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Article

Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?

by
Antoine Fourré
1,2,
Rob Vanderstraeten
2,
Laurence Ris
1,
Hilde Bastiaens
2,
Jozef Michielsen
2,3,
Christophe Demoulin
4,
Ben Darlow
5 and
Nathalie Roussel
2,*
1
Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium
2
Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, 2610 Antwerpen, Belgium
3
Orthopedic Department, University Hospital, 2650 Antwerp, Belgium
4
Department of Sport and Rehabilitation Sciences, University of Liège, 4000 Liège, Belgium
5
Department of Primary Health Care and General Practice, University of Otago, Wellington 6021, New Zealand
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2023, 20(9), 5611; https://doi.org/10.3390/ijerph20095611
Submission received: 2 March 2023 / Revised: 16 March 2023 / Accepted: 19 April 2023 / Published: 23 April 2023
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Abstract

:
Background: Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette. Methods: Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes. Results: In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP. Conclusions: The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.

1. Introduction

The leading cause of disability worldwide is low back pain (LBP) [1,2]. All clinical guidelines for the management of LBP recommend diagnostic triage to differentiate LBP presentations into those with features of underlying serious pathology (such as infection or cancer), those with features of specific LBP (such as radiculopathy or spinal stenosis) and those with non-specific LBP [3,4,5,6]. However, there is a lack of studies exploring the ability of first-line healthcare practitioners (HCPs) to suspect the presence of an underlying pathology. However, although most patients suffer from non-specific LBP, the ability to recognize the possibility of serious spinal pathologies is crucial as the management of patients with specific LBP will be completely different [6].
Although non-specific LBP is explained by a combination of biological, psychological and social factors, many HCPs still consider LBP to be the result of one single (biomedical) factor [2] and focus care on this biomedical factor. However, clinical guidelines underline the importance of evaluating psychosocial factors as these could lead to an increased risk of chronicity [7,8,9].
Optimal management of patients with non-specific LBP includes explanation, reassurance, promotion of movement, return to work and self-management. However, many HCPs, especially those with a biomedical orientation [10], do not follow these recommendations [10,11,12] and manage patients with LBP in a guideline-inconsistent way. This approach is associated with increased use of diagnostic imaging, opioids, spinal injections and surgery, contributing to persistent disability and enormous costs for society [1,13,14].
Therefore, the objectives of this study were (1) to question physiotherapists about their knowledge of evidence-based guidelines for the management of LBP and their application in clinical practice; (2) to examine their knowledge, attitudes and beliefs concerning LBP and the association with their self-reported knowledge of the guidelines; and (3) to assess their recommendations about activity and work and their ability to suspect or detect a specific cause of LBP in a clinical vignette.

2. Materials and Methods

2.1. Design

This cross-sectional study reports baseline assessment from a randomised controlled study registered on clinicaltrials.gov (NCT05284669). The study was approved by the local ethical committee. The results of this study are reported using the STROBE guidelines for observational studies [15].

2.2. Setting

This study was carried out using an online setting. Participants accessed an internet platform (https://qualtrics.com) (accessed on 10 September 2022) detailing study information using their own internet device (e.g., computer, tablet or smartphone). After providing informed consent, participants were invited to complete the online survey.

2.3. Participants

Licensed Dutch- and French-speaking physiotherapists in Belgium and France were informed about the possibility to participate in an online study. Various strategies were used [16] to contact clinically active physiotherapists in Belgium and France. Invitations were shared in two languages (Dutch and French) in broad networks such as national associations (e.g., Axxon, Domus Medica, etc.), local networks of university departments and hospitals, registered physiotherapy associations, etc. Eligibility criteria were French-speaking or Dutch-speaking graduated physiotherapists working in Belgium or France. Exclusion criteria were no management of patients with low back pain and not being in possession of an internet-connected device. Recruitment took place between August 2021 and December 2021.

2.4. Outcomes

This study included five questionnaires: a self-developed socio-demographic questionnaire, the Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS) [17,18], the 10-item version of the Back Pain Attitudes Questionnaire (Back-PAQ-10) [19,20], the revised Neurophysiology of Pain Questionnaire (NPQ) [21,22] and questions relating to two clinical vignettes (one about a patient with non-specific LBP [23] and one about a patient with a specific LBP). All questionnaires were available in the language of the participant (either French or Dutch). The Back-PAQ and the NPQ were translated into Dutch using a back-and-forth translation process using Beaton’s guideline with four translators (two French-speaking and two Dutch-speaking) [24]. The HC-PAIRS and the vignette (non-specific LBP), translated in a previous study with the same process, were used for the French-speaking participants [25].

2.4.1. Sociodemographic

This questionnaire was developed for this study. It included several items related to personal factors (age, gender, region, clinical occupation and settings) of participants. Two questions (Yes or No answer) were asked; the first was about the confidence in their own knowledge of guidelines for the management of LBP, and the second was about their application of guidelines in clinical practice.

2.4.2. Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS)

The HC-PAIRS assesses attitudes and beliefs concerning physical impairments for patients with chronic LBP [26]. It consists of 13 statements that are rated on a seven-point Likert scale ranging from ‘totally disagree’ to ‘totally agree’. The total score ranges from 13 to 91. A high score on the HC-PAIRS reflects a belief in a strong relationship between pain and impairment [17]. The good psychometric properties of this questionnaire have been established in graduated HCPs, including physiotherapists [17,26,27].

2.4.3. Back Pain and Attitudes Questionnaire (Back-PAQ)

The Back-PAQ questionnaire (10-items version) [19] assesses attitudes and underlying beliefs about back pain on a five-point Likert scale. The scoring of the answers ranges from +2 to −2. Items 6-7-8 have a reversed score. The total score ranges from −20 to 20. A negative score reflects beliefs that are unhelpful and vice-versa. To interpret the Back-PAQ, five themes are related to the items: “the vulnerability of the back”, “the relationship between back pain and injury”, activity participation while experiencing back pain”, “psychological influences on recovery” and “the prognosis of back pain”. All items were written in the second person to personalise the questionnaire. The purpose of this personalisation is that responders present their own beliefs rather than projecting their beliefs onto people with LBP or presenting their beliefs about people with LBP [19].

