Physical activity for patients with chronic low back pain: What are physical therapists prescribing?

Abstract

BACKGROUND:

Despite the extensive evidence supporting physical activity (PA) for managing chronic low back pain (CLBP), little is known about PA prescription by physical therapists treating patients with CLBP.

OBJECTIVE:

1) Explore how PA prescriptions provided by outpatient physical therapists treating patients with CLBP align with PA guidelines. 2) Examine the barriers and facilitators of PA prescription among physical therapists working with patients with CLBP.

METHODS:

We conducted a qualitative study with outpatient physical therapists who treat CLBP. Semi-structured interviews provided an understanding of physical therapist experience with PA prescription among patients with CLBP. The interviews were transcribed, coded, and analyzed thematically.

RESULTS:

The 18 participants had an average of 13.4 (6.4) years of clinical experience in outpatient physical therapy. Thematic analysis revealed: 1) Physical therapists’ articulate knowledge of PA guidelines and importance of physical activity; 2) Patient factors take priority over the PA guidelines for people with CLBP; and 3) The importance of building and maintaining a strong patient-therapist relationship influences physical therapist prescription of PA for patients with CLBP.

CONCLUSION:

When providing PA recommendations for patients with CLBP, general movement recommendations are emphasized in place of explicit PA prescriptions. Our findings highlight factors for consideration when prescribing movement and PA for patients with CLBP.

Keywords

Physical activity chronic low back pain physical therapy decision making pain management

1. Introduction

Over the last 25 years, the global years lived with disability due to low back pain has increased by 53%, making low back pain a leading cause of disability worldwide [1]. Among non-surgical approaches, clinical practice guidelines for managing chronic low back pain (CLBP) include recommendations for physical activity (PA) guidance and prescription [2, 3, 4]. The World Health Organization, PA Guidelines for Americans, and the American College of Sports Medicine (ACSM) recommend that adults participate in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity PA per week to experience health benefits [5, 6, 7]. For patients with CLBP who cannot achieve the minimum recommended levels, evidence suggests that even low levels can be beneficial [8]. For patients with CLBP, the benefits of performing regular PA include reduced disability, psychological distress, and risk for multiple chronic diseases and mortality [4, 9, 10]. Despite these recommendations, patients with CLBP are significantly less physically active compared to the general population or matched controls [8, 11, 12].

According to the PA Guidelines and ACSM, the optimal PA prescription includes the components of frequency, intensity, time, and type (FITT) [5]. The FITT components ensure that prescriptions are specific, tailored, and address all recommended dimensions of PA to obtain health benefits. Additionally, the use of FITT components within a specific prescription allows for measurable means of PA progression and provides a universal language for healthcare providers and exercise specialists to communicate, promote, and progress PA prescriptions.

Previous evidence has demonstrated how PA promotion and prescription implementation by healthcare providers can result in increased levels of PA in inactive individuals [13]. Among healthcare providers, physical therapists have a role in prescribing therapeutic exercise, are trained to conduct exercise tests, and prescribe exercise to patients with complex, comorbid conditions, physical impairments, and disabilities [14]. Yet, the evidence that physical therapists incorporate PA prescription into clinical practice for patients with CLPB is limited. Freburger et al. [15] found that 66% of patients with neck or back pain who were surveyed received an exercise prescription from a physical therapist during an episode of care, of which 52% were prescribed walking. Barriers to PA prescription for patients with CLBP include fear avoidance behavior and concern for pain exacerbation [16]. However, according to previous research, these barriers can be overcome and healthcare providers can successfully incorporate behavior change theory to promote long term participation in PA [17, 18].

Although PA is recommended for patients with CLBP, to our knowledge, no studies to date have examined perspectives among United States of America (USA)-based physical therapists related to PA prescriptions for patients with CLBP. Due to the differences in healthcare systems and education, further exploration of PA promotion and prescriptions among USA-based physical therapists is essential. Therefore, the purpose of this study is to: 1) examine how physical therapist PA prescriptions for patients with CLBP align with ACSM guidelines, including FITT components; and 2) explore barriers and facilitators of PA prescription for physical therapists working with patients with CLBP.

