Chronic Low Back Pain and Yellow Flags: Interview Results; Why, How and What Physiotherapists Do

Below are the results of my MSc research in to how different physiotherapists manage chronic low back pain patients with yellow flags. I’ve spared you the details of the methodology but if a few people are interested I will share them as well. Essentially I conducted interviews with six different physiotherapists on how they would manage a chronic low back pain patient with yellow flags using a vignette. These interviews were transcribed and analysed and the results are below.



The theoretical, selective and open codes were organised in to a coding tree as shown in appendix 8 (which I can send you if interested it, it is not below). The integrative diagram in figure 6.1 helped to organise some of the codes, and understand their role in what is done with patients.

Why, how what

Figure 6.1: A grounded theory of why, how and what physiotherapists do to help a typical CLBP patient with yellow flags

The analysis produced the grounded theory;

Physiotherapists seek to help CLBP patients with yellow flags for altruistic and egotistic reasons, by establishing what they feel is technically best for the patient and working out how to get the patient to do that. What they do with patients relies on “Sackettian” reasoning, paradigm-based approaches, sub-classification, clinical auditing, graded exposure, education, and an uneasy relationships with manual therapy.

6.1 Help the patient

In looking at how and why clinicians choose to do what they do with patients the central theme that emerged was that everything appeared to be for the good of the patient. Some clinicians used language that suggested a strong empathy to help the patient, others a professional pride in getting the best results and others competitiveness with colleagues. For example the first two open codes to be identified in interview 1 were empathy and understanding. It became clear from the non-verbal clues in particular that this was a genuine interest in the patient as opposed to a superficial interest. Then in subsequent interviews it became clear physiotherapists would avoid giving certain questionnaires, as they did not want to burden patients. Interview 5 stated he would go to the gym with patients to get them started on an exercise programme. Furthermore KM’s interview notes stated on several occasions that there were genuine signs of caring for the patient in the vignette, such as appearing to wince when discussing the patient’s symptoms and changes in tonality and pace of speech, which suggested caring. There was a clear altruistic drive.

The other codes that developed highlight some of the reasons physiotherapists continue to practice. All therapists indicated a confidence in being able to help the patient. Confidence was one of the earliest open codes to emerge. For example phrases like the below were used.

Interviewee 1: “I would be confident I can help”

Interviewee 1: “I would expect progress in 1-2 sessions”

Interviewee 2: “You think that you would be 80-90% certain you could sort this”

Interviewee 4: “I get results”

The interviewees were so confident that only one even mentioned the possibility of referring to another healthcare professional and this was only if the patient did not follow what they suggested. Suggesting that even this physiotherapist felt he was able to help the patient. Generally this confidence was associated with a professional pride, with two of the interviews generating the open code confidence coming from a place of doubting the patient. Their primary aim was to help the patient to get results but they felt that the patient’s feedback could be a barrier to this and that their own approach could avoid potential misdirection from the patient’s feedback. Yet the approach came from a position of care for the patient. For example interview 6 generated the open code “treatment independent of patient” based on the description of this concept as shown below.

Interviewee 6: It is quicker for me to find out from the patient’s objective signs, if this is a good movement or not. Then I don’t even really need the patient to tell me if they feel better or not.

One particular interviewee would often start sentences by highlighting common mistakes other therapists make. Initially this was not coded for specifically but on re-analysis it was a key feature in the communication.

Interview 5: It’s one of the naïve things, that people who have had slight contact with the subgrouping approach would almost certainly put him in the flexion category, because he says he’s got pain on sitting.

Interview 5: I think it can be a trap to fall into, particularly with patients who may present with yellow flags, of thinking, “I have all this pain science information in my brain. I must insert it into your brain, and you must understand it”, and going down that route.

This was initially coded as “derision of colleagues” and later as “professional competitiveness”. On re-analysing the other transcripts this element came through in all the interviews to a degree. So much so that it may be that being professionally competitive, achieving professional competitive success and helping patients others cannot, may be part of the egotistic, for the self, motivation for these physiotherapists in helping the patient.

Two key theoretical codes explain how physiotherapists chose to do what they did with the patient in the vignette; what’s technically best for the patient, and, helping the patient to do what’s technically best.

6.2 What is technically best for the patient

what is technically best for the patient

Figure 6.2 How physiotherapists decided what was best and what they would do

In order to help the patient as best they could, whatever the motivation, the physiotherapists would strive through their assessment to establish what was technically best for the patient as show integrative diagram in figure 6.2. Given the breadth of approaches covered there were significant differences in how each physiotherapist would manage the patient, these differences were driven by the different paradigms the therapists had as the reasoning processes were broadly very similar. Yet despite the differences in paradigms the approach used was very similar when the analysis was taken to a partial level of abstraction.