2.4.4. Neurophysiology of Pain Questionnaire (NPQ)

The Neurophysiology of Pain Questionnaire (NPQ) assesses how an individual conceptualises biological mechanisms underpinning pain [21]. The NPQ includes 19 questions with three response options (true; undecided; false). The scoring is 1 for a correct answer and 0 for a wrong or undecided answer. Higher scores reflect better knowledge of the pain neurophysiology. This questionnaire was included to evaluate if physiotherapists accurately understand the neurophysiology of pain [22,28] as pain education could improve kinesiophobia and pain catastrophising in patients with chronic LBP [29].

2.4.5. Clinical Vignettes

Two clinical vignettes were used in this study. The first vignette was one of the three vignettes developed by Rainville et al. [23]. It describes a patient with non-specific LBP. The participant was asked to give his/her opinion on the appropriate level of activity for the patient, with choices ranging from 1 (no limitations on activity) to 5 (limit all physical activity) and assess the patient’s ability to work from 1 (full-time) to 5 (remain out of work). If the score of the participant was between 1 and 2, it was considered guideline-consistent [25]. If the score was between 3 and 5, it was considered guideline-inconsistent [25]. The total score ranging from 2 to 10 was calculated using the sum of the two items.
A second vignette was developed to analyse the capacity of physiotherapists to suspect a specific underlying spinal pathology (i.e., to evaluate the skills of the diagnostic triage) and describe the symptoms of a patient with a specific cause of LBP (lumbar spinal stenosis). The methodology of Jette et al. was used to develop this vignette [30]. Participants answered an open question: “In your opinion, what are the causes/contributing factors to the pain of this patient?” Answers of the participants were scored on two criteria: “ability to suspect a specific LBP” and “ability to detect the correct specific LBP”. Participants were scored 1 (“yes”) if they suspected or detected the specific LBP in the vignette and 0 (“no”) if they did not.

2.5. Statistical Methods

Data were downloaded from Qualtrics and sorted using Microsoft Excel (16.57) (Microsoft Corporation, Redmond, WA, USA). IBM Statistics 28 (IBM SPSS, Armonk, NY, USA) was used to perform statistical analyses. Only participants with complete data (i.e., all questionnaires completed) were included in the statistical analyses.
Descriptive statistics were used for all the questionnaires and vignettes. Normality tests of outcomes results were performed (Kolmogorov–Smirnov Test). Kruskall–Wallis and Mann–Whitney tests with a significance of 0.05 were used to compare the total score of the questionnaires with the knowledge of the guidelines, groups of physiotherapists seeing less (<15) or more (15–20) patients with LBP per month and the ability to suspect or detect the specific diagnosis of LBP. Both vignettes were analysed using descriptive statistics to determine the number of physiotherapists giving guideline-inconsistent recommendations and being able to suspect or detect a specific cause of LBP.

3. Results

In total, 2447 HCPs opened the questionnaire online. After exclusion of participants (see Figure 1), 527 physiotherapists from two countries (59% females and 41% males; see Table 1) were included in the data analysis.
Their clinical occupation was mainly full-time (81%). Two-thirds of the physiotherapists (63%) reported seeing at least 10 new patients with LBP per month. The majority (63%) of the physiotherapists reported they were uncertain or did not know the content of guidelines on the management of LBP and only 31% reported applying them in clinical practice.

3.1. Knowledge, Attitudes and Beliefs of Physiotherapists

Descriptive statistics are detailed in Table 2. No significant differences were found in the scores of the questionnaires between physiotherapists seeing less (<5) or more (15–20) patients with LBP per month except for the Back-PAQ (p = 0.02). No significant differences were found between Belgium and France for these questionnaires (data not shown).
The results of the Back-PAQ were analysed by theme and are detailed in Table 3. The worst scores were related to the theme “vulnerability of the back”, with 43% of physiotherapists having neutral or negative beliefs.
Physiotherapists were sub-grouped based on the self-reported knowledge of guidelines for the management of LBP. The scores of participants reporting that they know the guidelines were significantly better (i.e., more guideline-consistent) for the HC-PAIRS, Back-PAQ and NPQ (p < 0.001) compared to those who reported to be unfamiliar with them (see Figure 2).

3.2. Vignettes

The descriptive results of the vignette describing a patient with non-specific LBP are presented in Table 4. Most of the physiotherapists (63%) gave guideline-inconsistent recommendations for work. Concerning activity, 24% of the physiotherapists gave guideline-inconsistent recommendations.
A significant difference between the self-reported knowledge of the guidelines and the vignette’s total score was found (p = 0.009). No significant difference was found between the self-reported application of the guidelines and the vignette’s total score (p = 0.079).
The descriptive results of the vignette describing a case with specific LBP are presented in Table 5. Fifty-four percent of the physiotherapists suspected the presence of a specific underlying cause of LBP in this vignette and only 30% of them mentioned the correct spinal pathology. Participants who suspected the presence of a specific cause of LBP had significantly better scores in the NPQ (p = 0.037). Participants who detected the specific cause of LBP (spinal stenosis) had significantly better scores in the Back-PAQ and NPQ (p = 0.004).

4. Discussion

The results of this study revealed that a low proportion of physiotherapists in Belgium and France report knowing or using LBP guidelines. Physiotherapists not familiar with the guidelines were more likely to have attitudes indicating a strong relationship between pain and impairment, beliefs about LBP that are unhelpful, inadequate knowledge on the neurophysiology of pain and guideline-inconsistent recommendations regarding work. Half of the physiotherapists in this study did not suspect a specific cause of LBP in a clinical vignette.

