Physicians' determinants for sick-listing LBP patients: a systematic review

General practitioners' stay-at-work practices in patients with musculoskeletal disorders: using Intervention Mapping to develop a training program

OBJECTIVES

To describe current stay-at-work practices among Danish general practitioners (GPs) in relation to patients with musculoskeletal disorders, to identify potential avenues for improvement, and to suggest a training program for the GPs.

DESIGN AND SETTING

We followed the principles of Intervention Mapping. Data were collected by means of literature searches, focus group interviews with GPs, and interaction with stakeholder representatives from the Danish labour market.

RESULTS

GPs' current stay-at-work practices were influenced by systemic, organisational, and legislative factors, and by personal determinants, including knowledge and skills relating to stay-at-work principles and musculoskeletal disorders, recognition of the patient's risk of long-term work disability, their role as a GP, and expectations of interactions with other stay-at-work stakeholders. GPs described themselves as important partners and responsible for the diagnostic and holistic assessments of the patient but placed themselves on the side line relying on the patient or workplace stakeholders to act. Their practices are influenced both by patients, employers, and by other stakeholders. We propose a training course for GPs that incorporate both concrete tools and behaviour change techniques.

CONCLUSIONS

We have identified varied perspectives on the roles and responsibilities of GPs, as well as legislative and organisational barriers, and proposed a training program. Not all barriers identified can be addressed by a training course, and some questions are left unanswered, among others - who are best suited to help patients staying at work?

Two-Year Follow-Up on Return to Work in a Randomised Controlled Trial Comparing Brief and Multidisciplinary Intervention in Employees on Sick Leave Due to Low Back Pain

PURPOSE

To study return to work (RTW) at 2-year follow-up in a randomised controlled trial comparing brief intervention (BI) and multidisciplinary intervention (MDI) in employees on sick leave due to low back pain (LBP) stratified for job relations.

METHODS

In total 476 employees on sick leave for 4-12 weeks due to LBP were divided into strata with weak or strong job relations, based on perceived risk of losing job and influence on job planning. In each stratum participants were allocated to BI or MDI. All participants received BI, i.e. a clinical examination by a rheumatologist and physiotherapist. In addition, MDI involved a case manager who made a rehabilitation plan in collaboration with the participant. The primary outcome was time to RTW. Secondary outcomes were median weeks in different employment status and selfreported pain, disability and psychological health. Sustained RTW was estimated by work status the last 4 weeks before the 2-year date.

RESULTS

Participants with strong job relations who received BI had a higher RTW rate (hazard ratio = 0.74 (95% CI 0.57; 0.96)) and spent more weeks working than participants who received MDI. In the stratum of weak job relations, no difference was seen regarding RTW and weeks working. For health-related outcomes and sustained RTW no significant results were found in neither stratum.

CONCLUSIONS

Employees with strong job relations achieved higher RTW rates when receiving BI compared to MDI, while no difference was found between intervention groups for employees with weak job relations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14136384. Registered 4 August.

Chronic low back pain beliefs and management practices in Africa: Time for a rethink?

BACKGROUND

Chronic low back pain (CLBP) beliefs are important psychosocial risk factors affecting the occurrence and progression of CLBP. To address pain beliefs and implement recommended biopsychosocial approaches for CLBP management, an understanding of the beliefs of patients and healthcare professionals (HCPs), and also CLBP management practices, is necessary. A narrative review was conducted to explore CLBP beliefs and practices in African countries.

METHODS

Two systematic searches were conducted using seven databases (MEDLINE, Embase, PsychInfo, CINAHL Plus, AMED, PubMed and Web of Science) with combined variations of the terms "Management", "Guidelines", "Chronic Low Back Pain", "Beliefs", "Patients", "Healthcare Professionals" and "Africa".

RESULTS

Five studies and one standard treatment guideline document were included. No systematically developed African CLBP treatment guideline was found, although CLBP practices were identified in two African countries. CLBP management in African countries appears to be biomedically orientated. Only three research articles investigated the CLBP beliefs of patients in Africa, with none assessing HCP beliefs. Unhelpful CLBP beliefs (catastrophizing and fear avoidance) and biomedical thoughts about the causes of CLBP were identified. Unhelpful CLBP beliefs were associated with increased disability.

CONCLUSIONS

Management practices for CLBP in African countries appear to contradict recommended biopsychosocial management guidelines by developed countries and are not sufficiently documented. Research on CLBP beliefs and CLBP management practices in Africa is lacking. To enhance the uptake of biopsychosocial approach in Africa, research around CLBP beliefs in African CLBP patients and HCPs is required.

