Environmental Physiotherapy for Chronic Spinal Pain Management: An International Modified Delphi Study

Chronic spinal pain is a major public health challenge, but its management seldom considers the environmental impact of healthcare practices. This study aimed to identify consensus-based recommendations for integrating environmental sustainability into chronic spinal pain care.

Clinical practice guidelines on chronic spinal pain and literature on sustainable practices were reviewed to develop an initial set of statements. Following the ACCORD reporting guideline, a modified three-round Delphi study was conducted to obtain international consensus on the statements' agreement and importance. Physiotherapists from clinical, educational, and research backgrounds participated. The initial domains included environmental advocacy and policies, education, research and innovation, community engagement, sustainable clinical practices. Consensus was defined as an interquartile range (IQR) ≤ 1 for both dimensions.

The preparatory review of clinical guidelines and sustainability literature identified five domains and informed the development of 47 statements and seven questions. Of the 150 experts invited, 49 participated (44 in Round 1, 35 in Round 2, 30 in Round 3), representing diverse clinical, educational, and research backgrounds from multiple world regions. By the end of the three rounds, 49 statements were classified as consensus recommendations; items with a median of 3 were reported separately as uncertain statements.

This international Delphi study achieved broad consensus on integrating sustainable physiotherapy practices for chronic spinal pain management. The findings contribute to a framework that can inform future guidelines and orient research, education, and policy toward more sustainable care.

Chronic spinal pain management is increasingly promoted within conservative care models, yet its environmental sustainability remains largely unexplored in pain research. This international modified Delphi study establishes expert consensus on integrating sustainability considerations into physiotherapy for chronic spinal pain. By providing a structured framework, the findings inform future research agendas, guideline development, and professional education, contributing to more sustainable and responsible pain management aligned with planetary health challenges.