4.1. Physiotherapy in Belgium and France

In both countries, patients need a referral prescription from a physician to have access to physiotherapy and to be reimbursed by the health social security system [31]. In Belgium, the number of sessions is limited to 18 sessions. Direct access to physiotherapy is not yet implemented in Belgium but an experimental study is currently performed to evaluate the (cost-)effectiveness of direct access [32]. In France, direct access is allowed for specific cases (acute LBP and ankle sprain in multidisciplinary centers) but it is not widely implemented. The results of this study found that knowledge, attitudes and beliefs of physiotherapists are equivalent in Belgium and France.

4.2. Knowledge of the Guidelines and Questionnaire Scores (HC-PAIRS, Back-PAQ and NPQ)

The low proportion of physiotherapists reporting to know guidelines for the management of LBP is striking as significantly more guideline-inconsistent attitudes and behaviours (i.e., reflected by significantly worse scores on HC-PAIRS, Back-PAQ, NPQ, recommendations based on clinical vignette) were observed in physiotherapists uncertain of or not knowing clinical guidelines. This proportion is significantly higher compared to a study in Australia where only 19% of physiotherapists were uncertain of clinical guideline recommendations [33]. These differences might be explained by a combination of reasons: undergraduate education [34], promotion of guidelines (media campaigns, professional bodies, insurance/funding) [35], health system design [36,37] and a cultural shift toward evidence-based care.
However, our results are in line with previous studies; one reported that only 12% of physiotherapists were aware of clinical guideline recommendations [38], and another one reported that only 52% of physiotherapists used guidelines in clinical practice [39]. A systematic review found that physiotherapists questioned the relevance of guideline recommendations (such as assessing cognitive, psychological and social factors of patients) or felt they had inadequate clinical skills [40]. A recent study found that the proportion of physiotherapists providing guideline-recommended treatment is still low and has not increased since 1990 [41]. It is relevant to report that a high proportion of physiotherapists (30%) in this study were working as solo practitioners. Working in isolation could have an impact on the development of clinical expertise and implementation of evidence-based care. These results are highly concerning and reveal the urgent need to develop better strategies to implement evidence-based guidelines.
Concerning the HC-PAIRS, recent studies using the 13-item version in physiotherapists in the USA [42] and New Zealand [27] found lower scores (i.e., median of 31 compared to 42 in our study), suggesting a more bio-psychosocial orientation of participants in these countries. Higher scores on the HC-PAIRS are not only associated with a more biomedical treatment orientation, but this can also negatively influence health attitudes and behaviour of the patients [43]. It is known that HCPs’ beliefs about LBP might be associated with the beliefs of their patients [44]. While this study did not investigate the effective management of physiotherapists during actual consultations, the high scores of the HCPs who were clinically active physiotherapists are nevertheless concerning as it might suggest that these physiotherapists provide predominantly biomedical management to their patients. Self-reflection strategies should be implemented in the education of physiotherapists to understand how their beliefs about pain align with evidence and the negative effects that biomedically focused care can have on patient outcomes [45].
The short version of the Back-PAQ (10-item) with −2 to +2 scoring was chosen in this study to facilitate the interpretation of results. Negative scores represent beliefs that are not helpful concerning LBP. Physiotherapists in this study seeing more patients (15–20) per month had significantly better beliefs concerning LBP compared to those seeing less (< 5). The clinical expertise of physiotherapists working with more patients with LBP could have influenced this result, but it is important to note that no difference was observed for the other questionnaires (HC-PAIRS and NPQ). On average, physiotherapists presented positive scores, meaning they have beliefs more aligned with helping recovery. Similar results were found in recent studies [46,47]. Nevertheless, there was a lot of room for improvement. The analysis of the Back-PAQ themes showed that 43% of physiotherapists had negative or neutral answers concerning the items related to the vulnerability of the back. This means that many physiotherapists believed that is easy to injure the back and that caution is needed. These beliefs related to the need of protection reflect guideline-inconsistent beliefs related to the biomedical model. In other countries, some studies presented lower (worse) scores for the Back-PAQ in physiotherapists [27,48]. These results highlight the urgent need to develop interventions aiming to enhance beliefs of physiotherapists as they can influence the prognosis of the patient [49].
The knowledge about the physiology of pain in physiotherapists was explored in this study with the NPQ. The mean score of 66% (12.6 ± 3.2) cannot be considered as good for graduated physiotherapists. Our results are higher than those observed in studies from Meeus et al. [50] and Moseley [28] with a mean of 56% (10.71 ± 3.08) and 55% (10.45 ± 3.61), respectively. Nevertheless, recent studies from Stern et al. [51] and Lane et al. [52] (using a shorter version of the NPQ (12-item) [21]) showed higher scores in physiotherapists with a mean score of 75% (9 ± 1.5) and 80% (9.6 ± 1.1), respectively. Even with these higher scores, Stern et al. concluded that physiotherapists had limitations in pain science [51]. Pain neuroscience education is an approach to reconceptualise how pain works [53]. However, this is relatively new, and one hypothesis might be that some physiotherapists in our study had not benefitted from these new insights since graduation.
Reassurance about the pain experience is recommended in the clinical guidelines and could positively influence pain ratings, disability and limitations in movement of the patient [54]. In one study, a NPQ mean score of 90% was required for practitioners to be included and deliver pain neuroscience education [55,56]. Unfortunately, barriers to implementation in practice exist and the evolution of knowledge in pain science may not be delivered appropriately to physiotherapists and patients [57,58,59].

