Enhancing service delivery for chronic low back pain: evidence for patient-centred physiotherapy and the objective measurement of outcome.

This thesis incorporates two studies, whose combined aims were to inform and improve the physiotherapy management of chronic low back pain (CLBP) patients in primary care. A qualitative study explored patients' perceptions of physiotherapy for CLBP, in order to influence service redesign. Twenty-five people who had received physiotherapy for CLBP were purposively sampled. They participated in semi-structured interviews that explored their physiotherapy experience. Framework analysis was conducted on the data. The findings demonstrated that CLBP patients' expectations of physiotherapy were not consistently met and that attending physiotherapy did not consistently facilitate self-management of CLBP. Activity and participation were important to CLBP patients. However, in this sample, activity limitations and participation restrictions were not consistently addressed in physiotherapy. A definition of patient-centred physiotherapy for CLBP was generated from the patients' perspective; the physiotherapy received by this sample was not consistently patient-centred by this definition. A quantitative study explored the potential for using gait and sit-to-stand (STS) analysis as objective measures, in order to enhance outcome measurement in CLBP patients. Convenience samples of 17 CLBP patients and 20 people without LBP were recruited. An optical motion analysis system was used to compare the spatial and temporal gait parameters, temporal STS parameters, and pelvic and spinal kinematic parameters of each sample. The relationship between CLBP patients' self-reported pain and disability levels and the objective measures of gait and STS was explored. The CLBP sample demonstrated statistically significant reductions in several parameters compared to the control sample: stride length and pelvic side flexion during normal gait, pelvic side flexion and spine flexion during fast gait, and peak spinal flexion during STS. An association was demonstrated between increased pain intensity and increased pelvic side flexion during fast gait. New knowledge on the physiotherapy management of CLBP emerged from this research. Methods of enhancing patient-centredness and facilitating self-management emerged from the qualitative study. The differences detected in the quantitative study suggested that measuring gait and STS might provide useful additional outcome measures for CLBP patients, in order to overcome some of the limitations of self-report measures. They might also assist with classifying and planning individually-tailored treatment approaches for CLBP patients. Although generalisation is limited by the sample sizes, the implications (for practice and education) and suggestions for further work arising from this research are important in attempts to enhance physiotherapy for CLBP