Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study

PURPOSE

Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study.

MATERIAL AND METHODS

This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study.

RESULTS

Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists.

CONCLUSION

The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

Becoming confidently competent: a qualitative investigation of training in cognitive functional therapy for persistent low back pain

BACKGROUND

Physiotherapists trained to deliver biopsychosocial interventions for complex musculoskeletal pain problems often report difficulties in confidence and competency at the end of training. Cognitive Functional Therapy (CFT) is an individualized biopsychosocial intervention and understanding the facilitators and barriers to training in CFT will help inform future training programs. This study aimed to explore physiotherapists' and trainers' perceptions of the process of developing competency in CFT.

METHODS

A cross-sectional qualitative design using interviews of 18 physiotherapists and two trainers investigated training in CFT for persistent LBP via reflexive thematic analysis.

RESULTS

Physiotherapists reported undergoing a complex behavior change process during training. Four themes emerged: 1) Pre-training factors; 2) Behavior change process; 3) Physiotherapy culture and context; and 4) Confident competence and beyond. Key components included graduated practice exposure linked to experiential learning with feedback and clear competency guidelines. Pre-training and contextual factors were facilitators or barriers depending on the individual. Physiotherapists supported ongoing learning, even after competency was achieved.

CONCLUSIONS

This study provides insight into the processes of change during progress toward competency in CFT. It highlights facilitators and barriers to competency including physiotherapy culture and the clinical environment. The study also describes important educational components, including experiential learning and clinical integration, which may be used to inform future post-graduate training.

Development of an interdisciplinary training program about chronic pain management with a cognitive behavioural approach for healthcare professionals: part of a hybrid effectiveness-implementation study

BACKGROUND

Many applied postgraduate pain training programs are monodisciplinary, whereas interdisciplinary training programs potentially improve interdisciplinary collaboration, which is favourable for managing patients with chronic pain. However, limited research exists on the development and impact of interdisciplinary training programs, particularly in the context of chronic pain.

METHODS

This study aimed to describe the development and implementation of an interdisciplinary training program regarding the management of patients with chronic pain, which is part of a type 1 hybrid effectiveness-implementation study. The targeted groups included medical doctors, nurses, psychologists, physiotherapists, occupational therapists, dentists and pharmacists. An interdisciplinary expert panel was organised to provide its perception of the importance of formulated competencies for integrating biopsychosocial pain management with a cognitive behavioural approach into clinical practice. They were also asked to provide their perception of the extent to which healthcare professionals already possess the competencies in their clinical practice. Additionally, the expert panel was asked to formulate the barriers and needs relating to training content and the implementation of biopsychosocial chronic pain management with a cognitive behavioural approach in clinical practice, which was complemented with a literature search. This was used to develop and adapt the training program to the barriers and needs of stakeholders.

RESULTS

The interdisciplinary expert panel considered the competencies as very important. Additionally, they perceived a relatively low level of healthcare professionals' possession of the competencies in their clinical practice. A wide variety of barriers and needs for stakeholders were formulated and organized within the Theoretical Domain Framework linked to the COM-B domains; 'capability', 'opportunity', and 'motivation'. The developed interdisciplinary training program, including two workshops of seven hours each and two e-learning modules, aimed to improve HCP's competencies for integrating biopsychosocial chronic pain management with a cognitive behavioural approach into clinical practice.

CONCLUSION

We designed an interdisciplinary training program, based on formulated barriers regarding the management of patients with chronic pain that can be used as a foundation for developing and enhancing the quality of future training programs.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Improving musculoskeletal physiotherapists' confidence in patient-centred care informed by acceptance and commitment therapy: A descriptive study

BACKGROUND

Patient-centred care is essential for high quality musculoskeletal care, however, few evidence-based opportunities exist that address the barriers to implementation for clinicians.

OBJECTIVE

To develop and evaluate a simulation-based educational strategy for musculoskeletal physiotherapists to increase knowledge and confidence in patient-centred care.

METHODS

Repeated-measures, single-group educational interventional descriptive study. Primary outcome was participant-reported knowledge and confidence in patient-centred care. Customized survey data was collected at baseline (T1) (N = 22), immediately after a face-to-face workshop (T2) (N = 22), and six weeks after the workshop (T3) (N = 17). Secondary outcomes included sustained implementation using the Normalization Measure Development (NoMAD) tool. Repeated-measures ANOVA was used to analyse primary outcomes.

RESULTS

Our participants were typically female (72%), early career (mean 3.3 years post-graduate) and culturally diverse (67%). Significant increases in participant confidence were noted at all time points on all five learning outcomes (repeated measures ANOVA, p < 0.001 to p = 0.009). Participants had very high baseline knowledge and no further increases were found following the intervention (p > 0.05). Normalization Measure Development data indicated high coherence, high cognitive participation, and high reflexive monitoring, with neutral results for collective action.

