Manual Therapy 18 (2013) 438e442

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Manual Therapy
journal homepage: www.elsevier.com/math

Professional issue

Complexity in the physiotherapy management of low back disorders:

Clinical and research implications
Jon Joseph Ford*, Andrew John Hahne 1
Low Back Research Team, Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria 3085, Australia

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 20 November 2012
Received in revised form
17 January 2013
Accepted 18 January 2013

Over the past decade a wide variety of approaches for the management of low back disorders (LBD) have
been developed and evaluated in clinical trials. As a consequence physiotherapists and researchers
interested in LBD are faced with a range of issues to do with complexity. These issues will be explored
and suggestions made to improve the delivery of high quality research evidence and better patient
outcomes.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Back pain
Treatment
Classication
Randomised controlled trial

1. Introduction
Physiotherapists are an important service provider in the
management of LBD. Presumably physiotherapists have a belief
that their treatment is effective but this contention is not strongly
supported by the research literature (Koes et al., 2010). This paper
aims to explore the impact of complexity on the physiotherapy
management of LBD from a clinical and research perspective.

2. Complexity in clinical and research practice

Inherent in the large repository of clinical knowledge and
associated methods for managing LBD (Koes et al., 2010; Delitto
et al., 2012) is complexity. For example, 122 hours of postgraduate training is recommended to attain prociency in the
McKenzie method (The McKenzie Institute Australia, 2012). Basic
application of the Maitland style of manual therapy (Jones and
Rivett, 2004; Maitland et al., 2005) is also a complex task requiring:

A conceptual understanding and ability to practically apply
hypothetico-deductive reasoning

Knowledge and practical skills to perform a large number of
clinical techniques
* Corresponding author. Tel.: 61 3 5989 6331; fax: 61 3 9479 5768.
E-mail addresses: j.ford@latrobe.edu.au (J.J. Ford), a.hahne@latrobe.edu.au
(A.J. Hahne).
1
Tel.: 61 3 9479 5801; fax: 61 3 9479 5768.
1356-689X/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2013.01.007

An understanding of complex concepts such as movement diagrams and grades of motion

An ability to identify the relationship between symptoms when
different techniques are applied

A signicant degree of measurement rigour in reassessing the
effect of treatment
Physiotherapists who use methods such as the McKenzie and
Maitland approaches (Foster et al., 1999; Jackson, 2001; Li and
Bombardier, 2001; Gracey et al., 2002; Byrne et al., 2005) face
further complexity when considering the inuence of a range of
additional relevant factors. To this end pathoanatomical, impairment, psychosocial, neurophysiological and genetic factors (Ford
et al., 2007; OSullivan, 2012) as well as the patients perspective
(Jones and Rivett, 2004) all need consideration.
Given this complexity it is not surprising that a large number of
variable and somewhat mutually exclusive management methods
for LBD have been developed. Recent reviews of the classication
literature show over 80 different subgrouping systems (Ford et al.,
2007; Fairbank et al., 2011; Karayannis et al., 2012). There are some
commonalities between the classication approaches of McKenzie
and May (2003), Petersen et al. (2003) and the authors group (Ford
et al., 2011a) as well as between the methods of OSullivan (2005)
and Sahrmann (2002). However, there is less overlap between
many other classication approaches including recent recommendations from Fritz et al. (2007), the Start Back group (Hill et al., 2011)
and psychological based classications (Bergstrom et al., 2012). An
even wider array of treatment approaches have been described in the