2. Materials and methods

2.1 Methodological approach and study design

We conducted a qualitative study to help us understand the common meaning and lived experiences related to the concept of “PA prescription among physical therapists treating patients with CLBP.” The University’s Internal Review Board (IRB) approved the study (CHRMS 19_0160) in accord with the Declaration of Helsinki of 1964 and its later amendments. All participants completed the IRB-approved consenting process before participating.

2.2 Participants and recruitment

Physical therapists were recruited for interviews using a community flyer, emails to professional contacts, and postings in online forums. The fliers were posted at outpatient clinics in the county where the researchers were located. In order to expand our geographical diversity, we sent the flier by email invitation to outpatient physical therapy clinics that have participated as clinical physical therapy education sites across the USA. We also posted the invitation flier on social media, including Facebook, Twitter, and LinkedIn. Inclusion criteria for physical therapists were current licensure in the USA and at least one year of self-reported clinical experience treating patients with CLBP. Participants were excluded if they were unable to attend the interview.

2.3 Data collection

2.3.1 Brief questionnaire

Before the interviews with physical therapists, a brief questionnaire was used to collect demographic information, number of years spent in clinical practice, and experience treating patients with CLBP. Experience treating patient with CLBP was assessed by asking participants to quantify the percentage of current clinical practice working with patients with CLBP. The answers were used to inform prompts during the interviews.

2.3.2 Semi-structured interviews

We developed the interview guide by starting with interview questions used in previous, relevant studies [19, 20] and modifying them to help us achieve the study aims. We collected additional input on the interview questions from expert physical therapists in the area of treatment for patients with chronic back pain. Subsequently, we conducted two rounds of pilot testing of the interview questions with physical therapists from a local clinic who provided additional input on the questions’ wording and focus. The study team created the two vignettes based on previous experience working with patients with chronic low back pain. The vignettes were designed to convey scenarios of patients with CLBP who had the ability and the interest to participate in physical activity despite their CLBP symptoms.

The semi-structured interviews included two case vignettes about patients with a history of CLBP: 1) 36-year-old female who recently underwent a promotion at work resulting in an increased amount of travel and decreased time for PA; and 2) 60-year-old male with a recent cardiac surgery who wants to be active but is concerned about his age and pain. Full case vignettes are provided in the Supplement. Participants were asked how the information presented in the case vignettes would guide their prescription of PA. The 30–45-minute phone interviews were conducted by Doctor of Physical Therapy students with limited clinical perspectives and thus least likely to introduce bias. The interviews were audio-recorded and transcribed verbatim.

2.4 Data analysis

2.4.1 Quantitative data: Brief questionnaire

Using the responses from the brief questionnaires, we completed exploratory analyses by calculating descriptive statistics. All data management and analysis were completed using Microsoft Excel (Version Office 365-ProPlus, Microsoft, Albuquerque, NM).

2.4.2 Qualitative data: Interviews

Interviews were conducted until data saturation was met, meaning that no new themes or information were being collected [21]. Researchers (KB, NF, KM, and LS) thematically coded all interview transcripts for commonalities or contrasts and identified common themes within the data. Two different researchers coded each transcript. The two sets of codes were compared, and the entire research team discussed discrepancies. The final list of codes was used to develop themes and categories that represented the analyzed data. To determine the credibility of the analyzed results, we performed reverse coding using our major themes. We further enhanced credibility by having two additional members (MW and NG) re-evaluate the final three major themes and sub-themes by re-reading the transcripts to ensure that our results represent the data.