CONCLUSION

A novel, psychologically-informed, simulation-based educational strategy is effective in improving musculoskeletal physiotherapist confidence in patient-centred care. Participants reported implementation of skills learnt in the workshop into subsequent clinical practice.

Perspectives on chronic musculoskeletal pain management among healthcare professionals in Bhutan: A qualitative study

INTRODUCTION

Musculoskeletal pain disorders continue to be one of the leading causes of disability worldwide. Best practice care recommends patient-centred biopsychosocial models of care. Little is known about the chronic musculoskeletal pain management in low- and middle-income countries.

OBJECTIVES

To explore the management of chronic musculoskeletal pain by healthcare professionals in Bhutan.

METHODS

This study employed a qualitative design involving 19 Bhutanese healthcare professionals managing chronic musculoskeletal pain in Bhutan. We collected data using a semi-structured interview guide. Thematic analysis was done manually.

RESULTS

Healthcare professionals reported that patients rely on a combination of home remedies and seek help from local healers and hospitals for chronic musculoskeletal pain management. While healthcare professionals understand chronic musculoskeletal pain as multi-dimensional phenomenon, the primary focus was on identifying and treating structural anomalies. Time constraints, inadequate knowledge and skills, lack of confidence, facilities and expertise were reported as barriers to the effective management of chronic musculoskeletal pain. They proposed a need for clinical guidelines, relevant skills training and creating awareness of chronic musculoskeletal pain.

CONCLUSION

The management of chronic musculoskeletal pain in Bhutan is focused on identifying and treating physical abnormalities. Healthcare professionals consider psychosocial dimensions important but lack any form of actionable interventions in this domain.

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Physiotherapists Using the Biopsychosocial Model for Chronic Pain: Barriers and Facilitators-A Scoping Review

The use of the biopsychosocial model in primary care physiotherapy for chronic pain is far from the recommendations given in research and current guidelines. To understand why physiotherapists have difficulty implementing a biopsychosocial approach, more insight is needed on the barriers and facilitators. This scoping review aimed to investigate and map these barriers and facilitators that physiotherapists working in primary care reportedly face when treating patients with chronic musculoskeletal pain from a biopsychosocial perspective. Four electronic databases (PubMed, Embase, CINAHL and ERIC) and the grey literature were searched. Studies were included if they investigated the experiences of physiotherapists in the treatment of chronic pain from a biopsychosocial perspective in primary care. Extracted data were discussed and sub grouped in themes following a qualitative content analysis approach. To align with current use of theories on behavior change, the resulting themes were compared to the Theoretical Domains Framework. After screening, twenty-four studies were included. Eight groups of barriers and facilitators were identified, thematically clustered in six themes: knowledge, skills, and attitudes; environmental context and resources; role clarity; confidence; therapeutic alliance; and patient expectations. The results of this review can be used to inform the development of implementation programs.

Acupoint catgut embedding for chronic low back pain: A protocol for systematic review and meta-analysis

BACKGROUND

The treatment of acupoint catgut embedding (ACE) effective and safe for patients with chronic low back pain (CLBP) is not yet known. This systematic review will objectively and systematically evaluate the efficacy and safety of ACE in CLBP according to the existing evidence.

METHODS

The protocol of this systematic review and meta-analyses has been registered in PROSPERO with the registration number CRD42019142256. The following electronic databases from inception to November 29, 2022 will be searched: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Wan Fang Data and Chinese Science Journal Database. Randomised controlled clinical(RCTs) using ACE to treat CLBP will be included. Outcomes will include pain intensity, instrument with assessment function and disability, quality-of-life, and costs. Adverse events will be reported for safety assessment. By screening the titles, abstracts, and full texts, two independent reviewers will select studies, extract data, and assess study quality. Data synthesis, sensitivity analysis, subgroup analysis and risk of bias assessment will be conducted using RevmanV.5.3 software. The Grading of Recommendations Assessment, Development and Evaluation system will be used to assess the quality ofthe evidence.

RESULTS

The efficacy and safety of ACE in the treatment of CLBP has not yet been determined.

CONCLUSION

This systematic review will objectively and systematically evaluate the efficacy and safety of ACE in CLBP according to the existing evidence, which can give high level clinical recommendations to improve patient care and clinical outcomes.

