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- Widerström, Birgitta
(författare)
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A treatment-strategy-based classification system for decision-making in patients with low-back pain : a biomedical approach: development and inter-examiner reliability
- 2012
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Low-back pain (LBP) is a common, disabling and costly disorder and its treatment includes a range of interventions. Increased demands are put on effective care and rehabilitation offered to this population. Despite extensive research and sophisticated investigation methods, knowledge of the exact origin of LBP is limited and consequently approximately 80% of cases are classified as non-specific. To identify subgroups among these is therefore a priority research task. Physiotherapists can, through a careful patient interview and physical examination, distinguish different clinical presentations, classify these and then decide on appropriate treatment strategies. Aim: The main purpose of this thesis was to develop and examine the inter-examiner reliability of a new treatment-strategy-based classification system for clinical decision- making in low-back pain patients in primary health care. In Study I clinical data were collected for the classification system when 16 patients with low-back pain were examined, classified into four different treatment strategies- pain modulation, stabilisation exercise, mobilisation, and training - and treated according to one of these. The clinical examination and differences in specific clinical signs and symptoms were analysed and resulted in a classification algorithm, in which the classification process can be followed. All treatment was individualised. A progressive treatment flow towards increased physical loading and function as the clinical status improved was reported. In Study II the inter-examiner reliability (agreement) of this classification algorithm was investigated. Two pairs of experienced physiotherapists trained in Orthopaedic manual therapy (OMT), with no previous experience of the classification system, examined and classified 64 adult patients with low- back pain. The agreement in their judgments was compared by calculating raw agreement (%) and the kappa coefficient (κ). Further, inter-examiner reliability was examined for five selected clinical signs and symptoms (examination items), identified as important for classification. Agreement was substantial (80%, κ = 0.72) when the two pairs classified patients into one of the four classifications. Agreement on the five specific clinical signs and symptoms was diverse. The assessments of neurological signs and symptoms had almost perfect agreement (92%, κ= 0.84), while those for irritability and uni-or bilateral signs were moderate (82%, κ= 0.41 and 62%, κ= 0.42, respectively). For the identification of a specific movement pattern and specific segmental signs the agreement was fair (68% κ=0.38 and 67%, κ= 0.28, respectively). Conclusion: The two studies in this thesis have presented and examined the inter- examiner reliability of a new treatment-strategy-based classification system for decision-making in patients with low-back pain, in primary health care. A classification algorithm where the differences in clinical status are described, and a progressive treatment flowchart, have been presented. The new classification system and three of its examination items can readily and reliably be used by experienced OMT-trained physiotherapists in primary care. The two examination items that had low agreement should be revised or clarified before future use in the classification system.
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| 2. |
- Widerström, Birgitta
(författare)
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Clinical decision-making in physiotherapy for low back pain in primary health care
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and Aims: Low-back pain (LBP) is a complex and heterogeneous disorder commonly encountered at physiotherapy clinics, with most cases associated with an unknown cause (NSLBP). Identifying LBP subgroups for targeted treatment has been highlighted as a priority research task. It is unclear how various physiotherapy treatment options are selected and matched to patients with nonspecific low back pain (NSLBP) in primary healthcare. The main purpose of this thesis was to explore physiotherapists’ clinical decision-making in LBP, through the development and evaluation of a new decision-making treatment-strategy-based classification system (TREST) and through interviews with clinical physiotherapists (PTs) in primary healthcare. Designs and participants: This thesis is based on four studies with divers designs. Study I, a multicase study with descriptive and pre-post-test experimental design, included one single physiotherapist and 16 patients with NSLBP and presents and describes a treatment-strategy-based classification (TREST) process. Study II investigates inter-examiner agreement between 4 experienced and Orthopaedic Manual Therapy (OMT) trained PTs (2 pairs) on the categorization of 64 patients with NSLBP to TREST subgroups and on 5 of its suggested subgroup criteria. Study III employs secondary logistic multiple regression analyses of the 128-examination data collected in Study II to examine the feasibility of subgroup criteria included in TREST. Study IV is a qualitative descriptive study exploring clinical reasoning in the decision-making and treatment of NSLBP in primary healthcare, through semi-structured interviews with 15 clinical PTs care in two different regions in Sweden. Results: Study I describes the categorization of NSLBP into one of four treatment-based subgroups: pain modulation, stabilization exercise, mobilization, and training and the criteria for each subgroup. Study II shows substantial chance corrected inter-examiner agreement for the categorization to subgroups, whereas agreement on suggested criteria varied from fair (specific segmental signs, specific movement pattern) and moderate (uni-bilateral spinal signs, irritability), to almost perfect (neurological signs and symptoms). Study III identifies how the individual PTs applied criteria in the subgroup categorization and support feasibility of criteria: the presence or absence of neurological signs and symptoms, bilateral spinal signs and segmental signs as well as level of irritability and disability, in the categorization of NSLBP. In Study IV, decision-making was influenced by working approach at workplaces and healthcare priorities, disorder categorization and bodily examination findings, patients’ capabilities and participation and physiotherapists’ convictions and terms as well as their confidence in treatment and themselves, while insufficiency limited their decision-making. Treatment focuses on patient education and physical exercise as well as combining treatments and treating with atypical goals. Conclusion: TREST can be reliably used by experienced OMT trained physiotherapists to categorize NSLBP to subgroups and inter-examiner agreement was moderate to almost perfect from three out of five examination items. Feasibility are supported for TREST subgroup criteria: neurological signs and symptoms; bilateral spinal signs; segmental signs; as well as level of irritability and disability. Decision-making was influenced by external circumstances (workplace and healthcare priorities), the disorder (categorization and bodily examination findings), patients (capabilities and participation), physiotherapists (personal convictions and terms, confidence in treatments and themselves, while insufficiency limited their decision-making). Treatment focuses on patient education, physical exercise and combined treatments.
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| 3. |
- Widerström, Birgitta, et al.
(författare)
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“How does physical examination findings influence physiotherapists’ decision-making when matching treatment to patients with low back pain?”
- 2021
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Ingår i: Musculoskeletal Science and Practice. - : Elsevier. - 2468-8630 .- 2468-7812. ; 53
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Tidskriftsartikel (refereegranskat)abstract
- Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. Objective: The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. Design: This was an exploratory interview study using inductive content analysis. Method: Fifteen semi-structured individual interviews were used to collect data of physiotherapists’ treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. Findings: Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). Conclusion: This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.
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