2.5 Qualitative standards for rigor

Rigor in qualitative research is determined by examining the study’s dependability, credibility, transferability, consistency, and confirmability [22]. Methods used to ensure rigor for this study included: 1) using a semi-structured interview guide that was pilot tested before data collection; 2) recording the interviews and transcribing them word by word; 3) maintaining a clear data trail; 4) in-depth description of the qualitative themes; 5) re-evaluation of codes by two additional coders; 6) comparing the qualitative with the brief questionnaires (data triangulation); and 7) using self-reflective strategies such as debriefing with the research team, using systematic tables for data collection, and having multiple coders [22, 23]. To further enhance the study’s rigor, we followed the Standards for Reporting Qualitative Research.

3. Results

3.1 Participants

Eighteen physical therapists from ten USA states dispersed in the Northeast, Southeast, Northwest, and Midwest were interviewed. The participants had an average of 13.4 (SD $=$ 6.4) years of clinical experience with 39.0% (SD $=$ 14.8) of their clinical practice composed of patients with CLBP. See Table 1 for information on the demographics and clinical experience of the interviewed physical therapists.

Table 1
Characteristics of participants

Characteristic	Mean/percent (SD)
Gender
Female	33.0%
Male	67.0%
Age, years	39.1 ( $\pm$ 6.9)
Clinical experience, years	13.4 ( $\pm$ 6.4)
Physical therapist’s practice composed of patients with CLBP	39.0% ( $\pm$ 14.8)
Physical activity question on intake form	67%
Electronic health record prompt for physical activity prescription	11%

Abbreviations: ICD-International Classification of Disease, CLBP-Chronic Low Back Pain.

3.2 Thematic analysis

Thematic analysis revealed the following themes: 1) Physical therapists’ articulate knowledge of physical activity guidelines, FITT principles, and importance of physical activity; 2) Patient factors take priority over the PA guidelines for people with CLBP; and 3) The importance of building and maintaining a strong patient-therapist relationship influences physical therapist prescription of PA for patients with CLBP. See Table 2 for quotes that support the themes and related subthemes.

Table 2
Supporting quotations of emergent themes from physical therapist interviews

Physical therapists’ knowledge of PA recommendations
Themes and subthemes	Quotations
Importance of physical activity	“I think just getting people moving has a huge benefit.” (PT1)
	“Importance of cardiovascular activity on, not only the healing process, but also, just overall fitness levels and health.” (PT5)
Knowledge of guidelines	“… walking 30 minutes vigorously or moderate to vigorous every night” (PT1)
	“The ideal is the ACSM, 150 minutes per week … walking 20 to 30 minutes, 5 days a week” (PT2)
	“my recommendation would be 30 minutes of cardio at least 5 times a week … strength training I would say 2 to 3 times a week” (PT3)
Prioritizing the patient over knowledge of PA recommendations
Perception of common barriers	“Fear that it will happen again.” (PT14)
	“You kind of get the sense that they aren’t necessarily motivated or super into activity, so those patients I am going to promote them to just get out of the house.” (PT15)
	“They always have an excuse for you.” (PT16)
	“… the biggest and hardest thing to deal with is compliance, especially if you’re dealing with someone with CLBP.” (PT9)
Lack of comfort	“I would feel uncomfortable initially giving that person an exercise program outside of the basic things they can do, whether it be for lack of safety or lack of adherence, or just concern for the patient’s well-being.” (PT4)
	“Start with performing activities of daily living, then lets progress them to doing physical activity, but this progression occurs very slowly to prevent setting the patient back.” (PT18)
Non-specific recommendations	“My exercise prescription for him is first, I’m going to say he needs to get moving during the day … getting up to go to the bathroom or get coffee, that kind of thing.” (PT15)
	“… even just doing a little more is better than nothing.” (PT8)
Importance of building and maintaining a strong patient-therapist relationship
Rapport	“I can make recommendations, but I give them this only as a guide … I want them to feel comfortable.” (PT5)
	“You’ve got to get a rapport with them quickly because you don’t want them to think you’re calling them out for being a couch potato.” (PT10)
	“Talking it on a personal level and really trying to connect with them on their level … using their language.” (PT14)
Selling our product	“You try to really try to soft sell.” (PT11)
	“The common thing I see amongst patients is, they want to know that you have an investment in them, so if you can sell it to them, right, you’re getting their buy-in because you’re educating them and you’re really explaining to them why they should engage in some form of physical activity, whether for weight loss or pain science, or what have you, have the patient really buy-in and educate them the best you can, make sure you’re treating them as a person.” (PT15)

Theme 1: Physical therapists’ articulate knowledge of physical activity guidelines, FITT principles, and importance of physical activity.

