Low back pain (LBP) continues to be the leading cause of years lived with disability, resulting not only in suffering for the individual but also in significant economic impacts on society.1,2 Most individuals with LBP experience non-specific pain, which has a variable prognosis and is defined as not being attributable to a known specific pathology.3

Patients suffering from LBP are frequently seen in primary healthcare settings.4 In Sweden, as in many other countries, patients have direct access to or the option of self-referral to a physical therapist, potentially making the physical therapist the first healthcare professional a patient encounters. This places a considerable responsibility on the physical therapist to manage the patient's condition.5 This responsibility involves navigating uncertainties and clinical risks related to identifying serious pathologies while considering modifiable prognostic factors through a biopsychosocial model.6,7 Clinical guidelines recommend incorporating health-related and psychosocial factors into clinical reasoning.8-10 Thus, early identification of patients at risk for a poor prognosis addressing modifiable factors within the rehabilitation process is crucial for achieving a successful outcome.11,12 Utilizing patient-reported outcome measures (PROMs) to screen for factors in patient management is recommended. This approach enhances clinical examination, promoting shared decision-making and patient-centered care.13-17 This has also been highlighted by the World Health Organization (WHO).18 PROMs are “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else”.19

Numerous PROMs measuring various factors and constructs are available and recommended.20-22 To target treatment, guidelines recommend shorter PROMs, such as the STarT Back tool, which includes questions on several constructs to stratify patients according to specific risk levels based on prognostic factors.23,24 The outcome from the STarT Back tool is shown to be positively related to factors important for recovery, such as kinesiophobia, pain catastrophizing, disability, and pain intensity.25

Previous research has yielded mixed results regarding the use of PROMs by physical therapists managing patients with LBP in primary healthcare related to health and psychosocial factors.17,26,27 One study indicated that physical therapists in primary health care in Sweden used PROMs for pain and disability at a higher rate (>40 %), while their usage of PROMs for health-related and psychosocial factors was much lower (<15 %).26 A similar trend was observed among physical therapists in Spain, who assessed psychosocial factors to a very low extent and employed structured PROMs for these factors even less frequently.28 In addition, research has shown conflicting results regarding the physical therapists’ ability to identify psychosocial factors.29-31

Research has identified several barriers that hinder physical therapists' use of PROMs in their clinical practice. These barriers include the resources, time, and competence required for the use of appropriate PROMs.26-28,32-41 While some studies suggest that knowledge about PROMs or having higher education may significantly affect usage, other studies have found no such association.28,29,40,42 There is a paucity of studies examining factors that influence or impact physical therapists' use of specific PROMs for health-related and psychosocial factors. To enhance physical therapists' understanding of and encourage the use of PROMs, particularly those addressing health-related and psychosocial aspects, it is essential to gain more insight into the factors influencing their use. Therefore, we aimed to investigate the factors affecting the use of PROMs among physical therapists managing patients with LBP within a Swedish primary health context, regarding PROMs for pain, disability, health-related, and psychosocial factors.

The demographic data of the participants are presented in Table 1. Most of the physical therapists were female (n = 828, 67 %) and had worked as physical therapists for more than five years (n = 970, 79 %). Twenty-three percent (n = 275) of the physical therapists held a master’s degree or PhD, and 12 % (n = 147) were advanced clinical specialists. Most physical therapists used PROMs for pain (n = 885, 83 %), while the use of PROMs for disability (n = 297, 28 %), health-related (n = 152, 14 %), and psychosocial factors (n = 141, 13 %) were less common (Table 1).

Important factors associated with the physical therapists' use of PROMs for disability, health-related, and psychosocial factors were educational level (Master/PhD) or being an advanced clinical specialist. Our findings largely align with previous research on the overall use of PROMs, reporting that education and increased knowledge seem to be associated with a higher use.28,40-42 Copeland et al.40 surveyed physical therapists in New Zealand on their use of PROMs and reported that 40 % used PROMs, which was explained by having a master’s degree or education about PROMs.40 This was also the case among physical therapists in Saudi Arabia, where those with a higher education or an advanced specialty were more likely to use PROMs.42 Among Dutch physical therapists, increased knowledge and the use of an electronic journal system were associated with a higher likelihood of utilizing PROMs.41 In contrast, Brinkman et al.61 found that the physical therapists' use of PROMs was more closely linked to patient characteristics. They noted that physical therapists often select patients for PROMs based on their preferences.61

Unlike recent studies on factors affecting physical therapists' use of PROMs for managing LBP, we examined four groups of specific PROMs that measure various constructs. The low-to-very-low percentage of physical therapists who used PROMs for health-related (14 %) and psychosocial factors (13 %) was associated with being an advanced clinical specialist or having a higher educational level. This is somewhat consistent with the findings of Otero-Ketterer et al.28 who reported that only 14 % of surveyed physical therapists in Spain assessed psychosocial factors in clinical reasoning. Furthermore, only 50 % of these physical therapists used structured PROMs.28 The use of these PROMs was associated with working in a larger city, being in a private practice setting, or having received education about psychosocial factors.

