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Physical Therapy and Manual Physical Therapy for Patients with Non-Specific Low-Back Pain: Differences in Patient Characteristics with Implications for Diagnostic Classification

Rob A. B. Oostendorp, PhD, PT, MT
Lonneke M. van Berkel, MSc, PT
C. D. Dorine van Ravensberg, PhD
Gwendolijne G. M. Scholten-Peeters, PhD, PT, MT
Jan J.M. Pool, BSc, PT, MT
Raymond A. H. M. Swinkels, PhD, PT, MT
Peter A. Huijbregts, PT, DPT, FAAOMPT, FCAMT

Abstract: A previous study compared socio-demographic characteristics, health problem characteristics, and primary process data between a database sample of patients referred to physical therapy (PT) versus a sample of patients referred for specific manual physical therapy (MPT) diagnosis and management. This study did not differentiate between patients based on affected body region or diagnosis. The present study is a secondary analysis of these data for patients with non-specific low-back pain (LBP). Statistical analysis indicated that the MPT patient sample was significantly (P<0.01) different from the PT database sample with regard to socio-demographic data: The MPT patients were more often male, younger, had attained a higher level of post-secondary education, and were more often gainfully employed. The MPT sample was also significantly (P<0.01) different from the PT sample with regard to health problem characteristics indicating more often acute, recurrent, non-surgical LBP of shorter duration and unknown etiology in the MPT sample. Both samples were also significantly different with regard to the most common impairments, limitations in activities, and restrictions in participation. After correction for socio-demographic differences, both samples remained significantly different for pathology, recurrence, and mechanism of injury. Diagnosis and management with MPT resulted in a significantly better outcome at discharge than PT as determined by the therapist based on patient verbal report (P=0.0000); however, data on recurrence and the unclear influence of socio-demographic data as well as the absence of more reliable, valid, and responsive outcome measures render these outcome data somewhat equivocal. Interpretation of these data with regard to their potential use in diagnostic classification of patients with non-specific LBP is discussed.

Key Words: Manual Physical Therapy, Physical Therapy, Non-Specific Low Back Pain, Patient Characteristics, Diagnostic Classification

In the Netherlands as in other parts of the world, non-specific low-back pain (LBP) is a health problem responsible for high health care and wage substitution costs1. Physical therapy (PT) ranks among the more prominent interventions used for this patient group.

In an earlier article2, we discussed how manual therapy interventions have been an inextricable part of PT prac- tice since the very beginning of the profession, and we explained their justifiable continued inclusion in the PT scope of practice. Internationally, manual physical therapy (MPT) is integrated firmly within the profession as a whole and, for example, in the United States, entry-level education has over the years placed an increasing emphasis on MPT curricular content including thrust techniques3-6.

In the Netherlands, physical therapists use thrust and non-thrust manual interventions at a high frequency in clinical practice7. However, the MPT education and reimbursement situation is unique as compared to other countries: in the Netherlands, entry-level PT education deals almost entirely with non-thrust manual techniques and MPT is considered a clinical specialization within PT. To become a registered manual therapist, one has to successfully complete one of five available post-graduate diploma or professional Master’s degree programs conforming to IFOMT standards8. Registered manual therapists then enter into capitated care contracts with insurance providers separate from and at a higher reimbursement rate than non-registered colleagues. This unique position for MPT in the Netherlands has led to separate professional profiles defining a distinct PT and MPT scope of practice9-10 and even separate clinical practice guidelines for PT and MPT diagnosis and management of patients with non-specific LBP11-15.

With regard to the management of patients with LBP, it has been argued that absence of patient classification other than an all-encompassing category of non-specific LBP results in heterogenous populations that preclude the therapist picking up on a real and present effect when studying specific therapeutic interventions16. The identification of diagnostic subgroups using a treatment-based diagnostic classification model has the potential for greater treatment efficacy. Recent research has resulted in clinical prediction rules predicting the likelihood of a positive outcome with thrust manipulation and stabilization for specific subgroups of patients with non-specific LBP17-20. One could argue as to whether the sharp delineation between PT and MPT as exists in the Netherlands is a natural or desirable situation. However, it does provide us with a unique avenue to study sociodemographic and health problem characteristics that may serve as predictive variables that may prove helpful in the identification of diagnostic subgroups from the larger population of patients with non-specific LBP.

In our attempt to identify a subgroup of patients with non-specific LBP who might benefit more from a MPT than a PT referral, we collected data on socio-demographic, health problem, and primary process characteristics for 1,198 MPT-patients2. This article discusses the secondary analysis of these data collected for a subgroup of 381 patients with non-specific LBP (32% of the total population of 1,198) referred to MPT. This secondary analysis means to answer the following questions:

  1. What is the distribution of patients referred to MPT for LBP with regard to socio-demographic characteristics, health problem characteristics, and primary process data?
  2. Is there a difference in socio-demographic characteristics between patients with LBP referred to MPT versus PT?
  3. If so, is the distribution of patients referred to MPT versus PT different with regard to health problemcharacteristics after correction for the differences in socio-demographic characteristics?
  4. Can the data collected be used in the identification of a diagnostic subgroup of patients with non-specific LBP that may benefit more from specific MPT diagnosis and management?

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