# Where is the patient in the records? Evaluating physiotherapists’ first visit in occupational health primary care pathway for low back pain

## TL;DR

This study evaluates how well physiotherapists in occupational health follow biopsychosocial guidelines for low back pain, finding that training improves documentation but gaps remain.

## Contribution

The study introduces a structured evaluation of physiotherapists' documentation aligned with biopsychosocial guidelines in occupational health primary care.

## Key findings

- Training improved documentation of psychological and social dimensions of low back pain assessment.
- Person-centred care aspects were rarely documented, even after training.
- High-risk patients showed no records meeting quality criteria in either group.

## Abstract

Clinical guidelines recommend a biopsychosocial approach to low back pain (LBP) management, with physiotherapists playing a key role in occupational health primary care (OHPC). However, little is known about how their clinical behaviours at the first visit align with guideline-oriented biopsychosocial principles. Therefore, we evaluated LBP management quality in OHPC by applying predefined criteria to physiotherapists’ documentation.

Based on a cluster-randomised implementation study data (ISRCTN11875357) we analysed 98 electronic patient records (EPRs) documented by 28 physiotherapists across diverse OHPC units. The intervention arm had received 3–7 days of biopsychosocial training. A stratified random sample of EPRs from individuals with LBP was reviewed using a structured researcher’s evaluation tool. Each item was scored dichotomously (yes/no) and evaluated against predefined quality criteria with stepwise thresholds for different work disability risk groups.

Step I, multidimensional biopsychosocial assessment of LBP, was documented in fewer than half of the records (36.5% in the intervention vs 16.7% in the control arm, p=0.081). The biological dimension was well documented in both arms (100% vs 95.8%, p=0.245), while psychological (58.1% vs 25%, p=0.009) and social (54.1% vs 29.2%, p=0.038) dimensions were more frequently documented in the intervention arm.

Step II quality criteria (low-risk patients) were met in 58.1% of intervention versus 4.2% of control records (p<0.001), and step III (medium-risk) in 55.4% versus 4.2% (p<0.001). No EPRs met step IV (high-risk) quality criteria.

The intervention arm more often documented psychosocial assessments, risk stratification, behavioural strategies and advice to stay active. Person-centredness (ie, goals, values, resources, expectations) was rarely documented (36.5% vs 0%, p<0.001).

Training in guideline-oriented biopsychosocial approach was associated with more frequent documentation of behaviours aligned with high-quality LBP management. However, overall quality varied, and person-centred aspects remained underreported. Complementary implementation strategies are required to ensure consistent delivery and documentation of biopsychosocial clinical practice in OHPC.