The physical therapists articulated knowledge about PA recommendations for patients with CLBP. Physical therapists’ knowledge was further sub-divided into two subthemes: 1) recognition of the importance of movement among patients with CLBP and 2) recognition of the national guidelines and clinical recommendations for PA. The importance of general movement was expressed via statements such as “motion is lotion” and comments on the health benefits from moving more. Physical therapists also verbalized their understanding of PA guidelines, which aligned with the ACSM guidelines. When guidelines were mentioned, the participants would state something such as “30 minutes 5 times a week” or “150 minutes of walking a week.” Related to the ACSM guidelines, the participants acknowledged understanding and value of the FITT components. The interviews also highlight that the physical therapists distinguish the benefits of aerobic versus therapeutic exercise, such as targeted strengthening exercises for CLBP. Many of the physical therapists described familiarity with resources available in their clinics to support PA prescription including progressive walking and running guides, community walking options, and lists of local facilities such as recreation centers and gyms.

Theme 2: Patient factors take priority over the PA guidelines for people with CLBP.

After the initial opening questions related to PA and CLBP, the interviewer provided specific examples via case vignettes. During this time, the physical therapists focused on the multiple PA participation barriers they perceived the patient to have, their lack of comfort in providing a prescription, and their fear that pushing the patient too much would result in symptom exacerbation, such as radiculopathy. The combination of these factors led to them verbalizing the need to provide general movement recommendations, such as “move as much as possible” over specific recommendations related to any of the FITT components or the minimum recommendations for health benefits. None of the physical therapists’ recommendations incorporated the FITT principles, including progressive intensity, time, and type of PA. The details in the vignettes focused on the patients’ history of PA engagement, interest in being physically active, and desire not to exacerbate pain symptoms. In follow-up questions to the vignettes and general movement recommendations, the physical therapists cited multiple barriers to specific PA prescriptions. The barriers included lack of patient motivation, concerns about exercise adherence, self-efficacy, exercise history, health education, the presence of pain, fear avoidance, psychosocial factors, social determinants of health, LBP acuteness, and environmental barriers, such as access to facilities (both geographic proximity and financial). Participants also shared information about their lack of comfort in addressing PA barriers and the fear of exacerbating pain.

Theme 3: The importance of building and maintaining a strong patient-therapist relationship influences physical therapist prescription of PA for patients with CLBP.

Throughout the interviews, whenever physical therapists discussed providing a recommendation related to specific PA, they also verbalized the need to include a rationale for their recommendation in deference to developing and maintaining a positive relationship with their patient. Two sub-themes further characterize the importance of the positive relationship with patients to the physical therapists: 1) building rapport, and 2) “selling our product.” According to the physical therapists, building rapport was an important component of ensuring patient trust. After trust is built, physical therapists felt they could “bargain” with their patients to increase adherence with recommendations or suggestions related to physical activity. While “selling our product” was characterized as the perceived need to provide evidence behind all movement recommendations in order to maintain a positive patient-therapist relationship. The clinicians’ view related to the importance of a patient-centered relationship further highlights the interest of having the patient perform PA, but not wanting the patient to become upset, overwhelmed, or fearful of returning for subsequent physical therapy sessions. When discussing these interests, physical therapists also listed some of the above-mentioned PA participation barriers.

4. Discussion

The qualitative interviews identified that physical therapists are aware of the PA guidelines, the recommendations for patients with CLBP, and the value of incorporating PA and exercise prescriptions into clinical practice (theme 1). However, the prescriptions verbalized by participants were general movement recommendations that lacked the FITT components that should accompany their prescription (theme 2). The use of general recommendations was further emphasized during the case-based interview questions, during which clinicians continued to recommend that the patient in the vignette move more, but a specific PA prescription was never recommended (theme 2).

