ARTICLE IN PRESS

Manual Therapy 13 (2008) 441–449

www.elsevier.com/math

Physiotherapy for low back pain: Differences between public and

private healthcare sectors in Ireland—A retrospective survey
Sarah N. Casserley-Feeneya,, Gerard Buryb, Leslie Dalyc, Deirdre A. Hurleya
a
School of Physiotherapy & Performance Science, University College Dublin, Health Sciences Centre, Belfield, Dublin 4, Ireland
b
School of Medicine & Medical Science, University College Dublin, Ireland
c
School of Public Health & Population Science, University College Dublin, Ireland
Received 10 October 2006; received in revised form 21 March 2007; accepted 22 May 2007

Abstract

Objectives: European clinical guidelines for low back pain (LBP) recommend early referral of appropriate patients to health services
such as physiotherapy. The current study aimed to investigate any differences between the physiotherapy management of LBP, and
the physiotherapist and patient profiles in public and private health settings in Ireland.
Design: A retrospective chart survey of all LBP patients referred for physiotherapy to one Dublin City hospital and three
neighbouring private practices in 2003 was conducted.
Results: In total, 249 physiotherapy charts (hospital [H] n ¼ 93; private practice [Pr] n ¼ 156) were identified and demographic,
LBP, and management details analysed. Only charts containing full LBP duration and physiotherapy treatment data were included
in the analysis of these parameters (LBP duration: H ¼ 84, Pr ¼ 130; physiotherapy treatment: H ¼ 79, Pr ¼ 155). There were
significantly higher percentages of female (H ¼ 66%; Pr ¼ 50%: p ¼ 0.017), older (H ¼ 46 years; Pr ¼ 36 years: po0.001), and
chronic LBP patients (412 weeks; H ¼ 50%; Pr ¼ 2%: po0.001) in the public setting. Public patients had significantly longer
waiting times for physiotherapy (median H ¼ 10 weeks; Pr ¼ 0; po0.001), and more treatment (H ¼ 5.1; Pr ¼ 2.5: pp0.001) than
private patients. While treatment approaches were similar for both settings, there was a significantly higher use of advice and spinal
stabilisation exercises in the public setting. However, there was minimal difference in the management of acute or chronic LBP in
both setting suggesting poor adherence to European guidelines.
Conclusions: Findings showed longer waiting times, and a higher number and duration of physiotherapy treatments for acute and
chronic LBP in the public setting suggesting the need to develop publicly funded primary healthcare in Ireland.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: Physiotherapy; Low back pain; Healthcare settings; Clinical guidelines

1. Introduction countries (Henmila, 2004). Annually, LBP costs the

Low back pain (LBP) with a lifetime prevalence of
approximately 60–80% (Torensten et al., 1998) is
recognised internationally as a major health, social
and economic burden with direct and indirect costs
accounting for between 0.8% and 2.1% of gross
domestic product (GDP) in some US and European
Corresponding author. Tel.: +353 1 7166523, +353 878534933;
fax: +353 1 7166501.
E-mail address: sarah.casserley@ucd.ie (S.N. Casserley-Feeney).
Irish Exchequer in excess of h32 million, representing
27% (h500 million) of total disability payments (Leech,
2004). This is consistent with findings for the UK where
the direct and indirect costs of LBP are estimated at £1.6
and £10.7 billion, respectively, of which 37% of the
direct costs relate to physiotherapy (Mandiakis and
Gray, 2000). Indeed, physiotherapy services, which are
well established in public and private healthcare systems
worldwide (WCPT, 2006) are widely consulted by
LBP patients internationally (Philadelphia Panel, 2001;
Stanley et al., 2001; Moore and Hurley, 2005).

