM, Peters M, Stomp-van den Berg SG. Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Eur J Pain. 2005;9:173-183.
references.citation: Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, Potter R, Underwood MR. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet. 2010;375:916-923.
references.citation: Lambeek LC, Bosmans JE, Van Royen BJ, Van Tulder MW, Van Mechelen W, Anema JR. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. BMJ. 2010;341:c6414.
references.citation: Maetzel A, Li L. The economic burden of low back pain: a review of studies published between 1996 and 2001. Best Pract Res Clin Rheumatol. 2002;16:23-30.
references.citation: Maniadakis N, Gray A. Health economics and orthopaedics. J Bone Joint Surg Br. 2000;82:2-8.
references.citation: Pincus T, Vogel S, Breen A, Foster N, Underwood M. Persistent back pain—why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. Eur J Pain. 2006;10:67-76.
references.citation: Pincus T, Vogel S, Santos R, Breen A, Foster N, Underwood M. The attitudes to back pain scale in musculoskeletal practitioners (ABS-mp): the development and testing of a new questionnaire. Clin J Pain. 2006;22:378-386.
references.citation: Pincus T, Woodcock A, Vogel S. Returning back pain patients to work: how private musculoskeletal practitioners outside the National Health Service perceive their role (an interview study). J Occup Rehabil. 2010;20:322-330.
references.citation: Poiraudeau S, Rannou F, Baron G, Le Henanff A, Coudeyre E, Rozenberg S, Huas D, Martineau C, Jolivet-Landreau I, Garcia-Mace J, Revel M, Ravaud P. Fear-avoidance beliefs about back pain in patients with subacute low back pain. Pain. 2006;124:305-311.
references.citation: Rainville J, Carlson N, Polatin P, Gatchel RJ, Indahl A. Exploration of physicians’ recommendations for activities in chronic low back pain. Spine (Phila Pa 1976). 2000;25:2210-2220.
references.citation: Schaafsma F, Schonstein E, Ojajarvi A, Verbeek J. Physical conditioning programs for improving work outcomes among workers with back pain. Scand J Work Environ Health. 2011;37:1-5.
references.citation: Schaafsma F, Schonstein E, Whelan K, Ulvestad F, Kenny D, Verbeek J. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev. 2010;20:CD001822.
references.citation: Scheel IB, Hagen KB, Oxman AD. Active sick leave for patients with back pain: all the players onside, but still no action. Spine (Phila Pa 1976). 2002;27:654-659.
references.citation: Shaw W, Main C, Johnston V. Addressing occupational factors in the management of low back pain: implications for physical therapist practice. Phys Ther. 2011;95:777-789.
references.citation: Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-332.
references.citation: Waddell G. Preventing incapacity in people with musculoskeletal disorders. Br Med Bull. 2006;77–78:55-69.
references.citation: Waddell G, O’Connor M, Boorman S, Torsney B. Working backs Scotland: a public and professional health education campaign for back pain. Spine (Phila Pa 1976). 2007;32:2139-2143.
references.citation: Watson PJ, Bowey J, Purcell-Jones G, Gales T. General practitioner sickness absence certification for low back pain is not directly associated with beliefs about back pain. Eur J Pain. 2008;12:314-320.
references.citation: Werner EL, Cote P. Low back pain and determinants of sickness absence. Eur J Gen Pract. 2009;15:74-79.