4.3. Clinical Vignettes

The results of the non-specific vignette developed by Rainville [23] showed that a majority of physiotherapists (63%) gave guideline-inconsistent recommendations concerning return to work and guideline-consistent recommendations when advising the patient about activities. These results are comparable to other studies which showed guideline-inconsistent recommendations concerning work in 76% [25] and 50% [47] of physiotherapists. In another study, physiotherapists gave guideline-consistent recommendations concerning work and activity (60% and 88%, respectively) [39]. In comparison, our proportion of physiotherapists giving guideline-inconsistent recommendations for work is high. These results are concerning given the fact that physiotherapists follow their patients for multiple sessions and could potentially implement unhelpful beliefs related to work, favour a worse prognosis and increase long-term disability in patients with LBP. This major difference between recommendations for activity and work could be explained for different reasons. Firstly, return to work is a topic seldom included in curricula of physiotherapists or in postgraduate training, while the opposite is true for activity recommendations. Physiotherapy curricula are mainly based on the promotion of movement and activity in patients to recover their health. Secondly, physiotherapists in Belgium and France can discuss returning to work with patients but the final decision is made by the physician. Inter-disciplinary discussions about return to work are not usually implemented in private practice. Thirdly, a clinical vignette is completely different from an interview in a clinical setting, and this could influence the given recommendations. Current clinical vignettes lack the integration of psychosocial factors. New clinical vignettes should be developed to allow a better evaluation of the situation and context by health professionals.
Finally, half of the physiotherapists did not suspect the presence of a specific type of LBP in a clinical vignette despite clear indicators of a neurological condition that should arouse suspicion or concerns and influence clinical decision making. Only 30% of the participants detected the correct underlying specific pathology (lumbar spinal stenosis). These results are highly concerning and are similar to other studies [30,60,61] where only half of the physiotherapists recognised the specific pathology and performed clinical decision making. Even more concerningly, the cause of LBP was often wrongly attributed to the patient’s age or behavioural factors. (e.g., “the patient don’t follow the treatment correctly”). These results could be explained by the fact that guidelines are not consistent about which features would indicate a specific diagnosis, which may lead to confusion and inconsistency in management of patients [6]. This confusion could also have influenced physiotherapy curricula. Our results indicate that caution is needed before allowing direct access in Belgium or France. To avoid mismanagement of patients, strategies to better implement the diagnostic triage [62] and the suspicion of specific pathologies underlying musculoskeletal disorders should be developed.

4.4. Limitations and Strengths

This study had some limitations. The psychometric characteristics of the versions of the Back-PAQ and NPQ translated into Dutch were not studied. Moreover, the second clinical vignette (specific low back pain) was developed for the purpose of this study and was not validated. Their validity and psychometric characteristics should be analysed in future studies. To facilitate the recruitment procedure, volunteers were sought using broad advertising and accreditation points were given to physiotherapists when they finished their participation in the study. This point attribution could have biased the sample of physiotherapists recruited. Volunteer physiotherapists could be more aligned with knowledge creation and use. Nevertheless, offering “free” accreditation points may have encouraged those who generally do not follow learning opportunities. It is also important to acknowledge that this study only measures explicit attitudes and beliefs rather than implicit orientation of physiotherapists in a clinical setting. Implicit attitudes and beliefs could also greatly influence patient outcome because spontaneous and everyday clinical management is not always driven by deliberate analysis [17].
This study had several strengths as well. The recruitment of physiotherapists took place in two countries, and the sample of participants was large. This facilitated the gathering of up-to-date data on knowledge, attitudes and beliefs of physiotherapists in these countries. To the best of our knowledge, this is the first study to analyse the ability of physiotherapists to suspect the presence of a specific pathology causing LBP using a clinical vignette in Belgium and France. The variety of measured outcomes included in this study facilitated extensive results concerning the current knowledge, attitudes and beliefs of physiotherapists in these countries.

5. Conclusions

This study found that a high proportion of physiotherapists in France and Belgium were unfamiliar with guidelines related to LBP management and did not apply these in practice. This lack of knowledge concerning guidelines is reflected by beliefs that there is a strong relationship between pain and impairment, beliefs about LBP that are unhelpful and inadequate knowledge on the neurophysiology of pain. The majority of physiotherapists gave guideline-inconsistent recommendations concerning returning to work, which are known to negatively influence the prognosis of patients. Half of the physiotherapists in this study did not suspect the presence of a specific cause of LBP in a clinical vignette with features of spinal stenosis and neurological compromise. Future studies should develop and evaluate interventions aiming to better implement best practice and guideline-oriented management of LBP in physiotherapists. These future interventions should include all the aspects of clinical guidelines and the bio-psychosocial model, including important topics such as the capacity to suspect a specific cause of LBP, the evaluation of psychosocial factors and clinical tools to effectively reassure the patient about their condition.

Author Contributions

Conceptualisation, L.R. and N.R.; methodology, A.F., N.R., L.R., H.B. and J.M.; software, A.F.; validation, AF., R.V., L.R., H.B., J.M., C.D., B.D. and N.R.; formal analysis, A.F., R.V., N.R. and C.D.; investigation, AF., R.V., L.R., J.M. and N.R.; resources, A.F., L.R. and N.R.; data curation, A.F.; writing—original draft preparation, A.F. and N.R.; writing—review and editing, AF., R.V., L.R., H.B., J.M., C.D., B.D. and N.R.; visualisation, A.F.; supervision, N.R., L.R. and H.B.; project administration, N.R. and L.R.; funding acquisition, N.R., L.R. and J.M. All authors have read and agreed to the published version of the manuscript.

Funding

This study recieved financial support from the European Regional Development Fund (Interreg FWVl NOMADe—N° 4.7.360).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of UZA (20/51/714—08 February 2021). This cross-sectional study reports baseline assessment from a randomised controlled study registered on clinicaltrials.gov (NCT05284669).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