The capacity to work puzzle: a qualitative study of physicians' assessments for patients with common mental disorders

BACKGROUND

Entitlement to sickness benefits is a legal process requiring health-related reduced work capacity confirmed by a physician via a sickness certificate. However, there is a knowledge gap concerning physicians' clinical practice of work capacity assessments for patients with common mental disorders (CMD). Physicians claim more knowledge and skills in how to actually do the assessments. The aim of this study was to explore physicians' tacit knowledge of performing assessments of capacity to work and the need for sickness absence in patients with depression and anxiety disorders.

METHODS

We performed a qualitative study with open-ended interviews and a short video vignette of a physician and a patient with depression as stimuli. Participating physicians (n = 24) were specialized in general practice, occupational health or psychiatry and experienced in treating patients with depression and anxiety. Interviews were audio-recorded and transcribed verbatim. Inductive content analysis was used as the analytical tool.

RESULTS

Five categories were identified. Category 1 identified work capacity assessment as doing a jigsaw puzzle without any master model. The physicians both identified and created the pieces of the puzzle, mainly by facilitating strategies to make the patient a better supplier of essential information. The finished puzzle made up a highly individualized comprehensive picture required for adequate assessment. Categories 2-4 identified the particular essential pieces of information the participants used, relating to the patient's disorder, capacity in the work place and contextual everyday life. For the sickness absence assessment, apart from decreased work capacity, the physicians also took particulars of the work place into account; e.g. could the work place handle an employee with reduced capacity.

CONCLUSIONS

Physicians' tacit knowledge of assessing work capacity and the need for sickness absence for patients with CMD was identified as doing a jigsaw puzzle. The physicians became identifiers and creators of the pieces of the puzzle using a broad palette of essential information. Our findings contribute to the knowledge gap on clinical assessment and can be used as an educational tool. Because they are based on the professions' tacit knowledge, acceptance of the model can be expected to be high.

Impact of changes in welfare legislation on the incidence of disability pension. A cohort study of construction workers

Aims: Study objectives were to investigate how changes in social insurance legislation influenced the incidence of disability pension. Methods: The study included 295,636 male construction workers who attended health examinations between 1971 and 1993, aged 20-60 years and without previous disability pension. Via the Swedish National Insurance Agency national register we identified 66,046 subjects who were granted disability pension up until 2010. The incidence rates were calculated and stratified according to age and diagnosis. Results: The incidence rate of disability pension was fairly stable until the 1990s when large variations occurred, followed by a strong decreasing trend from the early 2000s to 2010. Trends in incidence rates, stratified by age and diagnosis, showed a consistent decrease in cardiovascular disease for all age groups. In subjects aged 30-49 years there was a high peak around 2003 for musculoskeletal diseases and psychiatric diseases. For the age group 50-59 years, musculoskeletal diagnosis, the most common cause of disability pension, had a sharp peak around 1993 and then a decreasing trend. In the 60-64 age group, the incidence rate for psychiatric diagnosis was stable, while incidence rates for musculoskeletal diagnosis varied during the 1990s. Conclusions: There are considerable variations in the incidence rate of disability pension over time, with different patterns depending on age and diagnosis. Changes in social insurance legislation, as well as in administration processes, seem to influence the variation.

Are there patient-related factors that influence sickness certification in patients with severe subjective health complaints? A cross-sectional exploratory study from different European countries

OBJECTIVES

To develop hypotheses about whether there are patient-related factors that influence physicians' decision-making that can explain why some patients with severe subjective health complaints (SHCs) are more likely to be granted sick leave than others.

DESIGN

Exploratory cross-sectional.

SETTING

Assessments of patient-related factors after watching nine authentic video recordings of patients with severe SHC from a Norwegian general practice. Our previous study showed that three of these nine patients were less likely than the remaining six patients to be granted sick leave by physicians from five European countries.

PARTICIPANTS

In total, 10 assessors from Norway, the Netherlands and France.

OUTCOMES

The direction in which the assessments may contribute towards the decision to grant a sickness certificate (increasing or decreasing the likelihood of granting sick leave).

RESULTS

Physicians consider a wide variety of patient-related factors when assessing sickness certification. The overall assessment of these factors may provide an indication of whether a patient is more likely or less likely to be granted sick leave. Additionally, some single questions (notable functional limitations in the consultation, visible suffering, a clear purpose for sick leave and psychiatric comorbidity) may indicate differences between the two patient groups.