All therapists had their own paradigms. These varied broadly around the areas for which they were selected purposively, but all interviewees considered multiple approaches. The physiotherapist purposively sampled for using Sahrmann approach commented on using various different exercise methodologies, Stuart McGill’s work, Diane Lee and Lind-Joy Lee’s work, McKenzie’s work, Mulligan’s and Maitlands. This was typical of the interviewees and highlights that whilst each had their own paradigms these were generally very broad. Interestingly their entire approaches appeared to emerge from these paradigms. So whilst all interviewees said they would use education, their descriptions were based within their own paradigms. For example those with more of a biomechanics leaning would talk of explaining the biomechanics to the patient. In contrast, interview 2 used the concept of finding the “primary driver” to help explain what was causing the patient’s symptoms and how this could be improved. Furthermore, one clinician went so far as to refer almost all questions around clinical reasoning to patient individuality. Using phrases like,

Interviewee 1: It just depends on the patient

Interviewee 1: All patients are different

Further within education all interviewees specified the importance of some form re-assurance. Again this would always be explained with their paradigms. Interestingly whilst interviewees described varying language to suit patients they very much stuck to their own paradigms in education.

The clinical reasoning behind the choices came down to four key factors, the patients presentation, trial based evidence, experience, and expert opinion as shown in the integrative diagram in figure 6.3.

Sacketian reasoning

Figure 6.3 “Sackettian reasoning”

The emphasis between these varied between interviewees. It was clear that all were keen to highlight they were “evidence-based” practitioners, although the transcripts suggest they were using more experience and expert opinion in clinical reasoning than would be fit with current definitions of evidence based practice. Thus this was coded as “Sackettian” reasoning, as KM felt it represented a transitioning from expert opinion based medicine towards the evidence based medicine paradigm (Smith and Rennie 2014).

Memo 14th September

The interviewees so far are very keen to appear evidence-based. Yet there are references to expert opinion and this appears to be forming a fourth component to Sackett’s description.

At first look the different approaches would manage the patient in the vignette in divergent ways. For example interview 2, outlined a detailed approach to exercise selection, while interview 4 suggested all exercises were broadly similar and interview 6 suggested exercises should be based around movements done during infant development. However, with a level of abstraction it was clear all interviewees were describing a graded approach to exercise as outlined within the integrative diagram in figure 6.4.

what physiotherapists do to help the patient

Figure 6.4 Outline of “what” physiotherapist would do to hep the patient in the vignette

One of the most interesting findings was the use of sub-classifying. It became clear that whilst some interviewees would use it in quite typical ways, by following models described by McKenzie (McKenzie and May 2003), O’Sullivan (Vibe Fersum et al. 2010, 2013) or McGill (2007) for example, others would vehemently state the individuality of the patient as a reason to avoid sub-classifying. Initially this seemed like a difference between interviewees but as more interviews were conducted it became clear that even those not labelling their decision making as sub-classifying were indeed covertly sub-classifying. They would specify specific criteria, which would lead them to carry out an intervention such as education or prescribing cardiovascular exercise.

This would be followed by a combination of exercise and education. Within these areas there are differences but all interviewees mentioned looking at movement patterns for compensations of some description throughout the kinetic chain. Within the exercise programme those with a more biomechanical paradigm were less keen on cardiovascular exercise whilst those with a more bio-psycho-social based paradigm were keen on giving this type of patient cardiovascular exercise. All interviews touched on the concept of graded exposure, pacing and functional restoration, placing an emphasis doing what they could now and gradually increasing this as they were able both in their exercise programme and in everyday life.

All interviewees appeared to feel that manual therapy could be useful but were very concerned about patients becoming reliant on manual therapy and wanted to place the emphasis on patient’s doing their home exercise programme.

Interview 4: I’d also be conscious, in doing that, [manual therapy] that there’s the danger of breeding that dependency on the physiotherapy service. Particularly if they are sedentary and they think, “Well, I’m going to go in. [interviewer 4] will fix my back with his acupuncture or his mobs [mobilisations] or manipulation.”

Three mentioned the use of manual therapy as a good time to deliver education interventions. Two also mentioned the potential for manual therapy to be more suitable for patients from certain cultures or with certain personalities and all suggested that when a specific restriction that was affecting function was present manual therapy could be useful.

