Patients' perceived needs for allied health, and complementary and alternative medicines for low back pain: A systematic scoping review

Abstract Objectives Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP. Methods A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990‐2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated. Results Forty‐four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed‐methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short‐term duration of these therapies. Conclusions Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient‐centred guidelines and service models for LBP. Understanding patients' concerns regarding active‐based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health‐care system.


| INTRODUCTION
Low back pain (LBP) is a major public health problem and has been identified as the leading cause of disability worldwide. 1 Approximately 80% of adults experience at least one episode of LBP during their lifetime. 2 One in five adults and adolescents experience persistent LBP symptoms. 2 Persistent LBP is associated with significant individual functional impairment, high utilization of health care, work absenteeism and long-term incapacity. 3 The economic burden of LBP is substantial and was estimated to exceed $US100 billion per year according to a review performed in 2006. 4 To address this problem, evidence-based guidelines have been developed to optimize treatment outcomes for people with LBP. Most clinical practice guidelines for chronic LBP recommend patient education, supervised exercises, multidisciplinary treatment and cognitive behavioural therapy, as well as short-term use of pharmacological therapies such as paracetamol, non-steroidal anti-inflammatory drugs and weak opioids. [5][6][7] Currently, the guidelines do not recommend the use of chiropractic therapies as unimodal or long-term interventions or complementary and alternative medicines (CAM), based on inconclusive and conflicting evidence regarding efficacy and potential risk of harm. [5][6][7][8] CAM therapies are heterogeneous and include a range of diagnostic and therapeutic modalities that lie outside of conventional health care in Western societies, but may be more mainstream in other settings. 9 Despite the lack of evidence, population-based studies have found that approximately a third of patients with LBP visit CAM practitioners and 45% seek care from chiropractors. 10,11 The high prevalence of CAM use among patients with LBP mirrors that of other chronic illnesses such as arthritis, cardiovascular disease, asthma and diabetes. 12,13 In this situation, it may be due to the high level of patient dissatisfaction with LBP management from medical practitioners, 14,15 a strong desire for pain relief that is not achieved through other treatment options in a timeframe acceptable to patients, 16 information from peers or other providers or a preference for passive therapies, rather than an active approach to LBP care. Furthermore, alignment of clinical practice with guidelines is suboptimal with <50% of patients with LBP being referred for active rehabilitation strategies, despite these being recommended in all guidelines, including the most recent NICE guidelines. 17,18 Currently, the utilization of health services for LBP does not adequately mirror recommendations in clinical practice guidelines or models of care. The uptake of clinical practice guidelines depends on a complex interplay of factors related to patients (micro level), health-care providers/organizations (meso-level) and health systems (macro level). While the suboptimal utilization of LBP clinical guidelines may be related to resource restraints at the level of health systems, or physician factors such as a lack of knowledge of recommended guidelines, the patient plays a pivotal role in use of guidelines and evidence-based medicine generally [19][20][21][22] The patient ultimately decides which services they will use. LBP guidelines have largely been developed by health-care professionals, who determine the primary outcomes, whereas the need for and success of health-care interventions may be differently perceived by the patient. 23 Therefore, identifying and understanding the patient perspective and their perceived needs of health services for LBP may provide insight into suboptimal patient uptake of, or adherence to, best-practice care for LBP. Identifying where patients' needs align with best practice and where and why they deviate may inform more effective patient-centred service delivery models. Within the context of physical therapies for LBP management, physiotherapy, chiropractic and some CAM modalities are the most frequently accessed treatment modalities. 24 Therefore, we aimed to conduct a systematic scoping review to provide a broad overview of the existing literature regarding patient perceived needs of physiotherapy, chiropractic therapy and CAM for LBP. Given the breadth of this topic, this review examines the perceived needs of allied health and CAM and does not cover medical services.