References

  1. Buchbinder, R.; Underwood, M.; Hartvigsen, J.; Maher, C.G. The Lancet Series call to action to reduce low value care for low back pain: An update. Pain 2020, 161, S57–S64. [Google Scholar] [CrossRef] [PubMed]
  2. Hartvigsen, J.; Hancock, M.J.; Kongsted, A.; Louw, Q.; Ferreira, M.L.; Genevay, S.; Hoy, D.; Karppinen, J.; Pransky, G.; Sieper, J.; et al. What low back pain is and why we need to pay attention. Lancet 2018, 391, 2356–2367. [Google Scholar] [CrossRef]
  3. Van Wambeke Leuven, P.U.; President, G.; Desomer, A.; Ailliet, L.; Berquin, A.; Demoulin Université de Liège, C.; de Liège, C.; Depreitere, B.; Dewachter, J.; Dolphens, M.; et al. KCE Report 287Cs Summary Low Back Pain and Radicular Pain: Assessment and Management. 2017. Available online: www.kce.fgov.be (accessed on 10 January 2021).
  4. Bernstein, I.A.; Malik, Q.; Carville, S.; Ward, S. Low back pain and sciatica: Summary of NICE guidance. BMJ 2017, 356, i6748. [Google Scholar] [CrossRef] [PubMed]
  5. Bardin, L.D.; King, P.; Maher, C.G. Diagnostic triage for low back pain: A practical approach for primary care. Med. J. Aust. 2017, 206, 268–273. [Google Scholar] [CrossRef]
  6. Finucane, L.M.; Downie, A.; Mercer, C.; Greenhalgh, S.M.; Boissonnault, W.G.; Pool-Goudzwaard, A.L.; Beneciuk, J.M.; Leech, R.L.; Selfe, J. International Framework for Red Flags for Potential Serious Spinal Pathologies. J. Orthop. Sports Phys. Ther. 2020, 50, 350–372. [Google Scholar] [CrossRef] [PubMed]
  7. Suri, P.; Delaney, K.; Rundell, S.D.; Cherkin, D.C. Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting. Arch. Phys. Med. Rehabil. 2018, 99, 1533–1539.e2. [Google Scholar] [CrossRef] [PubMed]
  8. Hill, J.C.; Dunn, K.M.; Lewis, M.; Mullis, R.; Main, C.J.; Foster, N.E.; Hay, E.M. A primary care back pain screening tool: Identifying patient subgroups for initial treatment. Arthritis Rheum. 2008, 59, 632–641. [Google Scholar] [CrossRef]
  9. Simula, A.S.; Ruokolainen, O.; Oura, P.; Lausmaa, M.; Holopainen, R.; Paukkunen, M.; Auvinen, J.; Linton, S.J.; Hill, J.C.; Karppinen, J. Association of STarT Back Tool and the short form of the Örebro Musculoskeletal Pain Screening Questionnaire with multidimensional risk factors. Sci. Rep. 2020, 10, 290. [Google Scholar] [CrossRef]
  10. Zadro, J.; O’Keeffe, M.; Maher, C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open 2019, 9, e032329. [Google Scholar] [CrossRef]
  11. Bahns, C.; Happe, L.; Thiel, C.; Kopkow, C. Physical therapy for patients with low back pain in Germany: A survey of current practice. BMC Musculoskelet. Disord. 2021, 22, 563. [Google Scholar] [CrossRef]
  12. Logan, G.S.; Dawe, R.E.; Aubrey-Bassler, K.; Coombs, D.; Parfrey, P.; Maher, C.; Etchegary, H.; Hall, A. Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: A retrospective review of 3609 medical records in Newfoundland using routinely collected data. BMC Fam. Pract. 2020, 21, 236. [Google Scholar] [CrossRef] [PubMed]
  13. Darlow, B.; Forster, B.B.; O’Sullivan, K.; O’Sullivan, P. It is time to stop causing harm with inappropriate imaging for low back pain. Br. J. Sports Med. 2017, 51, 414–415. [Google Scholar] [CrossRef] [PubMed]
  14. Chou, R.; Fu, R.; Carrino, J.A.; Deyo, R.A. Imaging strategies for low-back pain: Systematic review and meta-analysis. Lancet 2009, 373, 10. [Google Scholar] [CrossRef] [PubMed]
  15. von Elm, E.; Altman, D.G.; Egger, M.; Pocock, S.J.; Gøtzsche, P.C.; Vandenbroucke, J.P. For the STROBE Initiative The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. PLoS Med. 2007, 4, e296. [Google Scholar] [CrossRef]
  16. Dillman, D.A.; Smyth, J.D.; Christian, L.M. Internet, Phone, Mail, and Mixed-Mode Surveys: The Tailored Design Method; Wiley: New York, NY, USA, 2014; ISBN 978-1-118-45614-9. [Google Scholar]
  17. Houben, R.M.A.; Vlaeyen, J.W.S.; Peters, M.; Ostelo, R.W.J.G.; Wolters, P.M.J.C.; Stomp-Van Den Berg, S.G.M. Health Care Providers’ Attitudes and Beliefs towards Common Low Back Pain: Factor Structure and Psychometric Properties of the HC-PAIRS. Clin. J. Pain 2004, 20, 37–44. [Google Scholar] [CrossRef]
  18. Rainville, J.; Bagnall, D.; Phalen, L. Health care providers’ attitudes and beliefs about functional impairments and chronic back pain. Clin. J. Pain 1995, 11, 287–295. [Google Scholar] [CrossRef]
  19. Darlow, B.; Perry, M.; Mathieson, F.; Stanley, J.; Melloh, M.; Marsh, R.; Baxter, G.D.; Dowell, A. The development and exploratory analysis of the Back Pain Attitudes Questionnaire (Back-PAQ). BMJ Open 2014, 4, e005251. [Google Scholar] [CrossRef]
  20. Demoulin, C.; Halleux, V.; Darlow, B.; Martin, E.; Roussel, N.; Humblet, F.; Bornheim, S.; Flynn, D.; Salamun, I.; Renders, P.; et al. Traduction en français du «back pain attitudes questionnaire» et étude de ses qualités métrologiques. Kinésithér. Rev. 2017, 17, 22–23. [Google Scholar] [CrossRef]
  21. Catley, M.J.; O’Connell, N.E.; Moseley, G.L. How good is the neurophysiology of pain questionnaire? A rasch analysis of psychometric properties. J. Pain 2013, 14, 818–827. [Google Scholar] [CrossRef]