1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2007.05.017
 ARTICLE IN PRESS
442 S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449
‘Acute LBP’ (ALBP) is defined as pain that is present
for 12 weeks or less (p12 weeks), and ‘Chronic LBP’
(CLBP) as pain that is present for more than 12 weeks
(van Tulder et al., 2006). Maetzel and Li (2002) in a
comprehensive review of economic analyses, reported
that CLBP patients account for the largest proportion of
related costs, despite comprising the smallest proportion
of back pain sufferers. European Clinical Guidelines
advocate prompt management of LBP in the primary
care setting to prevent the development of chronic
disability, and to minimise the associated increase in
financial and social burdens (van Tulder et al., 2006).
Ireland, unlike most of its European counterparts, has
no national LBP guidelines, and the primary health care
infrastructure remains underdeveloped due to the
delayed implementation of the Irish Primary Care
Strategy (DOHC, 2001a), which aims to decrease the
burden on secondary care by providing prompt access to
local community-based multidisciplinary healthcare,
i.e. complementing existing general practitioner (GP)
services with nursing, physiotherapy and occupational
therapy, etc. Currently, publicly funded outpatient
physiotherapy services for LBP in Ireland are located
in urban-based secondary care hospitals, characterised
by long waiting times and medical practitioner referral
(Cremin and Finn, 2002; Moore and Hurley, 2005).
Whilst this public service is, in principle, available to all
patients, evidence suggests that GPs tend to reserve
referral for the 28% of the population (IMO, 2005) who
qualify for free healthcare via a means-tested medical
card (Casserley-Feeney et al., 2007). Conversely, private
physiotherapy is widely available in both urban and
rural community settings throughout the country, is
characterised by short waiting times and does not
require medical practitioner referral (Dunne, 2003).
However, as treatment charges apply, this effectively
limits the service to those who can afford to fund their
own treatment.
While the physiotherapy management of LBP has
been previously reported for many countries, there has
been no comparison of public and private services, nor
has any independent data been published for the
Republic of Ireland (Battie et al., 1994; Foster et al.,
1999; Li and Bombardier, 2001; Gracey et al., 2002). In
Ireland, 52% of the population hold private health
insurance (HIA, 2005), which is higher than most other
European countries, where less than 25% of inhabitants
rely on private healthcare (i.e. United Kingdom 85%
public, Propper, 2000; Germany 76% public, Thomson
and Dixon, 2006; Greece 75% public, WHO, 2006a, b).
Thus, an almost 50:50 two-tier ‘public–private’ model of
healthcare exists in Ireland and this is reflected in the
provision of physiotherapy services, where anecdotal
evidence of service inequity has been reported.
The aim of the current study was to establish the
differences if any, between the physiotherapy management
of LBP in the public and private healthcare sectors in
Ireland. This was addressed under three main headings:
 The profile of the patients.
 The physiotherapy management of LBP including
patient access to services.
 The profile of the physiotherapists.
2. Methods
A retrospective survey of public and private phy-
siotherapy charts for LBP patients managed within a
Dublin City healthcare area, who received treatment in
2003 was conducted. The Research Ethical Committee
of the participating hospital approved the study proto-
col. The study centres included the Physiotherapy
Department of a large teaching hospital in Dublin city
(‘Hospital setting’) and the three private physiotherapy
practices (‘Private practice setting’) within the same
healthcare area.
2.1. Definitions
The terms ‘Hospital’ and ‘Public’ are used inter-
changeably in this paper, and refer to patients treated in
the public hospital setting where all physiotherapy
treatment was funded by the Department of Health
and Children. ‘Waiting time’ referred to the length of
time in weeks from the date of referral by the GP to the
date of first physiotherapy treatment. In the private
setting, patients were given prompt appointments and
incurred no waiting period. ‘Treatment duration’
referred to the time in weeks from the first date of
physiotherapy treatment to the date of treatment
cessation.
2.2. Survey instrument
The researcher-administrated survey instrument was
developed following a literature review of previous
studies of a similar topic to enhance its content validity
(Foster et al., 1999; Gracey et al., 2002; Armstrong
et al., 2003). Face validity was then established by pilot
testing the tool on a total of 10 physiotherapy charts
(n ¼ 5 per setting) resulting in minor formatting
adjustments where ‘‘date of GP referral received’’ was
included and ‘landscape format’ was selected over
‘portrait format’. The resultant survey-instrument
comprised two sections which gathered information
regarding (i) ‘patient profile’ (i.e. age, gender, LBP
chronicity) and (ii) ‘physiotherapy management of LBP’
(i.e. waiting time, types of treatment, number and
duration of treatments). In addition, information
regarding physiotherapists’ profile was gathered from