| METHODS
We performed a systematic review to identify what is known about patients' perceived needs of physiotherapy, chiropractic therapy and CAM for LBP within a larger project examining the patients' perceived needs relating to musculoskeletal health. 25 A systematic scoping review was performed to enable a comprehensive exploration of the patients' perspective, map the existing literature and identify gaps in the evidence. 26,27  both MeSH terms and text words. Based on the outcomes of the search, we grouped the data broadly according to discipline, rather than specific intervention as most of the data in the included studies referred to disciplines, rather than interventions. To ensure objectivity in this framework, we developed operational definitions of each discipline to accommodate studies where specific interventions were reported. We have used the term "physiotherapy" to capture therapeutic exercise, general exercise or physical activity guided or prescribed by a physiotherapist, manual therapies, education, or other physical therapies or aids commonly applied or used by a physiotherapist. The term "chiropractic therapy" refers to spinal and joint manipulation delivered by chiropractors. The term "CAM" incorporates a variety of healing resources including acupuncture, homoeopathy, osteopathy, massage therapy, reflexology, heat therapy, naturopathy, traditional Chinese Medicine and Reiki. There is potential for overlap between the treatment modalities offered between the disciplines of physiotherapy, chiropractic therapy and CAM. The detailed search strategy is provided in the Appendix S1.

| Search strategy and study selection
Between three authors, LC (consultant Rheumatologist), TR (physiotherapist) and WP (PhD Candidate), the results of the search strategies were reviewed independently and in duplicate for relevance.
The initial screening was set to be open-ended, and all study designs were included to retain as many relevant studies as possible. Studies were included if they met the inclusion criteria: (i) patients older than 18 years, (ii) studies had to report on the patients' perspective of needs of physiotherapy, chiropractic and CAM for LBP and (iii) patients with LBP with or without leg pain, excluding LBP from fractures, malignancy, infection and inflammatory spinal disorders. Patients' perceived needs referred to patients' capacity to benefit from services, including their expectations of, satisfaction with and preferences for various services. 28 Only human studies in the English language and full-text articles were included. Those that appeared to meet inclusion criteria were retrieved, and the full text was assessed for relevance. A manual search of the reference lists of the obtained studies and review articles was conducted to identify further studies for inclusion in the review.

| Methodological quality assessment
To assess the methodological quality of the included studies, the first author reviewed all of the included studies (LC) while the second review was performed by one of two authors (TR and WP) who independently assessed all the studies. For qualitative studies, the Critical Appraisal Skills Programme (CASP) tool was used. 29 Hoy et al's 30 risk of bias tool was utilized to assess the external and internal validity of quantitative studies: low risk of bias of quantitative studies was defined as scoring 8 or more "yes" answers, moderate risk of bias was defined as 6 to 7 "yes" answers, and high risk of bias was defined as 5 or fewer "yes" answers. The reviewers discussed and resolved disagreements through consensus. Any disagreements in scoring were reviewed by the senior author (AW).

| Data extraction and analysis
One investigator (LC) extracted the data from relevant studies using a standardized data extraction form developed for this scoping review.
The following data were systematically extracted: (i) author and year of publication, (ii) study population (patient age and gender, population source, population size and duration of LBP), (iii) description of the study methods and (iv) primary study aim. Included studies were examined using the principles of meta-ethnography to synthesize qualitative data. 31 In the first stage, one author (LC) initially developed a framework of concepts and underlying themes, based on primary data in the studies and any pertinent points raised by the authors in the discussion. These key themes were then reciprocally translated across the included studies. In the second stage, two senior authors (FC and AW) with over 15 years of clinical rheumatology consultant-level experience and a senior physiotherapist (AMB) independently reviewed the framework of concepts and themes to ensure clinical meaningfulness.

| Overview of articles
The search returned 2202 articles, of which 44 studies explored LBP patients' perceived needs of physiotherapy, chiropractic therapy and CAM, based on the discipline definitions we developed. A PRISMA flow diagram detailing the study selection is shown (Figure 1).
The descriptive characteristics of the included studies are shown ( T A B L E 2 Patients perceived needs of allied health and complementary and alternative medicine (CAM) related to back pain

