Pressure to provide ongoing passive treatment for chronic low back pain
At a private physiotherapy clinic in Hamilton, the practice manager tells you to keep booking a 52-year-old man for weekly passive mobilisation and ultrasound. He has a 12-year history of non-specific low back pain, no red flags, and has completed 12 sessions with no meaningful change in function. He says the sessions 'help him cope' and that his ACC entitlement should cover ongoing treatment. The clinic's revenue is down 18% this quarter and the manager says 'if we discharge him, he will just go elsewhere; we need the bookings'. The patient has asked you not to send him back to his GP because 'they will just tell me to exercise'. You have already provided an exercise programme, which he has not followed.
1. What professional, ethical and legal issues arise?
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Several issues arise. Professional standards under the HPCA Act 2003 and the Physiotherapy Board's Code of Ethics require practice to be evidence-informed, patient-centred and free from financial conflict of interest. The manager is asking me to provide treatment primarily for revenue, which risks overtreatment and breaches the principle of acting in the patient's best interests. The patient is asking for ongoing passive treatment and ACC funding; ACC does not entitle him to unlimited sessions, and claiming for treatment that is not clinically indicated could be fraudulent. Informed consent is not valid if I misrepresent benefit. There is also a power imbalance: he has chronic pain and may feel abandoned if I discharge him. I must not collude with the manager or blame the patient. I would review the ACC contract and clinic policy, check whether there is any documented functional goal, and consider whether the passive treatment is providing meaningful benefit. If not, I have an ethical duty to change the plan, not simply continue. I would seek peer or professional advice if pressured.
2. How do you apply evidence-based practice and shared decision-making without abandoning him?
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Evidence for chronic non-specific low back pain supports exercise, self-management, education and biopsychosocial approaches; passive modalities such as ultrasound and massage have weak or no evidence for long-term benefit. I would use a shared decision-making conversation: acknowledge that the sessions help him cope, explore what specifically helps - touch, reassurance, time away from work - and explain the limits of passive treatment. I would set functional goals with him, offer a graded exercise and activity plan, and link him to a pain team or community programme. I would not simply say 'there is no evidence' and discharge him. I would offer a short, planned transition: reduce frequency, teach self-management, review at six weeks, and keep the door open. If he declines exercise, I would document that and still avoid ineffective treatment. The reasoning is that evidence-based practice includes patient values, not just research evidence, but it does not require providing ineffective care.
3. What do you say to the practice manager and what do you document?
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I would speak to the manager privately and directly: 'I can't book treatment that I don't believe is clinically indicated, and I'm accountable to the Board for that.' I would explain the professional, ACC and fraud risks, and the reputational risk to the clinic. I would propose alternatives: a pain self-management group, a review of the ACC pathway, or auditing bookings for clinical need. I would not be drawn into an argument about revenue; I would keep the focus on the standard of care. I would document the conversation, the patient's goals, the treatment plan, the evidence discussed, and the patient's response. If the pressure continued, I would escalate to the clinical lead or seek advice from the Physiotherapy Board or my professional indemnity insurer. Documentation should be factual and contemporaneous.