CONCLUSIONS

Next to the overall assessment, no notable effect of the complaints on functioning and suffering, a lack of a clear purpose for sick leave and the absence of psychiatric comorbidity may be factors that could help guide the decision to grant sick leave. These hypotheses should be tested and validated in representative samples of professionals involved in sickness certification. This may help to understand the tacit knowledge we believe physicians have when assessing work capacity of patients with severe SHC.

The structure and process of workers' compensation systems and the role of doctors: A comparison of Ontario and Québec

BACKGROUND

This study sought to identify impacts of compensation system characteristics on doctors in Québec and Ontario.

METHODS

(i) Legal analysis; (ii) Qualitative methods applied to documentation and individual and group interviews with doctors (34) and other system participants (31); and (iii) Inter-jurisdictional transdisciplinary analysis involving cross-disciplinary comparative and integrative analysis of policy contexts, qualitative data, and the relationship between the two.

RESULTS

In both jurisdictions the compensation board controlled decisions on work-relatedness and doctors perceived the bureaucratic process negatively. Gatekeeping roles differed between jurisdictions both in initial adjudication and in dispute processes. Québec legislation gives greater weight to the opinion of the treating physician. These differences affected doctors' experiences.

CONCLUSIONS

Policy-makers should contextualize the sources of the "evidence" they rely on from intervention research because findings may reflect a system rather than an intervention effect. Researchers should consider policy contexts to both adequately design a study and interpret their results. Am. J. Ind. Med. 59:1070-1086, 2016. © 2016 Wiley Periodicals, Inc.

Physicians' assessments of work capacity in patients with severe subjective health complaints: a cross-sectional study on differences between five European countries

OBJECTIVES

A comparison of appraisals made by general practitioners (GPs) in France and occupational physicians (OPs) and insurance physicians (IPs) in the Netherlands with those made by Scandinavian GPs on work capacity in patients with severe subjective health complaints (SHCs).

SETTING

GPs in France and OPs/IPs in the Netherlands gathered to watch nine authentic video recordings from a Norwegian general practice.

PARTICIPANTS

46 GPs in France and 93 OPs/IPs in the Netherlands were invited to a 1-day course on SHC.

OUTCOMES

Recommendation of sick leave (full or partial) or no sick leave for each of the patients.

RESULTS

Compared with Norwegian GPs, sick leave was less likely to be granted by Swedish GPs (OR 0.51, 95% CI 0.30 to 0.86) and by Dutch OPs/IPs (OR 0.53, 95% CI 0.37 to 0.78). The differences between Swedish and Norwegian GPs were maintained in the adjusted analyses (OR 0.43, 95% CI 0.23 to 0.79). This was also true for the differences between Dutch and Norwegian physicians (OR 0.55, 95% CI 0.36 to 0.86). Overall, compared with the GPs, the Dutch OPs/IPs were less likely to grant sick leave (OR 0.60, 95% CI 0.45 to 0.87).

CONCLUSIONS

Swedish GPs and Dutch OPs/IPs were less likely to grant sick leave to patients with severe SHC compared with GPs from Norway, while GPs from Denmark and France were just as likely to grant sick leave as the Norwegian GPs. We suggest that these findings may be due to the guidelines on sick-listing and on patients with severe SHC which exist in Sweden and the Netherlands, respectively. Differences in the working conditions, relationships with patients and training of specialists in occupational medicine may also have affected the results. However, a pattern was observed in which of the patients the physicians in all countries thought should be sick-listed, suggesting that the physicians share tacit knowledge regarding sick leave decision-making in patients with severe SHC.

"Lovely Pie in the Sky Plans": A Qualitative Study of Clinicians' Perspectives on Guidelines for Managing Low Back Pain in Primary Care in England

STUDY DESIGN

A qualitative study in south-west England primary care.

OBJECTIVE

To clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the English National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care.

SUMMARY OF BACKGROUND DATA

Merely publishing clinical guidelines is known to be insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians' perspectives on specific clinical guidelines can suggest ways to improve the relevance of guidelines for clinical practice.

METHODS

We conducted semi-structured interviews with 53 purposively sampled clinicians. Participants were 16 general practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21), or both (12). We used thematic analysis.

RESULTS

Official guidelines comprised just 1 of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organizational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology-"non-specific LBP"-unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services, and sparse commissioning of guideline-recommended treatments.

CONCLUSION

The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring that guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for public sector patients.

LEVEL OF EVIDENCE

N/A.

GPs' negotiation strategies regarding sick leave for subjective health complaints

OBJECTIVES

To explore general practitioners' (GPs') specific negotiation strategies regarding sick-leave issues with patients suffering from subjective health complaints.