Author & Year Results
Physiotherapy and exercise therapy (includes therapeutic exercise, general exercise or physical activity guided or prescribed by a physiotherapist; manual therapies; education; other physical therapies or aids) Expectations for physiotherapy, including a preference for physiotherapy and exercise therapy Amonkar (2011) 14 Patients value physiotherapy/osteopathy more than care delivered by medical practitioners Cooper (2009) 36 All participants "wanted direct access to a physiotherapist" and/or "follow up in the future" 36 The physiotherapist was seen as the expert in LBP Some participants thought that is "would be helpful if the patient was able to telephone the physiotherapist, using it as a form of helpline for LBP" 36 Crowe (2010) 70 "Most participants recognized exercise as effective" 70 "Low impact exercise was strongly favoured as a self-management strategy by participants" 70 15 participants identified that "healthcare professionals played a role in their self-management" 70 "The nominated professionals were predominantly physiotherapists or general practitioners" 70 Ferreira (2009) 65 On average, "patients perceived that an intervention would have to make them 'much better', which corresponded to 1.7 (SD 0.7) on the 4 point scale or improve their symptoms by 42% to make it worthwhile" 65 Grimmer (1999) 66 Patients chose to attend their physiotherapist for a variety of reasons, the most common of which were "convenience, reputation, previous good experience and/or recommendation" 66 Liddle (2007)  Only a few "patients prefer continual exercise, most prefer exercising only if pain reappears" 63 Schers (2001) 64 Only a few patients "would ask for a referral to a physiotherapist when symptoms would last a few more weeks" 64 Patients thought of physiotherapy "mainly as massage or other passive treatment" 64 Yardley (2010) 32 Exercise therapy and the Alexander Technique were perceived to be unlikely to cause harm, therefore participants were willing to try these interventions even when expectations for benefit were felt to be minimal Exercise therapy and the Alexander Technique were perceived to be another "opportunity to try something new since previous attempts to relieve back pain were unsuccessful" 32 Beliefs about physiotherapy and exercise Dima (2013) 38 Patients believe that manual therapies realign the spine, release the nerves and strengthen the muscles. They feel that physiotherapy results in temporary relief, and maintains/prevents worsening and cures back pain. Patients perceive exercise as strengthening muscles, reducing stiffness, improves mental state and weight loss. They think exercise results in temporary relief, maintenance, enables activity and cure. Grimmer (1999) 66 "Patients expected symptom relief at the end of the first treatment" 66 Heyduck (2014) 58 "Patients had very high expectations about rehabilitation (i.e. that it addresses their personal needs and is diversified)" 58 They had high expectations on the results of rehabilitation, that is that it improves somatic and psychological aspects. 63 "Patients believe that continuing exercises might prevent relapse but they face a conflict between knowing that they should perform and feeling it is difficult to adhere" 63 Scheermesser (2012) 62 9 of 13 agreed that "activity has a positive impact on health"; however, the "majority of patients felt that exercise was good but did not improve back pain" 62   67 "All participants acknowledged the importance of an exercise environment based on health promotion rather than remediation of the sick/injured" 67 12 of 18 participants reported that gym equipment was useful Yardley (2010) 32 "Few participants hope for a complete cure, but many were desperate to attain some degree of pain relief" 32 "Patients wanted insight into how to prevent or manage episodes of back pain better" 32 Exercise therapy and the Alexander Technique were perceived to be unlikely to cause harm, therefore participants were willing to try these interventions even when expectations for benefit were felt to be minimal Individualizing physiotherapy and exercise Keen (1999) 39 "Health professionals were rarely effective in enabling a participant to sustain (6 + months) increased physical activity except where an individual had regular contact with a health professional" 39 Exercise advice needs to be "tailored to the individual's circumstance" 39 (Continues)

Author & Year Results
Liddle (2007) 61 Patients "need individual exercises and advice regarding suitable lifestyle adaptations" 61 "Supervision of exercise programmes was considered important to provide individual correction" 61 "Participants wanted follow up and reassurance from the practitioner that they were carrying out instructions correctly and assistance with appropriate treatment progression in line with their stage of recovery" 61 Medina-Mirapeix (2009) 63 Patients know that they should perform exercises; however, they find it difficult to adhere   67 "All participants reported that they developed preferred exercise styles over time. The range of preferred exercise styles reinforced that the individual should be consulted in program design" 67 "Preferences ranged from individual to group, from unsupervised to closely supervised and included minimal disruption to their lives and exercises as part of recreational or routine daily practices" 67 Yardley (2010) 32 Patients "valued hands-on care, emotional support and detailed advice provided" 32 Concerns with physiotherapy and exercise Dima (2013) 38 They are concerned that it feels sore after manipulation, causing further damage and 'cracking' bones.
They are concerned about injuring the back and have difficulties maintaining motivation.
Slade (2009) 67 6/18 participants thought that "gyms were intimidating and prevented them from exercise engagement" 67 All "reported that compliance was difficult when they lacked confidence in correct exercise performance" 67 Westmoreland (2007) 43 "Disadvantages included the lack of a specific diagnosis, ineffective treatment and long waiting lists" 43 Yardley (2010) 32 Some participants were concerned that exercise therapy would make pain worse from previous experience Some patients were "concerned that physiotherapy would be difficult to fit into their lifestyle" 32 "Free time, bad weather, cost and lack of social support were perceived as obstacles to engaging in physiotherapy" 32 Exercise therapy was often perceived as unpleasant or difficult to keep up