J.J. Ford, A.J. Hahne / Manual Therapy 18 (2013) 438e442

RCT literature. In the authors recently published systematic reviews

41 conservative treatment types attempting to specically target
a LBD subgroup were identied (Hahne et al., 2010; Slater et al., 2012;
Surkitt et al., 2012; Richards et al., in press). The number of treatment
types in randomised controlled trials (RCT) investigating nonspecic treatment is likely to be far greater.
Large surveys show that this variability in classication and
treatment methods observed in the research literature is also
present in clinical practice (Jackson, 2001; Kent and Keating, 2005;
Spoto and Collins, 2008; Liddle et al., 2009). In theory clinical
reasoning is a strategy of value in interpreting and processing large
amounts of theoretical and clinical information into effective
treatment planning (Jones and Rivett, 2004). However, a range of
clinical reasoning approaches are used by physiotherapists (Jones
and Rivett, 2004) which are in themselves complex to apply and
challenging to learn, particularly for novice practitioners (Gobet
and Borg, 2011; Davies and Howell, 2012).
3. Physiotherapy for low back disorders e craft or profession?
The authors propose that complexity has had an impact on
external perceptions and internal realities regarding the nature of
physiotherapy and in particular manual therapy for LBD. Sections of
the medical community (Bogduk, 1996; Buchbinder, 2009) have
described physiotherapists practicing manual therapy as a craft
group dened as an occupation involving skill in making things (in
this case treating patients) by hand (Oxford Dictionaries, 2012). This
view contrasts starkly with common descriptions of physiotherapy as
a professional group founded on evidence-based principles (American
Physical Therapy Association, 2001; Herbert et al., 2005; Delitto et al.,
2012; Little and Davenport, 2012). An evidence-based approach encompasses integration of the best available evidence, clinical expertise
and patient values with regards to clinical decision making (Sackett
et al., 2000). Within the context of complexity, the question of physiotherapy as a craft or professional group warrants exploration.
Physiotherapists are potentially unique in their capacity to
manage LBD by combining high level theoretical knowledge and
manual skills within a biopsychosocial context (American Physical
Therapy Association, 2001). However there is large variability in
manual therapy standards in clinical practice (Boissonnault and
Bryan, 2005; Sizer et al., 2007; Davies and Howell, 2012) despite
efforts to develop recognised minimal competency levels
(International Federation of Orthopaedic Manipulative Physical
Therapists, 2008). Some developers of methods for managing LBD
have demonstrated a selective engagement with the evidence base.
An example of this is the recent trend of excluding pathoanatomical
factors from clinical protocols for LBD (Sahrmann, 2002; Fritz et al.,
2007; Macedo et al., 2010) despite a likelihood that concepts such
as tissue healing are important for developing effective treatment
(Adams et al., 2010; Hancock et al., 2011; Ford and Hahne, 2012).
Similar themes are evident in classication systems not accounting
for psychosocial and/or neurophysiological factors (Ford et al.,

439

2007; Fersum et al., 2010). Others have expressed strong reservations on the value of randomised controlled trials for evaluating
effectiveness of treatments (Clemence, 1998; Downing and Hunter,
2003; Milanese, 2011). These examples, in addition to the variable
and poorly integrated knowledge base already described, are
incongruent with professional group status as depicted in Fig. 1.
Such considerations may not sit comfortably for many physiotherapists who pride themselves on providing the highest quality of
care. Indeed, these comments on craft group status cannot be
broadly applied as different physiotherapists from different jurisdictions are likely to rate differently on the craft versus professional
group continuum (Boissonnault and Bryan, 2005; Sizer et al., 2007).
However, physiotherapists should be aware of the potential impact
of certain behaviours on shaping the external perception and internal reality of the profession (Jette, 2012).
It is the authors view that behaviours by some physiotherapists
and researchers tending towards craft group status are strongly
driven by the complexity of LBD. Predominantly this appears to
relate to the difculties in systematically identifying, interpreting
and integrating all relevant research and clinical knowledge as well
as a disconnect between clinicians and researchers around the
world. Therefore, a major challenge for the profession is to respond
in a coherent and integrated manner to positively deal with the
issue of LBD complexity.
4. Clinical practice implications
The authors believe physiotherapists should be cognizant of the
impact of complexity on clinical practice and resolute in aiming to
adhere to professional group standards. Suggestions to assist this
process include practitioners:

Establishing a sound foundation of knowledge and minimum
level practical skills across the range of commonly used LBD
management methods (e.g. Maitland and McKenzie methods)