DESIGN

Focus-group study.

SETTING

Nine focus-group interviews in three cities in different regions of Norway.

PARTICIPANTS

48 GPs (31 men, 17 women; age 32-65), participating in a course dealing with diagnostic practice and assessment of sickness certificates related to patients with subjective health complaints.

RESULTS

The GPs identified some specific strategies that they claimed to apply when dealing with the question of sick leave for patients with subjective health complaints. The first step would be to build an alliance with the patient by complying with the wish for sick leave, and at the same time searching for information to acquire the patient's perspective. This position would become the basis for the main goal: motivating the patient for a rapid return to work by pointing out the positive effects of staying at work, making legal and moral arguments, and warning against long-term sick leave. Additional solutions might also be applied, such as involving other stakeholders in this process to provide alternatives to sick leave.

CONCLUSIONS AND IMPLICATIONS

GPs seem to have a conscious approach to negotiations of sickness certification, as they report applying specific strategies to limit the duration of sick leave due to subjective health complaints. This give-and-take way of handling sick-leave negotiations has been suggested by others to enhance return to work, and should be further encouraged. However, specific effectiveness of this strategy is yet to be proven, and further investigation into the actual dealings between doctor and patients in these complex encounters is needed.

Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors are believed to influence the development of chronic low back pain. To date, it is not known how fear-avoidance beliefs (FABs) influence the treatment efficacy in low back pain.

PURPOSE

To summarize the evidence examining the influence of FABs measured with the Fear-Avoidance Belief Questionnaire or the Tampa Scale of Kinesiophobia on treatment outcomes in patients with low back pain.

STUDY DESIGN/SETTING

This is a systematic review.

PATIENT SAMPLE

Patients with low back pain.

OUTCOME MEASURES

Work-related outcomes and perceived measures including return to work, pain, and disability.

METHODS

In January 2013, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. A hand search of the six most often retrieved journals and a bibliography search completed the search.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

research studies that included patients with low back pain who participated in randomized controlled trials (RCTs) investigating nonoperative treatment efficacy. Out of 646 records, 78 articles were assessed in full text and 17 RCTs were included. Study quality was high in five studies and moderate in 12 studies.

RESULTS

In patients with low back pain of up to 6 months duration, high FABs were associated with more pain and/or disability (4 RCTs) and less return to work (3 RCTs) (GRADE high-quality evidence, 831 patients vs. 322 in nonpredictive studies). A decrease in FAB values during treatment was associated with less pain and disability at follow-up (GRADE moderate evidence, 2 RCTs with moderate quality, 242 patients). Interventions that addressed FABs were more effective than control groups based on biomedical concepts (GRADE moderate evidence, 1,051 vs. 227 patients in studies without moderating effects). In chronic patients with LBP, the findings were less consistent. Two studies found baseline FABs to be associated with more pain and disability and less return to work (339 patients), whereas 3 others (832 patients) found none (GRADE low evidence). Heterogeneity of the studies impeded a pooling of the results.

CONCLUSIONS

Evidence suggests that FABs are associated with poor treatment outcome in patients with LBP of less than 6 months, and thus early treatment, including interventions to reduce FABs, may avoid delayed recovery and chronicity. Patients with high FABs are more likely to improve when FABs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if FABs are present.

The social negotiation of fitness for work: Tensions in doctor–patient relationships over medical certification of chronic pain

The UK government is promoting the health benefits of work, in order to change doctors’ and patients’ behaviour and reduce sickness absence. The rationale is that many people ‘off sick’ would have better outcomes by staying at work; but reducing the costs of health care and benefits is also an imperative. Replacement of the ‘sick note’ with the ‘fit note’ and a national educational programme are intended to reduce sickness-certification rates, but how will these initiatives impact on doctor–patient relationships and the existing tension between the doctor as patient advocate and gate-keeper to services and benefits? This tension is particularly acute for problems like chronic pain where diagnosis, prognosis and work capacity can be unclear. We interviewed 13 doctors and 30 chronic pain patients about their experiences of negotiating medical certification for work absence and their views of the new policies. Our findings highlight the limitations of naïve rationalist approaches to judgements of work absence and fitness for work for people with chronic pain. Moral, socio-cultural and practical factors are invoked by doctors and patients to contest decisions, and although both groups support the fit note’s focus on capacity, they doubt it will overcome tensions in the consultation. Doctors value tacit skills of persuasion and negotiation that can change how patients conceptualise their illness and respond to it. Policy-makers increasingly recognise the role of this tacit knowledge and we conclude that sick-listing can be improved by further developing these skills and acknowledging the structural context within which protagonists negotiate sick-listing.