Chiropractic therapy
Willingness to try chiropractic therapy or preference for chiropractic therapy Carey (1996) 48 "61% of adults with acute severe LBP did not seek any health care during their most recent episode of pain however 24% initially sought care from a physician, 13% from a chiropractor and 2% sought care from other providers (physical therapist, nurse, massage therapist)" 48 Lyons (2013) 51 Participants across groups considered "chiropractic a primary not complementary LBP treatment and said that DCs offered many modalities" 51 Perceived benefit, expectations and concerns with chiropractic therapy Borkan (1995) 71 "Non orthodox and folk healers (include reflexology, chiropractors, acupuncture, spiritual healers, movement therapy) often perceived as being more empathic, more knowledgeable and having better diagnostic skills and providing more effective therapies" 71 Carey (1995) 49 "Patients who saw chiropractors reported a significantly higher degree of satisfaction than those who saw practitioners" (primary care physicians, orthopaedics and HMO) in the other 4 strata. 49 "Higher level of satisfaction among the patients who saw chiropractors persisted after adjustment for the number of visits and the use of radiography" 49 Carey (1996) 48 "Those who sought care from chiropractors were more likely to feel that treatment was helpful (99% vs 80%, p = 0.001) and less likely to seek care from another provider for that same episode of pain (14% vs 27%)" 48 Lyons (2013) 51 Patients "expected chiropractors to provide hands on treatments or spinal manipulation to deal with the cause of the pain" 51 "Some participants noted that chiropractic adjustments did not relieve their LBP for several treatments, provided short term relief or produced side effects e.g. muscle pain" 51   52 More participants reported satisfaction in the chiropractic group compared to patients treated by family physicians   53 "Satisfaction was higher for patients attending chiropractors (compared to physicians)" 53 "Chiropractic patients expressed greater satisfaction regarding information and treatment provided" 53 "Chiropractic patients also reported greater improvement at 1 mo as measured by subjective assessment" 53 Sigrell (2001) 59 "Patients' main expectations of chiropractic management are an accurate diagnosis, an explanation of the complaint or affliction and treatment that results in a positive outcome" 59 Sigrell (2002) 60 "High agreement on the expectations that the chiropractors should find the problem and should explain the problem to the patient" 60 "Agreement that the patient should feel better and be free of symptoms" 60 "80% of patients agreed that 'the patient' should be given advice about training and exercises" 60

