Physiotherapy for Low Back Pain Clients in Direct Access Practice: Competences and Implementations

Abstract

Although previous research conducted in Finland and other countries has shown direct access in physiotherapy to be an important method in preventing the recurrence of low back pain (LBP), data are still lacking on the level of required competences of physiotherapists, suitable classifications of LBP and the implementation of direct access practice after a continuing education program for physiotherapists. The purpose of this study was to examine two areas: physiotherapists’ core competences in direct access practice for LBP clients in the early phase of pain using tissue-structural classification, and the implementation of this practice after a continuing education program with clients’ and physiotherapists’ experiences. Participants consisted of 34 physiotherapists and 80 low back pain clients from public health care organizations in southern Finland. Data were collected from questionnaires, interviews and by physiotherapists’ reports of their clients. Both quantitative and qualitative methods were used when analyzing the data. The results showed that the physiotherapists’ core competences of clinical reasoning and critical reflection were on a good level when used with tissue-structural classification and the hypothetico-deductive method in the assessment of low back pain clients. Physiotherapists made constantly accurate diagnostic subgroups for their LBP clients. The agreement percentage between the physiotherapists and two reviewers was 74% (kappa 0.63; 95% CI, 0.47 to 0.77). Physiotherapists also analyzed their clinical reasoning systematically from their clients’ history to their choice of clinical tests and conclusions. They were able to justify their manual skills and the adequacy of the LBP classification in use and suggest other alternatives for their performance. Most of the clients (80%) were satisfied with the implementation of direct access physiotherapy in the early visit to a physiotherapist and with the information and advice they received. Three months after the physiotherapy visit, repeat visits were on a low level and only one of the employed people was on sick leave. The physiotherapists reported having felt their work to be meaningful which, according to a qualitative analysis, was connected with client satisfaction, reasonable division of labor, cooperation with their co-workers and an increase in professional appreciation. This research demonstrates the benefits, as outlined by clients and physiotherapists, of direct access to physiotherapy in the early phase of LBP as well as the use of tissue-structural classification (nociceptive pain mechanism) as one of the classifications in this stage. Clinical reasoning and critical reflection competences in the assessment of clients were shown to be important during the subclassification of LBP clients and during the evaluation of physiotherapists’ own performance. Continuing learning of these competences should also be included in education programs. The results of this research can be utilized in physiotherapists’ direct access practice as well as when planning the content of the education program for the practice.