all physiotherapists who provided treatment in both
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S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449
settings (i.e. years qualified, years experience in muscu-
loskeletal area, postgraduate courses completed since
qualification) by telephone interview by the researcher.
2.3. Sample
The study population was defined as the physiother-
apy charts of all patients, aged at least 18 years, who
attended for physiotherapy treatment for LBP between
1st January and 31st December 2003 in the participating
centres. In the hospital setting, all patients were referred
by their GPs. In the private practice setting, all patients
were GP or self-referred. Charts were excluded for the
following reasons: LBP due to an underlying condition/
diagnosis such as osteoporosis, inflammatory disease,
fracture including compression fractures, pregnancy
related or post partum LBP. Charts were also excluded
if patients were referred with more than one complaint,
if there were associated medico-legal proceedings, if they
still continuing treatment into 2004, or if they were not
referred by a GP (e.g. post surgical referral, etc.).
2.4. Procedure
Between May and November 2004, relevant phy-
siotherapy charts were accessed and coded by a non-
identifying integer, and data entered into the survey
instrument on site. The therapist data were collected in
December 2004, but related to their details at time they
treated patients (i.e. 2003).
2.5. Data analysis
Data were computerised, checked by one of the
authors (SCF) for errors by comparison with the raw
data and cleaned as required, then analysed using the
Statistical Package for the Social Sciences version 11.0
(SPSS Inc., Chicago, Illinois). Both descriptive and
inferential statistics were used. Descriptive statistics
were used to explore patient profiles and physiotherapy
management details. Differences between public and
private settings regarding patient profiles and phy-
siotherapy management details were investigated using
parametric (independent t test) and non-parametric tests
(w2-square test; Mann Whitney U test) as appropriate.
Data were further explored by dichotomising pain
duration (i.e. ALBP or CLBP) to stratify patients within
each setting and differences between public and private
in treatment details were examined using non-para-
metric tests (w2-square test; Mann Whitney U test) as
appropriate. Differences between public and private
settings regarding physiotherapist profile details were
examined using non-parametric tests (w2-square test;
Mann Whitney U test) as appropriate. Significance was
set at the 5% level throughout. For completeness, all
available hospital or private physiotherapy charts that
443
had been created were included. Where data relating to
a particular variable (i.e. pain duration or treatment
details) was missing, these charts were omitted from the
relevant analysis.
3. Results
A total of 308 patients were identified, of which 139
(45%) were in the hospital setting (H) and 169 (55%)
were in the private practice setting (Pr). In the public
setting, 46 charts were excluded (did not meet eligibility
criteria n ¼ 35; charts missing n ¼ 11). Within the
private setting, 13 charts were excluded as patients did
not meet eligibility criteria. Thus a total of 249 patient
charts were included (H ¼ 93, 37%; Pr ¼ 156, 63%).
3.1. Patients profile—public versus private
In the public setting there were a significantly higher
percentage of females, and a significantly older age
group than the private setting (mean difference ¼ 9.9
years, 95% confidence interval (CI): 6.147–13.742;
po0.001, Table 1). Data regarding pain duration were
available for 90% (n ¼ 84) of public patients and 83%
(n ¼ 130) of private patients, allowing classification as
‘ALBP’ or ‘CLBP’, and all analyses were based solely on
these data. There were significantly higher percentages
of ALBP patients in the private setting than the public
setting at the time of referral (98% vs. 50%; w2 ¼ 69.89;
df ¼ 1; po0.001), and at the start of physiotherapy
treatment (98% vs. 27%; w2 ¼ 120.34; df ¼ 1; po0.001;
Fig. 1). Furthermore, 23% of patients in the public
setting progressed from ALBP to CLBP while waiting
for physiotheraphy.
3.2. Physiotherapy management—public versus private
Patients in the public setting incurred a significantly
longer median waiting time of 10 weeks for physiother-
apy (po0.001), and received a significantly higher
number of treatments (mean difference ¼ 3.47, 95%
CI ¼ 4.18 to 2.78; po0.001) over a longer duration
(median difference ¼ 5.0 weeks, inter-quartile range
(IRQ) ¼ 7.6: po0.0001) compared to the private setting
(Table 1). Further analysis of the influence of LBP
chronicity (ALBP: Pr ¼ 126, H ¼ 22; CLBP: Pr ¼ 3,
H ¼ 55) showed that public patients with ALBP had a
significantly longer waiting time, number of treatments
and treatment duration than their counterparts in the
private setting (po0.001; Table 1). There were similar
trends for CLBP but there were not tested due to the low
number of CLBP patients in the private setting (n ¼ 3).
Of the 249 charts reviewed, data regarding treat-
ment approaches were available for 85% (n ¼ 79)
of public and 99% (n ¼ 155) of private patients.
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444 S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449