Author & Year Results
Characteristics of patients preferring chiropractic therapy Carey (1996) 48 Chiropractic care was more common among men than women and among younger adults than older "Those whose acute episode of pain did not begin at work were more likely to seek chiropractic care (66% vs 43%, P = .05)" 48 "Employed individuals were more likely to seek care from chiropractors" 48 No association between seeking care from chiropractor vs medical doctor based on ethnicity, education, income, insurance, worker's compensation status, population density, perceived health status, presence of leg pain or a previous history of surgery or recognition for LBP Strongest independent predictors of seeking care from a chiropractor for acute LBP was male gender, age <60 yo, attribution of cause to back pain to disc disease Carey (1999) 50 Proportion of chiropractic patients seeking care is greater than the proportion of patients with functionally disabling symptoms Sharma (2003) 54 "Self-referral to chiropractors was associated with history of LBP and acute LBP" 54 High proportion of self-pay patients with chiropractors "Older and higher income patients were more likely to select chiropractors" 54 "Patients who expressed confidence in the ability of their chosen providers to successfully treat their LBP were more likely to obtain care from chiropractors than were patients who lacked such confidence (OR6.08, 95%CI 3.84-9.63)" 54 "Patients with more favourable attitudes toward self-directed treatment and active behavioural involvement were somewhat more likely to choose chiropractors (OR "Almost all interviewed patients prefer Western medical treatment over traditional treatment" 62 Sherman (2004) 11 "More than half the respondents said they would be very likely to try acupuncture, chiropractic therapy or massage provided by their health plan for no additional cost and if their physician felt it was reasonable" 11 "Fewer respondents said they would be very likely to try meditation or Tai-chi" 11 "Respondents believed that massage would be most helpful CAM therapy for their current back pain and that meditation would be least helpful CAM" 11 Sherman (2010) 55 At baseline 1/3 rd of participants wanted acupuncture Skelton (1996) 15 "Of 37 patients who had never used CAM, 13 were largely satisfied with the care they were receiving and not considered an alternative and 6 had never heard of any form of CAM" 15 10 of 52 patients had consulted CAM (mainly osteopaths and chiropractors) and most of these "patients thought of CAM as experimental or as a desperate measure when their pain became intolerable or when an immediate GP consultation was unavailable or likely to be ineffective" 15 Westmoreland (2007) 43 "General agreement that NHS should provide spinal manipulation" 43 Perceived benefit of CAM and satisfaction with CAM Astin (1998) 47 "2 most frequently endorsed benefits from CAM were 'I get relief for my symptoms, the pain or discomfort is less or goes away, I feel better'" 47 Borkan (1995) 71 "Non orthodox and folk healers (include reflexology, chiropractor, acupuncture, spiritual healers, movement therapy) often perceived as being more empathic, more knowledgeable and having better diagnostic skills and providing more effective therapies" 71 Crowe (2010) 70 Some participants found heat therapy effective Dima (2013) 38 Patients think that acupuncture stimulates nerves, relaxes muscles and results in temporary relief or cure. and 1 mixed-methods study. 32 The median number of participants in the qualitative studies was 23 (range 7-121), and the median number of participants in quantitative studies was 643 (range 60-1555).

| Quality of studies
Quality assessments of the included studies are presented in the Appendix S1: Figures S1 and S2. Of the qualitative studies, physiother-

| Results of review
Three main areas of perceived need emerged (Table 2).

| Patients'
perceived needs related to the use of physiotherapy (incorporating therapeutic exercise, general exercise or physical activity guided or prescribed by a physiotherapist, manual therapies, education, other physical therapies or aids commonly applied or used by a physiotherapist)

Author & Year Results
Eaves (2015) 45 Some patients view engagement with CAM as a means to help them accept the personal responsibility for managing pain and contribute to positive behaviour change Hsu (2014) 44 Patients hoped that CAM would reduce pain, however many expected the amount of pain relief to be modest Many participants wanted CAM to help with functional outcomes, in particular "increase the ability to do activities which focused on work, hobbies, social life and activities of daily living" 44 Some participants expected CAM "to improve physical fitness, in particular muscle strength, flexibility and overall fitness" 44 May (2007) 40 Participants found heat and massage therapy helpful, as well as wearing a corset at work Pincus (2000) 42 There was higher satisfaction with osteopathy than GPs in the practice "The difference was stronger for aspects of care/communication and competence with osteopathy and weaker for satisfaction and efficacy" 42 Westmoreland (2007) 43 "Osteopathy was though to have reasonable premise as it involved moving or manipulating joints, which were loosened and put back into place" 43 "Physical benefits of osteopathy included pain relief, feeling better, looser with relief of tension and increased mobility" 43 "Psychological benefits included reassurance and improved understanding" 43 "Osteopathy also included the removal of fear and positive approach, which encouraged exercise rather than rest" 43 "Longer consultations with osteopathy allowed more time for explanation and thorough physical examination developed good rapport" 43 Concerns with CAM