  22. Demoulin, C.; Brasseur, P.; Roussel, N.; Brereton, C.; Humblet, F.; Flynn, D.; Van Beveren, J.; Osinsky, T.; Donneau, A.F.; Crielaard, J.M.; et al. Cross-cultural translation, validity, and reliability of the French version of the Neurophysiology of Pain Questionnaire. Physiother. Theory Pract. 2017, 33, 880–887. [Google Scholar] [CrossRef]
  23. Rainville, J.; Carlson, N.; Polatin, P.; Gatchel, R.J.; Indahl, A. Exploration of physicians’ recommendations for activities in chronic low back pain. Spine 2000, 25, 2210–2220. [Google Scholar] [CrossRef] [PubMed]
  24. Beaton, D.E.; Bombardier, C.; Guillemin, F.; Ferraz, M.B. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000, 25, 3186–3191. [Google Scholar] [CrossRef] [PubMed]
  25. Leysen, M.; Nijs, J.; Van Wilgen, P.; Demoulin, C.; Dankaerts, W.; Danneels, L.; Voogt, L.; Köke, A.; Pitance, L.; Roussel, N. Attitudes and beliefs on low back pain in physical therapy education: A cross-sectional study. Braz. J. Phys. Ther. 2021, 25, 319–328. [Google Scholar] [CrossRef]
  26. Bishop, A.; Thomas, E.; Foster, N.E. Health care practitioners’ attitudes and beliefs about low back pain: A systematic search and critical review of available measurement tools. Pain 2007, 132, 91–101. [Google Scholar] [CrossRef]
  27. Moran, R.W.; Rushworth, W.M.; Mason, J. Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners’ attitudes and beliefs toward low back pain: Reliability, convergent validity and survey of New Zealand osteopaths and manipulative physio. Musculoskelet. Sci. Pract. 2017, 32, 44–50. [Google Scholar] [CrossRef] [PubMed]
  28. Moseley, L. Unraveling the barriers to reconceptualization of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. J. Pain 2003, 4, 184–189. [Google Scholar] [CrossRef]
  29. Watson, J.A.; Ryan, C.G.; Cooper, L.; Ellington, D.; Whittle, R.; Lavender, M.; Dixon, J.; Atkinson, G.; Cooper, K.; Martin, D.J. Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J. Pain 2019, 20, 1140.e1–1140.e22. [Google Scholar] [CrossRef]
  30. Jette, D.U.; Ardleigh, K.; Chandler, K.; McShea, L. Decision-Making Ability of Physical Therapists: Physical Therapy Intervention or Medical Referral. Phys. Ther. 2006, 86, 1619–1629. [Google Scholar] [CrossRef]
  31. Leclercq, A.; Gauquier, K.D.; Ceuppens, A.; Boly, J. Consumption of Physiotherapy and Physical and Rehabilitation Medicine in Belgium; KCE: Brussels, Belgium, 2008. [Google Scholar]
  32. Severijns, P.; Denis, C.; Dankaerts, W.; Roussel, N.; Pitance, L.; Timmermans, A.; Marneffe, W.; Luyten, J.; Fourré, A.; Goossens, N. Direct access to physiotherapy for acute low back pain in Belgium: Protocol for a pragmatic pilot trial (The Direct-Physio trial). In Proceedings of the 10th Belgian Back Society Congress, Liège, Belgium, 9–10 December 2022. [Google Scholar]
  33. Ahern, M.; Dean, C.M.; Dear, B.F.; Willcock, S.M.; Hush, J.M. The experiences and needs of people seeking primary care for low-back pain in Australia. Pain Rep. 2019, 4, e756. [Google Scholar] [CrossRef]
  34. Ferreira, P.H.; Ferreira, M.L.; Latimer, J.; Maher, C.G.; Refshauge, K.; Sakamoto, A.; Garofalo, R. Attitudes and beliefs of Brazilian and Australian physiotherapy students towards chronic back pain: A cross-cultural comparison. Physiother. Res. Int. J. Res. Clin. Phys. Ther. 2004, 9, 13–23. [Google Scholar] [CrossRef]
  35. Buchbinder, R.; Jolley, D.; Wyatt, M. Population based intervention to change back pain beliefs and disability: Three part evaluation. Br. Med. J. 2001, 322, 1516–1520. [Google Scholar] [CrossRef]
  36. Fennelly, O.; Desmeules, F.; O’Sullivan, C.; Heneghan, N.R.; Cunningham, C. Advanced musculoskeletal physiotherapy practice: Informing education curricula. Musculoskelet. Sci. Pract. 2020, 48, 102174. [Google Scholar] [CrossRef]
  37. Piano, L.; Maselli, F.; Viceconti, A.; Gianola, S.; Ciuro, A. Direct access to physical therapy for the patient with musculoskeletal disorders, a literature review. J. Phys. Ther. Sci. 2017, 29, 1463–1471. [Google Scholar] [CrossRef]
  38. Simmonds, M.J.; Derghazarian, T.; Vlaeyen, J.W.S. Physiotherapists’ Knowledge, Attitudes, and Intolerance of Uncertainty Influence Decision Making in Low Back Pain. Clin. J. Pain 2012, 28, 467–474. [Google Scholar] [CrossRef]
  39. Hendrick, P.; Mani, R.; Bishop, A.; Milosavljevic, S.; Schneiders, A.G. Therapist knowledge, adherence and use of low back pain guidelines to inform clinical decisions—A national survey of manipulative and sports physiotherapists in New Zealand. Man. Ther. 2013, 18, 136–142. [Google Scholar] [CrossRef] [PubMed]
  40. Synnott, A.; O’Keeffe, M.; Bunzli, S.; Dankaerts, W.; O’Sullivan, P.; O’Sullivan, K. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. J. Physiother. 2015, 61, 68–76. [Google Scholar] [CrossRef]
  41. Zadro, J.R.; Ferreira, G. Has physical therapists’ management of musculoskeletal conditions improved over time? Braz. J. Phys. Ther. 2020, 24, S1413355519310627. [Google Scholar] [CrossRef] [PubMed]