Table 1
Patient profile and physiotherapy management details

Public hospital (H) Private practice (Pr) p value

Patient baseline characteristics n ¼ 93 n ¼ 156

Female % (n) 66 (61) 50.0 (78) 0.017
Age (yr) mean (SD) 46.0 (20.0) 36.0 (10.0) o0.001
Physiotherapy management details n ¼ 79 n ¼ 155
Waiting time (weeks) median (IQR) 10.0 (20.0) 0.0 (0.0) o0.001
Number of treatments mean (SD) 6.0 (3.5) 2.5 (2.0) o0.001
Treatment duration (weeks) median (IQR) 6.0 (9.6) 1.0 (2.0) o0.001
Physiotherapy management details stratified for ALBP/CLBP
ALBP (at time of treatment) n ¼ 22 n ¼ 126
CLBP (at time of treatment) n ¼ 55 n¼3
Waiting time (weeks) median (IRQ)
Acute LBP 1.92 (3.7) 0 (0) o0.001
Chronic LBP 11.7 (18.5) 0 (0) Not tested
Number of treatments median (IRQ)
Acute LBP 5.0 (4.0) 2.0 (2.0) o0.001
Chronic LBP 5.0 (3.0) 2.0 (0.0) Not tested
Treatment duration (weeks) median (IRQ)
Acute LBP 5.5 (5.1) 1.0 (2.0) o0.001
Chronic LBP 6.0 (10.1) 1.0 (0.0) Not tested

ALBP: acute low back pain (duration p12 weeks); CLBP: chronic low back pain (duration 412 weeks) (yrs: years, wks: weeks, SD: Standard
Deviation; IQR: Inter-quartile range).

100 and advice (H: 54%, n ¼ 43; Pr: 18%, n ¼ 29), with a
significantly higher use of the latter two interventions in
90
the public setting (po0.001). Furthermore, a signifi-
80 cantly higher number of patients in the private setting
Acute (H: 0.05%, n ¼ 4; Pr: 32.9%, n ¼ 51) attended for only
70 Chronic one treatment (w2 ¼ 34.96; po0.001).
60 Further analysis with stratification for pain duration,
found that apart from a significantly higher use of
50 advice in the public setting, there was no difference in
%

the treatments being used for ALBP in either setting,

40
(po0.001; Fig. 2a), with a similar trend for CLBP
30 although not tested due to small sample in the private
setting (Fig. 2b).
20

10
3.3. Physiotherapists profile
0
At referral** At start At referral** At start
physio- physio-
All nine female physiotherapists who treated patients
therapy*** therapy*** during the study period were analysed (H ¼ 5; Pr ¼ 4,
Hospital (n=84) Private (n=130)
Table 2). Those working in the private setting were
qualified for a significantly longer time period (median
Fig. 1. Low back pain duration in hospital (public) and private difference ¼ 12 years, IQR ¼ 9.75: p ¼ 0.033), and
settings had significantly more experience in the manage-
ment of patients with musculoskeletal conditions
(median difference ¼ 9.6 years; IQR ¼ 8.11: p ¼
The most common treatments were passive mobilisa- 0.027). Therapists in both settings had completed a
tions (H: 77%, n ¼ 61; Pr: 76%, n ¼ 117), home range of postgraduate courses, and only one respondent
exercises (H: 49%, n ¼ 39; Pr: 43%, n ¼ 67), core in the private setting had completed a Masters degree in
stability exercises (H: 46%, n ¼ 36; Pr: 25%, n ¼ 38), Manipulative Physiotherapy.
 ARTICLE IN PRESS
S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449 445