Campbell (2007) 33
Despite endorsements for "complementary and alternate therapies," the treatments were "viewed as having only transitory effects and unlikely to be maintained especially when participants had to personally bear the burden of the treatment costs" 33 "Appeared to recognize that the therapies allied to medicine (including osteopathy and reflexology) were limited in terms of the relief that they provided because the treatments were perceived to stand outside of the medical model" 33 Dima (2013) 38 Patients are concerned about painful needling, fear of needles with acupuncture Eaves (2015) 45 Despite initial improvement in pain, patients reported disappointment that massage therapy did not offer a cure Skelton (1996) 15 Of 37 patients who had never used complementary and alternate therapies, "8 questioned its legitimacy and feared being ripped off, 10 were unable to purse CAM through lack of information or lack of money" 15 Westmoreland (2007) 43 Adverse psychological effects of spinal manipulation included "that it was surprising, unexpected, initially frightening and embarrassing" 43 of exercise and some valued physiotherapist-delivered care more than care delivered by a medical practitioner. 14,32,61,66,70 Many studies reported that patients thought exercise was an important component of care for LBP and expected physiotherapist-delivered care in this context, incorporating therapeutic exercise and discussion about the impact of their LBP experience, as part of their LBP management. 40,41 However, some patients would ask for a referral to a physiotherapist only when symptoms lasted for at least a few weeks. 64 Some patients preferred exercising only when pain reappeared rather than continual exercise. 63 Cooper reported that patients wanted direct access to physiotherapists and some patients thought that it would be helpful if they were able to telephone the physiotherapist, using it as a form of helpline for LBP management. 36

| Perceived benefit of physiotherapy care
Seven papers identified the patients' perceived benefits of physiotherapy. 32,38,58,62,63,66,67 Of these studies, the main themes that emerged were that physiotherapy resulted in temporary relief of pain, 32,38,43,66 prevented worsening of LBP 32,38,63 and helped with mobility and function. 38 Patients wanted to learn pain management strategies through physiotherapy care, 32 and Grimmer reported that patients expected symptom relief at the end of the first treatment. 66 Physiotherapy was also perceived as being helpful for injuries, muscle strengthening, reducing stiffness, "realigning the spine" and "releasing the nerves". 38,43 Furthermore, patients believed that physiotherapy fostered health promotion, 67 addressed their personal needs, 58 improved their mental state 38,58 and helped with weight loss. 38 Yardley found that participants believed there would be little harm from physiotherapy care. 32

| Individualizing physiotherapy care
Five studies reported patients' preference for individualizing physiotherapy care, tailored to the patients' perceived needs. 32,39,61,63,67 Patients desired advice regarding suitable lifestyle adaptations and physiotherapy interventions tailored to their individual health needs, particularly within the context of exercise prescription. 39,61,67 Slade found that some participants preferred group exercise programmes, while others desired an individual exercise regimen, thus highlighting the importance of considering patient preference in designing an exercise programme tailored to meet their specific needs. 67 They also felt that supervision and follow-up of their exercise programme were important, 61 and that without regular contact, health professionals were rarely effective in supporting participants to continue increased physical activity. 39 Furthermore, patients wanted reassurance from the practitioner that they were performing the exercises correctly and other self-management strategies. 61

| Concerns with physiotherapy care
Patients' concerns related to physiotherapy were explored in 5 studies. 32,38,43,63,67 Dima reported that patients were afraid of injuring their back with physiotherapy. 32,38 They reported feeling sore after manipulation, which they believed may cause further damage to their back. 38 Moreover, patients were concerned about their ability to adhere to an exercise programme, especially due to a lack of free time, cost and lack of social support. 32,63 They also lacked confidence in correct exercise technique, which affected their compliance with rehabilitation. 67 Furthermore, patients were concerned about the lack of a specific diagnosis given by physiotherapists and that the treatments were ineffective. 43 3.5 | Patients' perceived needs for chiropractic therapy

| Willingness to try chiropractic therapy
Two studies reported on patients' willingness to try chiropractic therapy. 48,51 Lyons' study found that participants recruited from chiropractic and general practice clinics considered chiropractors as primary therapists rather than complementary therapists for LBP. 51 Carey reported that 13% of adults with acute severe LBP sought care from a chiropractor. 48

| Perceived benefit, expectations and concerns with chiropractic therapy
Eight studies described patients' perceived benefit, satisfaction and expectations of chiropractic therapy. 48,49,51,52,59,60,71 Three studies reported that patients who consulted chiropractors were satisfied with their management. 49,52,53 According to Sigrell's results, patients expected chiropractors to provide an accurate diagnosis and explain the cause of pain, 59 as well as offer advice about training and exercises. 60 Patients also expected that they should feel better and be free of symptoms with chiropractic therapy 60 and they wanted hands-on treatment or spinal manipulation from their chiropractors to treat the cause of pain. 51 One study explored the patients' concerns with chiropractic therapy. 51 Lyons concluded that some patients found chiropractic adjustments to not relieve their LBP for several treatments or that it provided short-term relief and produced side-effects such as muscle pain. 51