Our findings align with the study published by Freburger et al. [15], who concluded that PA is being underutilized as a treatment for chronic back pain and that the types of exercises prescribed do not follow current practice guidelines. Similar results have been found among other healthcare providers, including primary care physicians, nurses, physician assistants, and nurse practitioners [24, 25, 26]. Parallel results were identified in a systematic review that used surveys and clinical documentation data to examine if physical therapists follow evidence-based guidelines when managing musculoskeletal conditions [27]. Both the survey and documentation data led to the same conclusion in that physical therapists did not follow the evidence-based guidelines when managing musculoskeletal conditions [27].

Studies examining PA prescription among other healthcare providers have identified similar factors related to underutilization, including knowledge of the PA guidelines, perceived PA barriers of patients, and concerns about a negative impact on the patient-provider relationship [25, 26, 28, 29]. Phelan et al. [29] highlighted the impact of healthcare providers’ perceptions (related to patients’ likelihood of following their recommendations) on the decision to provide medical care for symptom management of CLBP or prescribing alternative, holistic approaches, such as PA. The study also identified that out of the 381 primary care providers, 52% prioritized providing medical care for symptom management of an acute exacerbation of CLBP, reflecting a biomedical model of patient management [29]. It is important to note that concentrating on the acute exacerbation is clinically appropriate but distinct from managing CLBP. By conceptualizing CLBP from the biomedical model instead of the biopsychosocial model, a clinician ignores essential components of managing CLBP, including social, psychological, and behavioral dimensions that impact CLBP and its associated flare-ups [30, 31]. It is also crucial to mention that by not assessing and addressing the psychosocial factors associated with pain, individuals are at greater risk of developing pain-related disability [32, 33].

During our study, particularly within our second and third theme, physical therapists illustrated the awareness of the psychosocial dimensions by verbalizing their perception about patients’ potential barriers, including lack of motivation, exercise adherence, self-efficacy, exercise history, health education, the presence of pain, fear avoidance, social determinants of health, acuteness, and environmental barriers, such as access to facilities (both geographic proximity and financial). However, they did not act upon the psychosocial dimensions. Other studies have found similar results, concluding that clinicians acknowledge the importance of contextual factors but do not assess or address these factors, a necessary component of behavior change [26, 34].

As highlighted by our second theme, our participants did not indicate methodologies of assessing patients’ contextual factors. Instead, the physical therapists based their decision to prescribe general movement on their perceptions. Without asking patients about PA barriers, physical therapists miss a vital opportunity to provide appropriate intervention. In the current study, an example of misleading assumption is related to the physical therapists’ decision to provide general movement recommendations instead of explicit PA prescriptions despite previous research identifying that patients with CLBP prefer to receive a high-intensity cardiovascular prescription, even if they are experiencing acute flare-ups [34, 35]. The mismatch between physical therapists’ perceptions and patient preferences highlights a potential communication gap regarding patients’ interests and goals.

Seeking information about patient goals and interests is a vital component of patient-centered care and strengthens the patient-therapist relationship, which, according to our third theme, is highly valued in clinical decision-making. Our findings are similar to Stenner et al. [36], who identified that physical therapists used assumptions instead of assessments to prescribe exercise to patients with non-specific low back pain. The study findings resulted in the conclusion that physical therapists provided recommendations based on adherence-oriented principles rather than the evidence [36], which is contrary to evidence-based practice. When describing the adherence aspect of exercise prescription, the authors identified a parallel theme to the current study, which was the attempt to “bargain” or “sell” the intervention to increase adherence to the therapists’ recommendations [36].