90
80 Private n=126
70 Hospital n=22
60
% 50
40
30
20
10
0
s

EP

SE

**

ck

ET
e
ob

se

IF
ce

th

pa

M
H

C
ci
M

O
vi

ot
er

Ad

H
Ex
Treatment Approaches

120

100

80 Private n=3
Hospital n=55
%

60

40

20

0
s

EP

SE

ce

er

ck

n
ob

se

io
IF
th

pa
vi
H

at
ci
M

O
Ad

ot

ul
er

ip
Ex

an
M

Treatment Approaches

Fig. 2. (a) Acute LBP: treatment approaches in public and private settings. (b) Chronic LBP: treatment approaches in public and private settings.

Table 2
Physiotherapist profile

Public hospital Private practice P value

(n ¼ 5) (n ¼ 4)

Physiotherapist characteristics
Years qualified median (IQR) 2.0 (5.0) 12 (14.8) 0.033
Years musculoskeletal experience median (IQR) 0.4 (3.6) 10 (11.8) 0.027
Postgraduate courses (n)
Weekend courses 5 4 ns
Short coursesa 3 3 ns
Masters degree 0 1 ns
a
Short courses comprises recognised musculoskeletal courses including: Postgraduate Diploma/McKenzie/Cyriax/Maitland/Mulligan.