A bibliometric analysis of self-efficacy in low back pain from 1980 to 2021

BACKGROUND

Self-efficacy is one of the important factors affecting chronic diseases. In the current epidemiological context of low back pain (LBP), LBP self-efficacy has become a topic of great practical interest for researchers. However, no bibliometric analysis related to LBP self-efficacy has been performed to date. The purpose of this study was to conduct and explore the current state of research in LBP self-efficacy from 1980 to 2021, by using bibliometric analysis and scientific mapping.

METHODS

Raw data were selected from the Web of Science (WOS) database, relevant literature on LBP self-efficacy was retrieved, and data were de-duplicated and cleaned. Excel was used for data processing. CiteSpace 5.8.R3 was used for bibliometric analysis and scientific mapping in publications and country, institution, journals, authors, references, and keywords. Statistical analysis was performed using IBM SPSS 25.0.

RESULTS

There were 822 references included. For this period, the total publication numbers were increased. A total of 103 regions had researchers in this area; the United States was the country with the largest volume of research. There were 94 disciplines, mainly in neuroscience. More research is likely to burst and develop quickly in general and internal medicine in the future. Spine was the most recognized journal. Cognitive-behavioral manifestations and older adults with LBP might be the frontiers and trends.

CONCLUSION

The volume of literature on LBP self-efficacy has increased linearly over the past 41 years and will continue to increase. The field of study has become more refined. This bibliometric analysis provides valuable support for future directions and research trends in LBP self-efficacy.

Inter-individual variability in mechanical pain sensation in patients with cervicogenic headache: an explorative study

Currently, evidence for effective physiotherapy interventions in patients with cervicogenic headache (CeH) is inconsistent. Although inter-individual variability in pain response is predictive for successful physiotherapy interventions, it was never explored in patients with CeH. Therefore the objective of the current study was to explore inter-individual variability in mechanical pain sensation, and its association with biopsychosocial-lifestyle (BPSL) characteristics in patients with CeH. A cross-sectional explorative analysis of inter-individual variability in mechanical pain sensation in 18 participants with CeH (29-51 years) was conducted. Inter-individual variability in mechanical pain sensation (standard deviations (SDs), F-statistics, Measurement System Analysis) was deducted from bilateral pressure pain thresholds of the suboccipitals, erector spine, tibialis anterior. BPSL-characteristics depression, anxiety, stress (Depression Anxiety Stress Scale-21), quality of life (Headache Impact Test-6), sleep-quality (Pittsburgh Sleep Quality Index), and sedentary time (hours/week) were questioned. Inter-individual variability in mechanical pain sensation explained 69.2% (suboccipital left), 86.8% (suboccipital right), 94.6% (erector spine left), 93.2% (erector spine right), 91.7% (tibialis anterior left), and 82% (tibialis anterior right) of the total variability in patients with CeH. The significant p-values and large F-statistic values indicate inter-individual differences in SDs. Significant associations between (1) lower quality of life and lower SDs of the suboccipital left PPT (p .005), and (2) longer sedentary time and higher SDs of the suboccipital left PPT (p .001) were observed. Results from our explorative study could suggest inter-individual variability in mechanical pain sensation at the left suboccipitals which associates with quality of life and sedentary time. These novel findings should be considered when phenotyping patients and 'individually' match interventions.

Preferred Communication Strategies Used by Physical Therapists in Chronic Pain Rehabilitation: A Qualitative Systematic Review and Meta-Synthesis

OBJECTIVE

Lack of clarity regarding effective communication behaviors in chronic pain management is a barrier for implementing psychologically informed physical therapy approaches that rely on competent communication by physical therapist providers. This study aimed to conduct a systematic review and meta-synthesis to inform the development of a conceptual framework for preferred communication behaviors in pain rehabilitation.

METHODS

Ten databases in the health and communication sciences were systematically searched for qualitative and mixed-method studies of interpersonal communication between physical therapists and adults with chronic pain. Two independent investigators extracted quotations with implicit and explicit references to communication and study characteristics following Standards for Reporting Qualitative Research and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Methodological quality for individual studies was assessed with Critical Appraisal Skills Programme, and quality of evidence was evaluated with GRADE-CERQual. An inductive thematic synthesis was conducted by coding each quotation, developing descriptive themes, and then generating behaviorally distinct analytical themes.

RESULTS

Eleven studies involving 346 participants were included. The specificity of operationalizing communication terms varied widely. Meta-synthesis identified 8 communication themes: (1) disclosure-facilitating, (2) rapport-building, (3) empathic, (4) collaborative, (5) professional accountability, (6) informative, (7) agenda-setting, and (8) meta-communication. Based on the quality of available evidence, confidence was moderate for 4 themes and low for 4 themes.

