1 Introduction [37] [18] [16,36] [3,31,45,47,49,50] [10,20,24,26] [14] [25,48] [17,19,28,32,39,42–44] [17,28,42,44] [13] [36] [24] [11] [41] 2 Methods 2.1 Design and setting We conducted a cross-sectional, nationwide postal survey of UK GPs and PTs, involved in the management of patients with LBP, between April and November 2005. Ethical approval for the study was obtained from the West Midlands Multi-centre Research Ethics Committee (MREC). Written consent was not sought from each participant for use of survey data, but consent of respondents was assumed if they completed and returned the questionnaire. 2.2 Questionnaire sample and mailing process n n n n [7] [2] 2.3 Questionnaire A filter question was used to identify those HCPs who had treated at least one patient with non-specific LBP (NSLBP) in the previous six months, so that only respondents with recent experience of managing patients with LBP were included in the analysis. 2.3.1 Demographics and practice information A number of demographic and practice questions, relevant to each profession, were included. Some items were pertinent to both professions: gender; years since qualification; postgraduate training in LBP; clinical interests/speciality and personal experience of back pain. Data gathered exclusively from GPs included whether they worked only in general practice and whether the practice was a single-handed or a group practice. Data gathered exclusively from PTs included how much of their clinical practice was based in the NHS, what proportion of their caseload was primary care patients, whether they worked alone or in a team, and grade of current job. 2.3.2 Attitudes and beliefs measure [28,39] [12] [34] [30] [28] 2.3.3 Clinical behaviour measures Appendix A [40] The clinical behaviour question regarding work was as follows: Please tick the one response that best describes what you would recommend this patient to do a. Be off work until pain has completely disappeared b. Return to part time or light duties c. please state number of weeks d. Return to normal work e. Be off work until pain has improved” [22] 2.4 Brief questionnaire The brief questionnaire sent to a sample of non-responders contained the filter question to ensure that respondents recently involved in the management of patients with LBP could be identified. Alongside key demographic questions, we included four items from the PABS.PT (two from each subscale chosen on the basis of factor loadings described by the tool’s developers and data from a pilot study), the vignette patient and the clinical behaviour questions related to work, activity and bedrest. 2.5 Statistical analysis [39] [28,39] The relationship between attitudes and beliefs and clinical behaviour was examined using ANOVA to test for an overall relationship with clinical behaviour and, when appropriate, for a linear trend across clinical behaviour groups (strictly in line, broadly in line and not in line with guidelines). The effect of non-response was examined by comparing responses from all responders to the full questionnaire to those completing the brief questionnaire. All analyses were carried out using the Statistical Package for Social Scientists for Windows (SPSS Inc., Chicago, IL, version 13). 3 Results n n n 3.1 Characteristics of respondents Table 1 3.2 Attitudes and beliefs n n r p 3.3 Diagnostic investigations n n Table 2 3.4 Clinical behaviour Table 3 n n Table 3 3.5 Relationship between attitudes and beliefs and clinical behaviour Fig. 1 F 1,986 p F 1,981 p 3.6 Effect of non-response n n n n For the GPs, gender mix and years in practice were similar for those completing the full and brief questionnaire. For the PTs, those completing the brief questionnaire were slightly less experienced (mean of 12 years experience versus 15 years) and more likely to be male compared to the full questionnaire responders (25% vs. 19% male). Responses to both behavioural subscale PABS.PT items and one of the two items from the biomedical subscale were similar to those for the full questionnaire. Responders to the brief questionnaire, from both professions, were more likely to agree with the statement that ‘patients with back pain should preferably practice only pain free movements’, indicating a more biomedical orientation. The responses to the items regarding work and activity advice were similar for responders to the full and brief questionnaires. GPs responding to the brief questionnaire reported bedrest advice that was less in line with guideline recommendations than the responders to the full questionnaire (19.3% strictly in line with guidelines compared to 38.4%, respectively), whereas the PTs completing the brief questionnaire reported bedrest advice that was more in line with guideline recommendations than the initial responders (35.0% strictly in line with guidelines compared to 21.8%, respectively). 4 Discussion 4.1 Main findings [15,29] A considerable proportion of HCPs in the UK continue to provide advice to patients about work that is not in line with guideline recommendations. The associations between attitudes, beliefs and reported clinical behaviour suggest that some HCPs continue to practice predominantly within a biomedical model, placing most importance on the severity of tissue damage when determining a patient’s level of pain and functional disability. Others have adopted a more behavioural approach to management, embracing the notion that the level of pain and functional loss may be influenced by psychological and social factors in addition to biomechanical factors. 4.2 Comparison to other studies [28] [30,39] [28] [39] [17,32,42] [28,44] 4.3 Implications for clinical practice and future research [35] [50] [51] [6,8,20,23,33] [27] [8] [9,21,30] Future work should further test the psychometric properties of the PABS.PT to assess responsiveness and determine appropriate cut offs for ‘high’ and ‘low’ scores on the subscales and what constitutes a clinically relevant change. Methods to assess HCP attitudes, beliefs and behaviours warrant further study. For example, the validity of using methods to measure implicit attitudes about LBP, such as those employing automatic responses, could be explored in an attempt to overcome potential social desirability bias in survey responses as HCPs become more aware of clinical guidelines. 4.4 Strengths and limitations [4,5,38] [11,39,41] [40,46] general specific 5 Conclusion This study shows the diversity of the attitudes and self-reported practice behaviour of UK GPs and PTs for patients with NSLBP. Many HCPs believed LBP necessitates some avoidance of activities and the need to be off work. For a patient with a history of being off work since onset of LBP four weeks previously, over a quarter of HCPs recommended further time off work. The attitudes and beliefs of HCPs were associated with their advice about return to work. Future studies need to investigate the associations between HCP factors and patient outcomes, and test if approaches aimed at modifying attitudes, beliefs and clinical behaviours of HCPs can be successful. Appendix A The vignette used in the questionnaire A 50-year-old office worker presents with a four-week history of low back pain with referral to the right buttock. The pain initially came on gradually over 24 h. Since the onset of the pain she has been unable to work and has been taking Diclofenac regularly. She also has had moderate to high levels of disability and particularly has difficulty bending and rising from a chair and can stand and walk only for short periods. There is no history of trauma. Her work consists mainly of computer work with some standing. She feels she has to move slowly and needs to lie down to rest more often than usual. She demonstrates some anxiety and has felt tired and worn out most of the time since the pain started. Her average pain over the last two weeks has been 4 out of a maximum of 10. Her general health is good. On physical examination, there is marked limitation of forward flexion and right paraspinal tenderness. Neurological examination is normal. All other case history, past medical history and physical examination findings are unremarkable, except that she has had two previous episodes of LBP.