4. Discussion percentage of patients with CLBP, significantly longer

This study has investigated for the first time the
physiotherapy management of LBP in public and
private healthcare sectors. The public physiotherapy
service was characterised by a significantly higher
waiting times, and higher number of treatments
over a longer time span for all LBP patients, in contrast
to the private sector where prompt management of
acute LBP conditions over a relatively short period was
the norm.
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446 S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449
The current study reports the situation for a major
city in Ireland and may be limited by its regional focus,
however the treatment venues are representative of
public and private physiotherapy venues in Ireland
(Dunne, 2004; Moore and Hurley, 2005), and patient
age and gender profiles are consistent with the arche-
typal patient with LBP internationally availing of
physiotherapy (Foster et al., 1999; Gracey et al., 2002;
Bekkering et al., 2004; Byrne et al., 2006). Furthermore,
the retrospective design necessitated a reliance on the
accuracy and completeness of physiotherapy charts
which creates obvious limitations, and the small number
of private chronic LBP patients prevented subgroup
analysis within this group. It is also acknowledged that
information regarding treatment effect or outcome is
unavailable, consistent with previous research findings
in Ireland and the UK (Foster et al., 1999; Caulfield and
Reilly, 2003). However, a pragmatic randomised con-
trolled trial is currently evaluating, for the first time, the
outcomes and costs for LBP patients managed by public
and private physiotherapy sectors in Ireland, and its
findings may have important implications for future
health policy regarding physiotherapy service provision
(Casserley-Feeney et al., 2006).
In the current study, results regarding patient profile
showed a significantly higher percentage of chronic LBP
patients within the public compared to the private
sector, and although this is consistent with previous
research, the proportion of patients with CLBP in the
public sector in this study (73%), was even higher than
previous studies (53%, Foster et al., 1999; Gracey et al.,
2002), while the proportion of patients with CLBP in the
private sector (2%), is much lower (20%, Foster et al.,
1999). This finding was surprising, and may be related to
GP referral strategies and the physiotherapy manage-
ment of public physiotherapy waiting lists. Previous
work by members of our research group found that GPs
in this healthcare area tend to delay referral of the
majority of patients to public physiotherapy services due
to the long waiting time preferring to manage them with
advice and medication only, while simultaneously
encouraging those who could afford private physiother-
apy to seek it as soon as possible (Fullen et al., 2006). It
is anticipated that the development of primary care
physiotherapy services, which are currently being
piloted in 10 national sites across Ireland, should
increase the availability of public outpatient physiother-
apy (DOHC, 2001a), when the Irish Governments
Primary Care Strategy is fully implemented. This should
facilitate more prompt access to primary care, including
out of hours services, as well as extended screening and
triage clinics for a variety of conditions, including LBP
(DOHC, 2001a). The benefits of such approaches have
been previously reported in the UK (Bartley, 2000), and
while Curley et al. (2004) demonstrated the effectiveness
of a physiotherapy-led LBP triage clinic in a public
hospital in the Republic of Ireland, this is clearly not
current routine practice in Ireland.
Secondly, the median waiting time for public phy-
siotherapy of 10 weeks reported in this study resulted in
23% of patients becoming chronic whilst waiting to
receive a public physiotherapy appointment. An earlier
GP survey reported a waiting time of 6 weeks for
public physiotherapy (Cremin and Finn, 2002), suggest-
ing that the situation is, if anything worsening and
confirms the disparate waiting times for non-emergency
services between the Irish public and private health
services in general (DOHC, 2001b). Conversely, prompt
access to appropriate services for patients failing to
return to normal activities (van Tulder et al., 2006) was
evident within the private physiotherapy sector in
Ireland. In view of the literature, which clearly
demonstrates the increased social and economic burden
associated with CLBP (Maetzel and Li, 2002), and
increased risk of poorer physical and psychosocial
outcomes for those with chronic rather than acute
presentations (Bekkering et al., 2004; Wand et al., 2004),
it is clear that physiotherapy management strategies to
minimise public physiotherapy waiting times are re-
quired to limit the development of chronicity, and
one issue that may be explored is that differences in
referral procedures for access to physiotherapy between
health settings. Public patients in Ireland require a
medical practitioner referral to access public physio-
therapy, whilst private physiotherapy is accessible by
self-referral. Internationally, self-referral to public ser-
vices, has been shown to reduce GP work burden,
patient waiting time, medication prescription costs,
tertiary referral rates and patient non-compliance with
treatment advice (Holdsworth and Webster, 2004;
Holdsworth et al., 2006) and to result in shorter, less
costly treatments and decreased utilisation of other
health services (Mitchell and de Lissovoy, 1997), and
this should be implemented in the public health service
in Ireland.
Furthermore, findings regarding physiotherapy man-
agement showed a significantly higher number and
longer duration of treatment within the public setting
compared to the private setting. The number of
treatments in the public setting is similar or lower than
previously reported for other countries (USA-8.5 treat-
ments, Mielenz et al., 1997; Northern Ireland-5, Gracey
et al., 2002; UK-5, Frost et al., 2004; Sweden 8.2,
Ekman et al., 2005; New Zealand-5.2, Monk, 2006;
Canada-7.5, Perreault and Dionne, 2006), but interna-