| Characteristics of patients preferring chiropractic therapy
Three studies explored the characteristics of patients who preferred chiropractic therapy. 48,50,54 Chiropractic care was more commonly preferred by males, employed individuals, those with more functionally disabling pain and those of higher income or self-funded individuals. 48 were unavailable for consultation. 15 One study by Chen found that higher out-of-pocket costs incurred by acupuncture or low frequency infrared radiation treatment, as well as female gender, were associated with less willingness to try these therapies. 72

| Perceived benefit and satisfaction with CAM
There were 9 studies that explored patients' satisfaction with CAM and the perceived benefit of CAM. 38,40,[42][43][44][45]47,70,71 Patients felt that CAM could address physical impairments perceived to be the cause of LBP, specifically CAM could relax muscles, stimulate nerves, manipulate and loosen joints and provide pain relief. 38,43,44,47 They also sought CAM therapies to improve function and physical fitness. 44 May and Crowe reported that some patients felt that heat therapy 70,73 and massage therapy were effective. 40 Patients thought the CAM practitioners were more empathic and understanding and had better diagnostic skills compared to medical doctors. 42,43,71 CAM practitioners were also perceived to provide longer consultations that allowed more time for thorough examination and explanation of the diagnosis. 43 Furthermore, patients thought there were psychological benefits of CAM, including reassurance, removal of fear and a positive approach. 43,45

| Concerns with CAM
Patients' concerns with CAM were addressed in 5 studies. 15,33,38,43,45 Patients commented on the fear of needling and pain from acupuncture. 38  This review found that patients believe that these therapies provide pain relief, loosen muscles and stimulate nerves 38,40,43,44,47,70,73 and they sought CAM to improve function and physical fitness. 44 These perceptions again highlight the attribution of LBP to a structural cause. Some patients also perceived CAM practitioners to be more understanding, empathetic and provide more time for consultations than medical practitioners and more capable of providing a diagnosis. 38 to educate patients about the mechanism of LBP and its natural history from a contemporary pain biology perspective. Despite the widespread use of CAM, the current evidence supporting the use of these therapies is limited. 8,105 Given the need and utilization of CAM, further studies are required to improve our understanding of the role of CAM, the evidence base for their use and potential for harm, thus guiding more cost-effective utilization of health-care resources.

| LIMITATIONS AND STRENGTHS
This review has a number of limitations. First, there have been few studies that directly examined the patients' perceived need for allied health and CAM. Thus, areas of perceived need have been determined from studies that are heterogeneous in their aims and designs, mainly conducted in English-speaking countries, had small sample sizes and were susceptible to bias. This may affect the ability of included studies to capture all areas of perceived need, and further research is required to further explore the patients' perceived need for allied health and CAM. The quality of the studies included in this review tended to be of low or medium quality, reflecting potential biases with recruitment strategy and data collection. Another limitation of this review is that there were no articles that examined participants with acute LBP only; therefore the results cannot be extrapolated to those with acute presentations of LBP. Furthermore, many of the included studies did not provide information regarding comorbidities, the severity of LBP and use of combination therapies.
These factors may influence the patients' perception of need for services and health care. For example, pain-related disability (and to some extent pain severity) is directly related to care-seeking behaviour. 106 Reporting these relevant descriptive factors may be an important feature of core reporting criteria for epidemiologic research in health services research related to LBP. Moreover, the majority of included articles evaluated middle-aged participants, with few articles focusing on younger and older populations, where LBP is also prevalent and represents an important cause of disability. 3,107 Additionally, some of the included studies are over 10 years old, and so care is needed in extrapolating these data to current patient needs for CAM and allied health. Despite these limitations, this review provides a comprehensive overview of the existing literature from 4 databases and included both qualitative and quantitative methodologies. Moreover, many of the findings were consistent across several studies, reflecting the strength of the findings.

| CONCLUSIONS
Our results suggest that patients may need more evidence-informed information about the mechanisms of LBP and its natural history and the effectiveness of current therapies for LBP. 108