  42. Rufa, A.; Kolber, M.J.; Rodeghero, J.; Cleland, J. The impact of physical therapist attitudes and beliefs on the outcomes of patients with low back pain. Musculoskelet. Sci. Pract. 2021, 55, 102425. [Google Scholar] [CrossRef] [PubMed]
  43. Sieben, J.M.; Vlaeyen, J.W.S.; Portegijs, P.J.M.; Warmenhoven, F.C.; Sint, A.G.; Dautzenberg, N.; Romeijnders, A.; Arntz, A.; Knottnerus, J.A. General practitioners’ treatment orientations towards low back pain: Influence on treatment behaviour and patient outcome. Eur. J. Pain 2009, 13, 412–418. [Google Scholar] [CrossRef]
  44. Darlow, B.; Fullen, B.M.; Dean, S.; Hurley, D.A.; Baxter, G.D.; Dowell, A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review: The association between health care professional attitudes and outcomes of patients with low back pain. Eur. J. Pain 2012, 16, 3–17. [Google Scholar] [CrossRef]
  45. Caneiro, J.P.; Bunzli, S.; O’Sullivan, P. Beliefs about the body and pain: The critical role in musculoskeletal pain management. Braz. J. Phys. Ther. 2020, 25, S141335552030407X. [Google Scholar] [CrossRef]
  46. Rialet-Micoulau, J.; Lucas, V.; Demoulin, C.; Pitance, L. Misconceptions of physical therapists and medical doctors regarding the impact of lifting a light load on low back pain. Braz. J. Phys. Ther. 2022, 26, 100385. [Google Scholar] [CrossRef] [PubMed]
  47. Christe, G.; Nzamba, J.; Desarzens, L.; Leuba, A.; Darlow, B.; Pichonnaz, C. Physiotherapists’ attitudes and beliefs about low back pain influence their clinical decisions and advice. Musculoskelet. Sci. Pract. 2021, 53, 102382. [Google Scholar] [CrossRef] [PubMed]
  48. Krug, R.C.; Caneiro, J.; Ribeiro, D.C.; Darlow, B.; Silva, M.F.; Loss, J.F. Back pain attitudes questionnaire: Cross-cultural adaptation to brazilian-portuguese and measurement properties. Braz. J. Phys. Ther. 2021, 25, 271–280. [Google Scholar] [CrossRef]
  49. Hayden, J.A.; Wilson, M.N.; Riley, R.D.; Iles, R.; Pincus, T.; Ogilvie, R. Individual recovery expectations and prognosis of outcomes in non-specific low back pain: Prognostic factor review. Cochrane Database Syst. Rev. 2019, 11, CD011284. [Google Scholar] [CrossRef] [PubMed]
  50. Meeus, M.; Nijs, J.; Elsemans, K.S.; Truijen, S.; De Meirleir, K. Development and properties of the Dutch neurophysiology of pain test in patients with chronic fatigue syndrome. J. Musculoskelet. Pain 2010, 18, 58–65. [Google Scholar] [CrossRef]
  51. Stern, B.Z.; Howe, T.-H. Hand therapists’ knowledge and practice-related beliefs about pain science: A survey study. J. Hand Ther. 2021, 34, 577–584. [Google Scholar] [CrossRef] [PubMed]
  52. Lane, E.; Magel, J.S.; Thackeray, A.; Greene, T.; Fino, N.F.; Puentedura, E.J.; Louw, A.; Maddox, D.; Fritz, J.M. Effectiveness of training physical therapists in pain neuroscience education for patients with chronic spine pain: A cluster-randomized trial. Pain 2022, 163, 852–860. [Google Scholar] [CrossRef] [PubMed]
  53. Louw, A.; Sluka, K.A.; Nijs, J.; Courtney, C.A.; Zimney, K. Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients, but a Primary Focus for Clinician Education. J. Orthop. Sports Phys. Ther. 2020, 51, 57–59. [Google Scholar] [CrossRef]
  54. Louw, A.; Zimney, K.; Puentedura, E.J.; Diener, I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother. Theory Pract. 2016, 32, 332–355. [Google Scholar] [CrossRef]
  55. Louw, A.; Farrell, K.; Choffin, B.; Foster, B.; Lunde, G.; Snodgrass, M.; Sweet, R.; Weitzel, M.; Wilder, R.; Puentedura, E.J. Immediate effect of pain neuroscience education for recent onset low back pain: An exploratory single arm trial. J. Man. Manip. Ther. 2019, 27, 267–276. [Google Scholar] [CrossRef]
  56. Louw, A.; Diener, I.; Landers, M.R.; Puentedura, E.J. Preoperative Pain Neuroscience Education for Lumbar Radiculopathy: A Multicenter Randomized Controlled Trial With 1-Year Follow-up. Spine 2014, 39, 1449–1457. [Google Scholar] [CrossRef]
  57. Alhowimel, A.; Alodiabi, F.; Alamam, D.; Alotaibi, M.; Fritz, J. Current Understanding of Pain Neurophysiology among Physiotherapists Practicing in Saudi Arabia. Healthcare 2021, 9, 1242. [Google Scholar] [CrossRef] [PubMed]
  58. Adillón, C.; Lozano, È.; Salvat, I. Comparison of pain neurophysiology knowledge among health sciences students: A cross-sectional study. BMC Res. Notes 2015, 8, 592. [Google Scholar] [CrossRef] [PubMed]
  59. Driver, C.; Oprescu, F.; Lovell, G.P. An exploration of physiotherapists’ perceived benefits and barriers towards using psychosocial strategies in their practice. Musculoskelet. Care 2020, 18, 111–121. [Google Scholar] [CrossRef] [PubMed]
  60. Ladeira, C.E. Physical therapy clinical specialization and management of red and yellow flags in patients with low. J. Man. Manip. Ther. 2018, 26, 66–77. [Google Scholar] [CrossRef]
  61. Steen, E.; McCrum, C.; Cairns, M. Physiotherapists’ awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice. Musculoskelet. Care 2021, 19, 306–318. [Google Scholar] [CrossRef]
  62. Almeida, M.; Saragiotto, B.; Richards, B.; Maher, C.G. Primary care management of non-specific low back pain: Key messages from recent clinical guidelines. Med. J. Aust. 2018, 208, 272–275. [Google Scholar] [CrossRef]