Previous studies have identified reimbursement for health promotion in clinical rehabilitation as a key barrier for physical therapists implementing regular PA promotion and prescription [37]. According to Traeger et al. [34], a reason why healthcare providers that are aware of the recommendations of using physical and psychological therapies over traditional pain medications, steroid injections, and spinal surgeries but do not implement it in regular practice is the fee-for-service reimbursement model. Furthermore, a German survey completed by general practitioners identified that the practitioners are aware of the recommendations related to managing CLBP but feel that they do not have the resources to provide the multidisciplinary team approach needed to address the contextual factors associated with CLBP [38]. In a qualitative study conducted in the United Kingdom, a primary care provider, stated that a non-pharmacological approach of using a multidisciplinary team is a “lovely pie-in-the-sky-plan” that is not feasible [39]. However, according to cost-benefit analyses, a psychosocial approach to managing CLBP, which includes multiple visits to various members of a multidisciplinary team, is less expensive than the current unnecessary care options, such as surgeries [34]. These findings highlight that reimbursement and the current fee-for-service payment model should not be a limiting factor in deciding between a biomedical and a psychosocial approach to managing CLBP.

Based on best practice literature for individuals with CLBP, our results, especially theme 2 and 3, indicate that the current level of PA recommendations for patients with CLBP by physical therapists is substandard, particularly since physical therapists are in an advantageous position to promote overall health through PA prescription and the benefits of PA for patients with CLBP [40]. The need to promote PA among patients with CLBP is further emphasized by literature that has identified that if CLBP is not managed, it can result in pain-related disability and health-related consequences, including increased healthcare-burden [32, 33]. The importance of incorporating PA into physical therapy is one reason why multiple organizations, including the American Heart Association, ACSM, and American Physical Therapy Association support the implementation of PA prescriptions by physical therapist [14, 25, 41, 42].

The main limitation of this study was the lack of ethnographic observations, which would have enhanced the data triangulation and increase our insight into the potential discussions between physical therapists and patients. Furthermore, gathering data on patient perspectives would provide insight into how patients with CLBP would like the PA prescription. Additionally, our findings are only generalizable to physical therapists, and other research among other healthcare providers needs to be done.

Despite these limitations, our study provides strong evidence that among physical therapists treating patients with CLBP, the implementation of PA prescription with FITT components is lacking. To our knowledge, this is the first study to characterize PA prescription by USA-based physical therapists treating patients with CLBP. Using our thematic results, we add depth to our understanding regarding PA prescription.

5. Conclusion

Our study identified that despite the evidence and awareness of the importance of promoting PA among patients with CLBP, physical therapists provided general movement recommendations instead of specific prescriptions using FITT principles. The decisions related to the PA prescriptions were impacted by the physical therapists’ perception of patient barriers and the concern about a negative impact on the patient-therapist relationship. These findings offer a deeper understanding of the potential mismatch between clinical guidelines and physical therapists’ clinical practice. Therefore, it is essential that clinicians critically appraise their prescription of movement and PA to patients with CLBP.Our study also provides a framework for future research, for which we recommend including multiple institutions, incorporating observations and data from electronic health records, and obtaining patient perspectives.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This project was funded through departmental internal funds.

Supplement: Vignettes

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Physical activity for patients with chronic low back pain: What are physical therapists prescribing?

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Methodological approach and study design

2.2 Participants and recruitment

2.3 Data collection

2.3.1 Brief questionnaire

2.3.2 Semi-structured interviews

2.4 Data analysis

2.4.1 Quantitative data: Brief questionnaire

2.4.2 Qualitative data: Interviews

2.5 Qualitative standards for rigor

3. Results

3.1 Participants

Table 1 Characteristics of participants

Table 2 Supporting quotations of emergent themes from physical therapist interviews

Theme 1: Physical therapists’ articulate knowledge of physical activity guidelines, FITT principles, and importance of physical activity.

Theme 2: Patient factors take priority over the PA guidelines for people with CLBP.

Theme 3: The importance of building and maintaining a strong patient-therapist relationship influences physical therapist prescription of PA for patients with CLBP.

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

Funding

Supplement: Vignettes

References

Table 1
Characteristics of participants

Table 2
Supporting quotations of emergent themes from physical therapist interviews