Interview 2: I would normally start treating if things are not helping that much and after a couple of sessions, unless there is a cultural implication, in that there are certain cultures that you can treat and they just get better. Arabs sometimes

Every physiotherapist highlighted the importance of education. Some would deliver this in a seated 1:1 discussion whilst others would deliver the education more informally during exercise or manual therapy interventions and with handouts or suggested books. The key open codes that developed around education were being wary of inflammatory language, pacing, use of analogies and explaining pain. Similarly all interviewees made comments to the effect that they were concerned about the issue of their language with patients. One in particular used the emotive term, “inflammatory language” which became an open code representing the fear of language that exacerbates symptoms. Within reconceptulising pain, there was a consistent thread of all physiotherapists wanting to uncouple the association of pain with harm. There was some contradiction in the attention the physiotherapists wanted to give to pain. One of the most interesting parts of this was the juxtaposition of physiotherapists that felt their role was to help patients out of pain, but feel they cannot ask a patient about their pain too frequently or place an emphasis on the pain for fear of contributing towards the patient having a fixation on their pain. However, some wanted to bring attention to the pain and use it to motivate patients. For example;

Interviewee 2: …letting him feel associated with his body as they are often so disassociated with the body. They are ignoring it and part of the rehabilitation process is to make them aware of the pain, so they often get a bit worse because they suddenly realise it’s around them.

All interviewees described some variation of the “clinical audit”. This involves taking an objective marker and performing a treatment and then re-assessing the patient afterwards. For example one physiotherapist described doing a “general nociceptive screen” where key tender points throughout the body would be assessed from head to toe. Whilst another described it simply as;

Interview 5: I really want to see, “Can I modify this patient’s pain?”

Then an intervention would be performed and this general nociceptive screen would be repeated. Several described using the specific movements patients complained of pain in, in this case sitting. They would apply an intervention and then re-assess sitting. Often this was used as way to gain patient compliance.

6.3 Help the patient do what is technically best

The last selective code that was developed was that in helping patients get better, physiotherapists felt the need to adapt their communication, assessment and interventions to help the patient do what’s technically best as shown in integrative diagram in figure 6.5.

Iterative cycle to help patients do what is best for them

Figure 6.5 Iterative cycle to help patients do what is best for them

All interviews placed a strong emphasis on understanding. There were two elements to this one more focused on the technical aspect and another more focused on understanding the patient’s expectations, beliefs and past experience so as to develop rapport and adapt the assessment and treatment to better suit the patient. For example interview 3 outlined how she would vary her treatment approach based on the patient’s previous experiences.

Interviewee 3: So if a patient comes in and he would have in addition to what we know now. He would say, “I have been to 2 different physio’s and they all
manipulated my back and each time it was terrible afterwards.” So of
course I would go over what I need to do, so I guess again it has a
lot to do with what the patient tells me.

There was a wide range of styles displayed for building rapport. For example interview 5 placed particular emphasis on rapport using humour.

Interviewee 5: I will probably say that to him. I would probably say, “You just keep going until I get bored”, or something like that, to make a bit of a joke of it. Because if I can get that kind of jokey link with him I always feel that I can get better compliance with things. I will probably tease him a bit about something along the way, just to make sure he knows that’s what’s going to happen.

All physiotherapists interviewed mentioned re-assurance and using the patients language. Broadly these were all strategies under rapport building which helped the physiotherapist to get the patient to do what the physiotherapist felt was technically best for them.

The simplest example of interviewees adapting is that they frequently stated they may only give a patient one or two exercises to gain compliance, despite that fact they felt the patient would benefit from more. This same theme shows up through the assessment and treatment process. For example interview 3 explained how adapted her approach to delivering a questionnaires depending on the patient.

Interviewee 3: Sometimes I would be a bit careful with handing them these
questionnaires. I would not just want to give them a questionnaire, I
would want to explain to them that I am interested to understand their
problems from a lot of different aspects.

Whilst interview 5 described using manual therapy if that was what the patient expected so that the patient would comply with his more active approach.

Interviewee 5: Just to see if I can get the jump on them in terms of if they expect a manual approach, and you don’t give it to them, then I feel like they don’t listen as well to my active approach.

There was a strong emphasis throughout the interviews on empowering patients to manage their own symptoms, for example.

Interviewee 1: The homework is the most important bit

In particular clinicians described using the clinical audit process to get buy in for a patient to complete their home exercises. Furthermore education was used to empower patients to understand their symptoms. For example interview 3 went as far as to state it was probably the biggest influence on the therapeutic outcome.

Interviewee 3: What I believe is that if I can manage this problem of pain
equals harm, if I can address this successfully then usually it can
be very successful in these patients. But it is probably mainly can I
get his trust and compliance. I guess this is the interaction between
myself and him. It is probably the main thing which I believe makes a
successful intervention or not.

The analysis shows that these therapists primarily made their decisions to help the patient as best they could, potentially with varied motivations. In order to do this they looked to find what was technically best for the patient using their paradigms. These decisions were based on a mixture of evidence from trials, expert opinion, experience and how the patient presented. With a level of extraction it was clear there were many commonalities as all interviewees used a variation of the clinical audit process, education, sub-classification, graded exposure and had an “uneasy” relationship with manual therapy. In order to help patients do what was technically best physiotherapists used an iterative cycle of understanding, building rapport, adapting and empowering.

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