Extending this foundation to incorporate the assessment and
appropriate management of the multiple dimensions relevant
to LBD (e.g. pathoanatomical, impairment, psychosocial, neurophysiological and genetic factors) as well as the patients
perspective

Appreciating the importance of a systematic approach to
organising complex bodies of knowledge (Jette, 2012) and
engaging with reasonable attempts to do so (Delitto et al., 2012)

Integrating new innovations for managing LBP with the practitioners existing knowledge and skill foundation rather than
substituting old for new

Purposeful endeavour in the clinic to improve clinical reasoning skills as a means of dealing with complexity (Jones and
Rivett, 2004; Davies and Howell, 2012)

Carefully considering the best available evidence (from all
types of research, not just RCT) in the context of the practitioners clinical experience and the patients perspective

Fig. 1. The continuum between craft and professional group status.

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In dealing with the complexity of LBD, the experience of the

authors is that practitioners, particularly those with less experience, appreciate and benet from structured and systematic clinical
mentoring (Ford et al., 2011a, 2011b, 2012a, 2012b). This approach
sets a level of minimum competency that can then be further
developed independently and includes:

The use of thorough and systematic assessment templates and
tools supported by a multi-dimensional classication system

Detailed clinical protocols outlining the necessary requirements of LBD management methods

Clinical decision making algorithms to assist in tailoring of
treatment to the patient (Helmhout et al., 2008; Foster and
Delitto, 2011) thereby avoiding a one size ts all approach

Formal clinical mentoring with regular review of patient
progress and practitioner feedback
Research has demonstrated the difculty in engaging practitioners
with evidence-based practice (Stevenson et al., 2006). The experience
of the authors is that structured clinical mentoring utilising a systematic method of knowledge organisation is an effective method of
changing practitioner behaviour in accordance with the evidence.
5. Research implications e the importance of classication
The issue of LBD complexity has signicant research implications. A pragmatic approach to RCT design favours choices that
maximise applicability of results to the real world. As such minimal restriction is placed on participant eligibility or prescriptive
operationalisation of the treatment applied (van der Windt et al.,
2008; Zwarenstein et al., 2008). In an ideal world where a pragmatic RCT demonstrates treatment effectiveness, issues of complexity can be considered as irrelevant, and broadly applicable
clinical recommendations can be made (van der Windt et al., 2008).
Pragmatic designs are commonly used in RCT for LBD but the results have not found evidence supporting the effectiveness of
physiotherapy (van der Windt et al., 2008).
Many have postulated that the complexity of LBP needs to be
accounted for in RCT by improved subgrouping or classication (Ford
et al., 2007; Fairbank et al., 2011; Karayannis et al., 2012). Sample
heterogeneity can diminish the chance of nding a signicant
treatment effect due to the reduced proportion of the sample for
which the treatment is appropriate. Recruiting participants that
belong to a homogenous subgroup who receive matched and specic
treatment is more likely to demonstrate effectiveness due in part to
a reduction in the clinical complexity the practitioner has to address.
Over the last decade a number of classication based trials have
been published, although to date the results have been mixed
(Slater et al., 2012; Surkitt et al., 2012). Given the number of classication and treatment approaches available for physiotherapists,
informed decisions must be made regarding further research in this
area. Data from a range of surveys suggest that physiotherapists
most commonly employ manual therapy, the McKenzie approach
and motor control retraining when treating LBD (Foster et al., 1999;
Jackson, 2001; Li and Bombardier, 2001; Gracey et al., 2002; Byrne
et al., 2005). Despite the publication of hundreds of RCT to date,
these popular methods of managing LBD have not been adequately
evaluated for efcacy in a manner consistent with clinical practice
and in accordance with classication principles (Slater et al., 2012;
Surkitt et al., 2012; Ford et al., 2012b). An additional consideration
is the fact that most clinicians incorporate a variety of methods
when managing LBD. Clinical trials need to reect this complexity
by evaluating multi-modal management approaches, despite the
potential limitations in not being able to attribute effect to one
specic treatment component (Jull and Moore, 2010). Once

