4. Discussion
We found a high prevalence of moderate practice habits and a low prevalence of good practice habits for LBP among the physiotherapist in Bangladesh. Though most of the currently practicing physiotherapists in Bangladesh were young, only less than one fourth was female. Half of the participants had a post-graduate degree and the impressive number of them had a specialization in musculoskeletal physiotherapy. However, data showed that there is a scarcity of physiotherapists in the government’s health sector in Bangladesh and most of them had worked in the city area. Dependency on passive electrical and physical modalities and exercise therapy were very high among the physiotherapist in Bangladesh. Very few used recommended intervention for example Mindfulness-based stress reduction therapy for LBP. Unsurprisingly, for diagnosis of LBP, all most all the physiotherapists advise radiological imaging, though most of the respondents reported that they mainly have seen chronic LBP patients in their practice.
Little is known about current practice patter of physiotherapists in low and middle-income countries compared to high-income countries. A most recent study that seen the practice pattern of physiotherapists in the low-income country has been done in Ghana in 2013. Like our study, this study reported that most physiotherapists used not recommended and partially recommended interventions 34. In our study, we have found 92.4% of physiotherapists offer exercise therapy for LBP. However, this rate was 100% in Ghana, although most of our participants were young and less experienced like Ghana. This indicated that physiotherapy is a relatively newer profession for low-income countries. However, a study conducted in 2010 in India, found the same picture as our study regarding the use of electrotherapy and exercise therapy6. Previous studies from Thailand (in 2005) and Nigeria (in 2007) reflected the same scenario 12,13. It means the practice pattern of physiotherapists in low and middle-income countries is almost the same over the one and half-decade. More studies from other low and middle-income countries can give us a recent practice pattern of physiotherapists. For an example of data from high-income countries, a systematic review estimated 50% of physiotherapists used not recommended interventions for LBP18. However, homogenous studies from low and middle-income countries are not yet enough for making a valid conclusion on practice pattern, more specifically for LBP.
In our study, we found half of the physiotherapists have masters and above degrees, and most of them are specialized in musculoskeletal physiotherapy, however, very few of them are a good practitioner. This indicates the necessity of revision of postgraduate courses in Bangladesh. It was impressive that the prevalence of good practice among young physiotherapist was higher than the aged. It is probably that the young generation is more connected with the outer world and conscious of modern treatment techniques. One the other hand, our study shows a higher number of physiotherapists who was graduated from a private institute and worked in the non-government institute were engaged in good practice. This finding is similar to the findings of other studies conducted in Bangladesh where the author found governments’ impassivity about the physiotherapy profession in Bangladesh 22.
Imaging has a very limited role in LBP management and unnecessary lumbar imaging is a harmful exposure to radiation. Imaging rates for LBP diagnosis are high all over the world. For example, 53.7% and 56% of patients with LBP are referred for imaging by general practitioners in the USA and Italy respectively 35,36. Surprisingly, this rate is up to 100% in India and China 37,38. In our study, we found 97.8% physiotherapist refer their patients for radiological imaging to diagnose LBP which is a clear waste of health-care resources in Bangladesh.
In our study, data have shown that Bangladeshi physiotherapist mainly relied on not recommended and partially recommended interventions. However, four out of five physiotherapists claim that the cure rate of their LBP patients is between 50-90%. Nonetheless, two systematic reviews and meta-analysis suggested that only those patients who received evidence-based physiotherapy were satisfied and feel confident about physiotherapy interventions 39,40. A large scale cohort study addressing the effect of physiotherapy on LBP patients in Bangladesh is needed to find the actual efficacy rate.
The first study in Bangladesh that evaluated the LBP practice pattern of an important professional group who are dealing with LBP predominantly. The study is focused on the top global cause of disability (i.e. LBP) and justified its management status (compared to evidence-based practice guidelines) in a low-income country. The response rate for this study was considerably high (70.8%) and a good number of representatives from the city and rural area appropriately reflect the national situation for Bangladesh. Despite this, limitations such as the measuring bias in self-reported data 41 should be recognized. The current data were based on participants’ freedom opinion and relied on their memory, which might oppose to actual intervention pattern of patients. The difference in interpretation might lead due to the use of predominantly closed questions. Future research with the combination of quantitative and qualitative data can overcome the limitation. Another important limitation of this study is that it does not characterize between cases of acute and chronic LBP according to guideline recommendation. For example, cognitive behavioral therapy is recommended for chronic low back pain but not for acute low back pain. However, the majority of the participant said that they mainly treat chronic LBP patients in their practice.
Our findings help advance the scientific literature in this area as an example of professional practice pattern evidence from a low-income country. This study has valuable implications for the management of LBP by the physiotherapist, especially in a low-income country like Bangladesh. The findings set as a database to exhibit future research, clinical practice, and education for the physiotherapy profession. Although, future clinical trials focusing on the specific evidence-based application of interventions used by Bangladeshi physiotherapists are needed to provide acuteness into the outcome of LBP management in Bangladesh. The current practice pattern is known from this study, which is a baseline reference point for further upgrades, and it’s helpful to reduce the burden of disability by improving LBP physiotherapy management adherence to evidence-based public health care.