Ijerph 20 05611 g001 550
Figure 1. Flow diagram concerning the recruitment of physiotherapists.
Figure 1. Flow diagram concerning the recruitment of physiotherapists.
Ijerph 20 05611 g001
Ijerph 20 05611 g002 550
Figure 2. Boxplots representing the relation of the HC-PAIRS (a), Back-PAQ (b) and NPQ (c) according to self-reported knowledge of the guidelines.
Figure 2. Boxplots representing the relation of the HC-PAIRS (a), Back-PAQ (b) and NPQ (c) according to self-reported knowledge of the guidelines.
Ijerph 20 05611 g002
Table
Table 1. Descriptive statistics for sociodemographic questionnaire results.
Table 1. Descriptive statistics for sociodemographic questionnaire results.
n (%) or Mean (SD)
Number of participantsTotal527100%
Belgium (French-speaking)15028%
Belgium (Dutch-speaking)27753%
France10019%
Age (year)
Age (by group)		 35(11)
22–3230458%
33–4310520%
44–547013%
55–65428%
>6661%
GenderFemale31259%
Male21541%
Years of practice 1211.6
Work setting (multiple answers allowed)Self (alone)16030%
Self (in a group with same profession)23845%
Multidisciplinary10320%
Medical house387%
Clinical workloadHospital10019%
Disability sector194%
50%296%
25%122%
LBP patients per month<515229%
5–10428%
10–1510319%
15–2019337%
>20377%
Self-reported knowledge of the guidelinesYes19737%
Uncertain31259%
No184%
Self-reported application of guidelines in practiceYes16331%
Sometimes32562%
No397%
Table
Table 2. Descriptive statistics for the HC-PAIRS, Back-PAQ and NPQ.
Table 2. Descriptive statistics for the HC-PAIRS, Back-PAQ and NPQ.
nMedian [Q1, Q3]MinimumMaximum
HC-PAIRS (13–91)52742 [36, 48]1369
Back-PAQ (−20–20)52712 [7, 16]−820
NPQ (0–19)52713 [11, 15]019
Table
Table 3. Scores of the Back-PAQ sub-grouped by theme.
Table 3. Scores of the Back-PAQ sub-grouped by theme.
Back-PAQ
Themes		ScoreVulnerability of the BackRelationship between Pain and InjuryActivity Participation While Experiencing Back PainPsychological Influences on RecoveryPrognosis of Back Pain
Score (%)−215.61.40.62.92.9
−119.213.10.74.34.3
07.86.40.88.38.3
116.720.110.144.344.3
240.8598840.140.1
Median [Q1, Q3] 1 [−1, 2]2 [1, 2]2 [2, 2]1 [1, 2]1 [0, 2]
Mean (SD) 0.5 (1.5)1.2 (1.1)1.8 (0.5)1.1 (0.9)1 (1.1)
Table
Table 4. Descriptive statistics for the clinical vignette (non-specific LBP) developed by Rainville [23].
Table 4. Descriptive statistics for the clinical vignette (non-specific LBP) developed by Rainville [23].
ActivityI Would Recommend This Patient to:Scoren (%)WorkI Would Recommend This Patient to:Scoren (%)
Guideline-consistentNot limit any activities179 (15)Guideline-consistentWork full-time at full capacity117 (3)
Avoid only painful activities2324 (61)Work full-time at moderate capacity2179 (34)
Guideline-inconsistentLimit activities to moderate exertion387 (17)Guideline-inconsistentWork full-time at ligth capacity3157 (30)
Limit activities to light exertion437 (7)Work part-time at light capacity4164 (31)
Limit all physical activities50Remain out of work510 (2)
Total527 (100) Total527 (100)
Table
Table 5. Scores of the HC-PAIRS, Back-PAQ and NPQ sub-grouped by the suspicion and detection of a specific cause of LBP.
Table 5. Scores of the HC-PAIRS, Back-PAQ and NPQ sub-grouped by the suspicion and detection of a specific cause of LBP.
Suspicion of a Specific Cause of LBPn (%)HC-PAIRS
Median [Q1, Q3]		Back-PAQ
Median [Q1, Q3]		NPQ
Median [Q1, Q3]
No243 (46)43 [36, 48]12 [7, 15]13 [10, 15]
Yes284 (54)41 [36, 48]13 [7, 16]13 [11, 15]
p = 0.172p = 0.058p = 0.037
Detection of the Specific Cause of LBPn (%)HC-PAIRS
Median [Q1, Q3]		Back-PAQ
Median [Q1, Q3]		NPQ
Median [Q1, Q3]
No369 (70)42 [36, 49]12 [7, 15]12 [10, 15]
Yes158 (30)41 [35, 47]13 [9, 17]14 [11, 15]
p = 0.081p = 0.004p = 0.004
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Fourré, A.; Vanderstraeten, R.; Ris, L.; Bastiaens, H.; Michielsen, J.; Demoulin, C.; Darlow, B.; Roussel, N. Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines? Int. J. Environ. Res. Public Health 2023, 20, 5611. https://doi.org/10.3390/ijerph20095611

AMA Style

Fourré A, Vanderstraeten R, Ris L, Bastiaens H, Michielsen J, Demoulin C, Darlow B, Roussel N. Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines? International Journal of Environmental Research and Public Health. 2023; 20(9):5611. https://doi.org/10.3390/ijerph20095611

Chicago/Turabian Style

Fourré, Antoine, Rob Vanderstraeten, Laurence Ris, Hilde Bastiaens, Jozef Michielsen, Christophe Demoulin, Ben Darlow, and Nathalie Roussel. 2023. "Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?" International Journal of Environmental Research and Public Health 20, no. 9: 5611. https://doi.org/10.3390/ijerph20095611

APA Style

Fourré, A., Vanderstraeten, R., Ris, L., Bastiaens, H., Michielsen, J., Demoulin, C., Darlow, B., & Roussel, N. (2023). Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines? International Journal of Environmental Research and Public Health, 20(9), 5611. https://doi.org/10.3390/ijerph20095611

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