The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).

PURPOSE

The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP.

DESIGN/SETTING

The design of this study was a systematic review.

METHODS

In October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis.

RESULTS

The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02-1.09) to 4.64 (95% CI, 1.57-13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive.

CONCLUSIONS

Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

Reasons for and factors associated with issuing sickness certificates for longer periods than necessary: results from a nationwide survey of physicians

Background

Physicians’ work with sickness certifications is an understudied field. Physicians’ experience of sickness certifying for longer periods than necessary has been previous reported. However, the extent and frequency of such sickness certification is largely unknown. The aims of this study were: a) to explore the frequency of sickness certifying for longer periods than necessary among physicians working in different clinical settings; b) to examine main reasons for issuing sickness certificates for longer periods than necessary; and c) to examine factors associated with unnecessary issued sickness certificates.

Methods

In 2008, all physicians living and working in Sweden (a total of 36,898) were sent an invitation to participate in a questionnaire study concerning their sick-listing practices. A total of 22,349 (60.6%) returned the questionnaire. In the current study, physicians reporting handling sickness certification consultations at least weekly were included in the analyses, a total of 12,348.

Results

The proportion of physicians reporting issuing sickness certificates for longer periods than actually necessary varied greatly between different types of clinics, with the highest frequency among those working at: occupational medicine, orthopedic, primary health care, and psychiatry clinics; and lowest among those working in: eye, dermatology, ear/nose/throat, oncology, surgery, and infection clinics. Logistic analyses showed that sickness certifying for longer periods than necessary due to limitations in the health care system was particularly common among physicians working at occupational medicine, orthopedic, and primary health care clinics. Sickness certifying for longer periods than necessary due to patient-related factors was much more common among physicians working at psychiatric clinics. In addition to differences between clinics, frequency of sickness certificates issued for longer periods than necessary varied by age, physicians’ experiences of different situations, and perceived problems.

Conclusions

This study showed that physicians issued sickness certificates for longer periods than actually necessary quite frequently at some types of clinics. Differences between clinics were to a large extent associated with frequency of problems, lack of time, delicate interactions with patients, and need for more competence.

The association between physicians’ attitudes to psychosocial aspects of low back pain and reported clinical behaviour: A complex issue

Background and aim

Physicians’ attitudes predict clinical decision making and treatment choices, but the association between attitudes and behaviour is complex. Treatment guidelines for non-specific low back pain (LBP) include recommendations of early assessment of psychosocial risk factors forchronic pain, patient education and reassurance. Implication of these principles is demanding, and many patients are not referred for appropriate treatments due to a lack of systematic screening of psychosocial risk factors for chronic pain. Even though health care providers recognise the need for psychosocial assessment in LBP, psychosocial issues are seldom raised in acute settings. The aim of this study is to evaluate how physicians’ attitudes towards assessing psychological issues of LBP patients are associated with their treatment practice, and to assess if their clinical actions follow current treatment guidelines.

Methods

The study was amixed methods study of primary care physicians (n = 55) in Finland. Physicians’ attitudes were measured with a psychological subscale of attitudes to back pain scales for musculoskeletal practitioners (ABS-mp). Treatment practice of LBP was evaluated by as king physicians to describe a typical LBP treatment process and by asking them to solve a LBP patient case. Members of the research team individually evaluated the degree to which psychosocial issues were taken into account in the treatment process and in the patient case answer. Qualitative and quantitative data were combined to examine the role of attitudes in the treatment of LBP.

Results

The attitudes of physicians were generally psychologically oriented. Physicians who addressed to psychosocial issues in their treatment practice were more psychologically oriented in their attitudes than physicians who did not consider psychosocial issues. Only 20% of physicians mentioned psychosocial issues as being a part of the LBP patient’s typical treatment process, while 87% of physicians paid attention to psychosocial issues in the LBP patient case. On the level of the treatment process, radiological investigations were over-represented and pain assessment, patient information and reassurance infrequently performed when compared to LBP guidelines.

Conclusions

Although primary care physicians were generally psychosocially oriented in their attitudes on LBP, psychological issues were inconsistently brought up in their reported clinical behaviour. Physicians recognised the need to assess psychosocial factors. Those who were psychologically oriented in their attitudes were more inclined to take psychosocial issues into account. However on a process level, evaluation and treatment of LBP featured biomechanical principles. LBP guidelines were only partially followed.

Implications

Clinical behaviour of physicians in the treatment of LBP is complex and only partly explained by attitudes.