Psychosocial factors are well-established predictors of persistent pain and disability in LBP.62 However, there is a low utilization of PROMs that assess these factors for patients with LBP, contrasting with recommendations found in the literature11,12 and clinical guidelines.8-10 Instead, in the clinical reasoning process, physical therapists' decision-making and treatment are reported to be influenced by the physical therapists' background, their perception of the patient, and their clinical experience.6,41 Physical therapists do not use PROMs to measure health-related and psychosocial factors, which may reflect their continued focus on biomechanical factors when treating LBP, despite recommendations advocating a psychosocial approach.8,63,64 Gardner et al.64 reviewed physical therapists' beliefs and attitudes in managing patients with LBP. They concluded that physical therapists tend to adopt a biomedical approach, focusing on tissue damage and selecting treatments based on this model which may overlook the influence of psychosocial factors.64 Another explanation might be that physical therapists are not confident or knowledgeable in delivering psychosocial interventions based on the outcomes of such PROMs.65 A review and meta-synthesis summarized that while physical therapists report a shift towards more bio-psychosocial and person-centred approaches, training interventions do not adequately help them feel confident in delivering all aspects.65 Furthermore, overall barriers to utilizing PROMs are due to several factors such as lack of time, competence, routine, and willingness to use them among patients and physical therapists.27 In addition, patients might not be motivated to complete or use PROMs due to time and reasons not measured in this trial. Future studies could therefore examine factors at the patient level such as their motivation and understanding of specific PROMs.

Our findings indicate that physical therapists with higher education levels are more likely to use specific PROMs. However, achieving a higher education does not necessarily mean to be informed about certain PROMs or follow recommended management strategies for patients with LBP. To further address the barriers to implementing specific PROMs, a transition strategy may be needed to enhance knowledge and change behaviours, ultimately increasing their usage.66 Educational meetings alone or combined with other interventions might improve professional practice, thus increasing the use of PROMs.67 Nevertheless, recent studies examining educational interventions involving PROMs have yielded varied results. One recent study explored the implementation of a guideline-endorsed treatment strategy for LBP based on the biopsychosocial model.68 The physical therapists' biopsychosocial orientation increased after implementation but decreased over time, highlighting the need to monitor changes.69 In addition, a study conducted among physical therapists in the Netherlands reported that the use of PROMs was not as high as expected following an implementation project.70 To enhance the use of PROMs for health-related and psychosocial factors, it may be essential to implement educational interventions that increase knowledge of a biopsychosocial approach to LBP, before expecting physical therapists to use such PROMs.

The strength of the present study is that we included a large group of physical therapists (n = 1237) working in primary health care in Sweden. Even so, we cannot rule out the possibility that the results might not represent all physical therapists working in primary care in Sweden as only 25 % of all surveyed answered. A possible limitation is the recall bias, which may have caused physical therapists to over- or underestimate their use of PROMs when answering the survey, potentially impacting the results. A further limitation is that we did not control for possible confounding factors in the multivariable analyses but still included demographic factors such as age and sex in the univariable analyses. However, we cannot rule out the risk of unmeasured confounding impacting our results.

The decision to classify the included PROMs into four groups can be debated. This was informed by findings from a previously published survey study on the same data, demonstrating a diverse use of various PROMs where few physical therapists (<15 %) used PROMs for health-related and psychosocial factors.26 We also chose to include the shorter PROMs used to stratify patients to risk for long-term pain and disability in the PROM group for psychosocial factors as they mainly comprise questions on such factors.

In hindsight, and to better understand what factors are associated with the physical therapists’ use of PROMs for managing patients with LBP, it would have been valuable to include questions about physical therapists’ attitudes, beliefs, and motivation to use them as this has been reported to be important.64 Other factors, such as patient expectations, may also influence the physical therapists’ use of certain PROMs in the clinical reasoning process, to align with the patient’s preference.

Few physical therapists use PROMs to assess health-related and psychosocial factors. Those with higher educational levels or advanced clinical specialists are more likely to incorporate such PROMs when managing patients suffering from LBP. Future studies need to examine educational interventions to enhance the understanding of the importance of specific PROMs in clinical reasoning from a biopsychosocial perspective.