tional comparison is fraught with difficulties due to
differences in healthcare systems and the heterogeneity
of research protocols, and no previous work has
compared public and private physiotherapy settings
directly. It might have been anticipated that pain
duration (greater chroncity in the public setting) would
influence these results, but results show that this was not
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S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449
the case. Rather the differences may be related to the
varying physiotherapist profiles which found that the
public setting, where clinicians invariably commence
their professional careers, had a higher percentage who
were qualified for a shorter time, and had less
musculoskeletal care experience. Previous literature has
found that less experienced therapists provide a higher
frequency and duration of physiotherapy treatment
(Gracey et al., 2002; Whitman et al., 2004; Swinkels
et al., 2005), and although therapist experience was not
shown to adversely influence patient outcome, this has
implications for the effective use of already stretched
public physiotherapy.
It is evident that patient characteristics such as the
socioeconomic group (Dunlop et al., 2001; Latza et al.,
2004; Carr et al., 2005), inevitably lower in the public
setting, and the presence of adverse psychosocial factors
(Pincus et al., 2002) may have influenced the number
and duration of treatments and should be considered in
future research.
Finally, investigation of specific physiotherapy man-
agement reveals a wide range of similar physiotherapy
treatment approaches were used in both settings,
notwithstanding a significantly higher use of advice
and core stability exercises in the public sector. It is
possible that lack of documentation by private phy-
siotherapists of ‘‘advice’’ as a treatment, gave rise to this
finding but this in itself warrants further investigation as
documentation of all treatment forms a minimum
standard practice (CSP, 2000). The routine practice of
‘‘multi-modal, multi-session physiotherapy treatment
packages’’ identified in this study, is consistent with
previous surveys of the public physiotherapy manage-
ment of LBP in Ireland and the UK (Foster et al., 1999;
Gracey et al., 2002; Armstrong et al., 2004; Byrne
et al., 2005). However, in view of current clinical
guidelines for LBP, the overall use of the recommended
approaches of advice, exercise and manipulation was
relatively low (o60%). Furthermore, similar ap-
proaches were used for acute and chronic LBP in both
settings, but it is unclear whether this was due to a lack
of awareness or lack of adherence to available guide-
lines, or may reflect the absence of national LBP clinical
guidelines, as well as the non-dissemination of European
Guidelines (van Tulder et al., 2006; Airaksinen et al.,
2006). Despite guidelines to encourage the use of
exercise, cognitive behavioural therapy (CBT) or multi-
disciplinary (MDT) management with CLBP, there was
no evidence for the use of these approaches in the
private setting, but there was some evidence for the use
of exercise in the public setting. In conflict with clinical
guideline recommendations, there was some use of
interferential therapy (H: 11%; Pr: 15.2%), but it was
considerably lower than previous surveys (41%, Foster
et al., 1999; 30%, Gracey et al., 2002). While spinal
manipulation is advocated for ALBP (UK BEAM,
447
2005), its use was extremely low in both settings
(H: 1.2%; Pr: 0%), and may reflect the lack of therapist
training in these techniques. Previously the effect of
manipulation for LBP by osteopaths, chiropractors and
physiotherapists in the public and private healthcare
sectors in the UK has been jointly investigated
(UK BEAM, 2004), but the singular effect of physio-
therapy treatment in various health settings remains
poorly understood. The current study provides an
insight into differences in physiotherapy services and
patient profiles between the public and private health-
care sectors in Ireland’s capital city, Dublin, and
provides a framework which could allow researchers
from other countries with similar disparate health care
systems to conduct comparative studies. While many
other European countries possess a two-tier healthcare
model (i.e. France, Belgium and Netherlands), the
extent of the public:private funding ratio varies and
may affect the quality of health services (NAO, 2004).
There is also scope to develop a Pan European study
that would investigate and compare the influence of
healthcare models on the delivery of physiotherapy, the
implementation of clinical guidelines for LBP and
patient outcomes.
5. Conclusions
This study identified, for the first time internationally,
differences between public and private physiotherapy
sectors regarding LBP patient profiles, physiotherapy
management of LBP physiotherapy and physiotherapist
profiles. It particularly emphasised differences in
public and private waiting times and that 23% of public
patients became chronic while waiting for public
physiotherapy treatment. It reinforced the concept of
an inequitable two-tier system of health care in Ireland
and justifies the need for further exploration of this topic
which is currently underway via a randomised con-
trolled trial. It is proposed that adherence to the recent
European Clinical Guidelines for LBP would be
enhanced in Ireland by the full implementation of the
Irish Primary Care Strategy to develop public
primary care services, as well as changes in the physio-
therapy management of LBP in line with the current
evidence base.
Acknowledgements
The authors thank Health Research Board Project
Grant for financial support, physiotherapists and
administrative staff who participated in the study and
Mr. Philip Phelan for some data collection.
Competing interests/disclosures
No conflict of interest for disclosure.
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448 S.N. Casserley-Feeney et al. / Manual Therapy 13 (2008) 441–449
Presentations
Oral presentation at the Society for Back Pain
Research Annual Conference, University of Warwick,
Coventry, UK, 10–11 November 2005.
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