evidence of effectiveness is identied, specic components of the

management method can be subsequently evaluated in new RCT.
Prioritising the validation of commonly used classication and
specic treatment methods does not negate the necessity for
clinical trials on emerging approaches for LBD. However, it does
provide a focus that maximises the capacity of the physiotherapy
profession to successfully build upon the existing knowledge
foundation using evidence-based principles.
6. Research implications e treatment integrity
Treatment integrity refers to the degree in which an intervention is
delivered as intended. Even with signicant training, treatment
integrity in RCT can vary substantially particularly if the treatment is
complex to administer (Borrelli et al., 2005; Helmhout et al., 2008; van
der Windt et al., 2008). Low treatment integrity increases the risk of
false conclusions being drawn regarding effectiveness due to the
treatment being inadequately applied to participants. A variety of
methods to improve treatment integrity have been described and
should be carefully considered during RCT planning (Borrelli et al.,
2005; van der Windt et al., 2008). These methods, particularly when
combined with classication principles, enable complex management
methods to be appropriately evaluated in an RCT setting.
Treatment design considerations necessitate a clearly dened
theoretical model with associated practical detail described in
clinical manuals (Craig et al., 2008; Helmhout et al., 2008; Foster
and Delitto, 2011). Expert practitioners should develop these.
Algorithmic approaches to clinical decision making should also be
used to maximise specicity and adaptability of the clinical protocol to participant presentation (Milanese, 2011). In the authors
recent RCT (Hahne et al., 2011) the use of session by session,
structured clinical notes with specic cuing regarding algorithmic
assessment and treatment process was a helpful strategy. Detailed
information sheets were also valuable, as the process of explaining
these resources to the participant reinforced critical treatment
components in the physiotherapists own mind.
Training of practitioners is an important component to treatment
integrity and should be of an appropriate duration for the complexity of the intervention being evaluated. For example, the physiotherapists in the Start Back trial (Hill et al., 2011) received nine days
of training in order to be competent in providing psychologically
informed physiotherapy to participants at high risk of a poor outcome. The training included teacher lead sessions, group discussion,
role play and interviewing of simulated patients (Main et al., 2012).
Delivery of treatment should be an audited process with constructive feedback provided to the trial physiotherapists. In a trial
completed by the authors this feedback was provided at weeks
three and seven of a 10 week program and also used monthly telephone hook ups to discuss difcult cases (Hahne et al., 2011).
Evaluation of treatment integrity at the participant level can also be
a useful strategy (Borrelli et al., 2005).
7. Research benets of classication and treatment integrity
measures
The issues associated with the complexity of LBD can be substantively ameliorated in RCT that recruit homogenous LBD subgroups, apply a matched and specic treatment and employ
adequate treatment integrity measures. In such trials, the likelihood
of the trial demonstrating results favouring physiotherapy treatment
is increased. Robust classication and treatment integrity measures
also enable other researchers to more precisely replicate trials with
positive ndings. A more detailed description of classication and
treatment procedures reduces the risk of systematic reviews erroneously pooling the results of clinically heterogeneous RCT for the

J.J. Ford, A.J. Hahne / Manual Therapy 18 (2013) 438e442

purposes of meta-analysis. Finally, these measures allow clinicians to

more easily interpret and replicate the management approach
thereby improving engagement with evidence-based practice and
translation of results to the clinical setting. However, despite these
benets, few RCT or systematic reviews have adequately addressed
classication and treatment integrity issues (Hahne et al., 2010;
Slater et al., 2012; Surkitt et al., 2012; Richards et al., 2012).
8. Conclusion
Physiotherapists working clinically and in research settings as
well as the profession as a whole should be aware of the challenges
LBD complexity brings to an evidence-based approach. The recommendations of this paper should assist clinicians and researchers in collaboratively working to overcome complexity issues
and deliver high quality research evidence and better patient
outcomes.
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