CONCLUSION

This study revealed limited operationalization of communication behaviors preferred by physical therapists in chronic pain rehabilitation. A conceptual framework based on 8 communication themes identified from the literature is proposed as a preliminary paradigm to guide future research.

IMPACT

This proposed evidence-based conceptual framework for preferred communication behaviors in pain rehabilitation provides a framework for clinicians to reflect on their own communication practices and will allow researchers to identify if and how specific communication behaviors impact clinical outcomes.

Patients' and physiotherapists' perspectives on implementing a tailored stratified treatment approach for low back pain in Nigeria: a qualitative study

BACKGROUND

Stratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation.

METHODS

A qualitative design with semistructured individual telephone interviews for physiotherapists and patients with LBP comprising research evidence and information on stratified care was adopted. Preceding the interviews, patients completed the Subgroups for Targeted Treatment tool. The interviews were recorded, transcribed and analysed following grounded theory methodology.

RESULTS

Twelve physiotherapists and 13 patients with LBP participated in the study (11 female, mean age 42.8 (SD 11.47) years). Seven key categories emerged: recognising the need for change, acceptance of innovation, resistance to change, adapting practice, patient's learning journey, trusting the therapist and needing conviction. Physiotherapists perceived stratified care to be a familiar approach based on their background training. The prevalent treatment tradition and the patient expectations were seen as major barriers to implementation of stratified care by the physiotherapists. Patients see themselves as more informed than therapists realise, yet they need conviction through communication and education to cooperate with their therapist using this approach. Viable facilitators were also identified as patients' trust in the physiotherapist and adaptations in terms of training and modification of the approach to enhance its use.

CONCLUSION

Key barriers identified are the patients' treatment expectations and physiotherapists' adherence to the tradition of practice. Physiotherapists might facilitate implementation of the stratified care by communication, hierarchical implementation and utilisation of patients' trust. Possibilities to develop a consensus on key strategies to overcome barriers and on utilisation of facilitators should be tested in future research.

Perspectives and experiences of physiotherapists and general practitioners in the use of the STarT Back Tool: a review and meta-synthesis

Introduction The STarT Back Tool (SBT) is used to triage people with acute low back pain (LBP) into treatment groups, matched to their risk of chronicity. It was developed in the UK where it has been shown to improve clinical outcomes, patient satisfaction, and reduce time off work. Successful implementation of the SBT outside the UK is dependent on health practitioner's attitudes and the healthcare system in which they work. Gaining health practitioners' perspectives on the SBT is an important step in implementation. Methods A computerised search of qualitative literature was conducted across seven databases in March 2021 using keywords to identify studies investigating the perspectives of physiotherapists and general practitioners on the use of the SBT in primary health care. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tool. Data were coded and analysed using reflexive thematic analysis. Results Eight articles met inclusion criteria and included the views of 76 physiotherapists and 65 general practitioners, working in primary health care in four countries. Three themes were created from the data: 'Making it work', identifies factors that influence implementation and continued use of the SBT. The second 'will I do it?', captured potential consequences of adopting the SBT, and the third, 'it's all about the patient' emphasised how the SBT may  affect patients. Discussion Physiotherapists and general practitioners found using the SBT frequently enhanced practice. General practitioners expressed concerns about time constraints and the SBT's potential to undermine clinical experience. Findings from this study will inform modifications to contextualise the tool to each healthcare environment.

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain

Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety-learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing Cognitive Functional Therapy to promote safety learning. A process is described in which experiential learning combined with "sense making" disrupts a person's unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.

Use of Mental Health Interventions by Physiotherapists to Treat Individuals with Chronic Conditions: A Systematic Scoping Review

Purpose: Physiotherapists work with people with chronic conditions and can act as catalysts for behavioural change. Physiotherapy has also seen a shift to a bio-psychosocial model of health management and interdisciplinary care, which is important in the context of chronic conditions. This scoping review addressed the research question "How do physiotherapists use mental health-based interventions in their treatment of individuals with chronic conditions?" Method: The Embase, MEDLINE, PsycINFO, and CINAHL databases were searched, and a variety of study designs were included. Data were categorized and descriptively analyzed. Results: Data were extracted from 103 articles. Low back pain (43; 41.7%) and non-specified pain (16; 15.5%) were the most commonly researched chronic conditions, but other chronic conditions were also represented. Outpatient facilities were the most common setting for intervention (68; 73.1%). A total of 73 (70.9%) of the articles involved cognitive-behavioural therapy, and 41 (40.0%) included graded exercise or graded activity as a mental health intervention. Conclusions: Physiotherapists can use a variety of mental health interventions in the treatment of chronic conditions. More detailed descriptions of treatment and training protocols would be helpful for incorporating these techniques into clinical practice.

Efficacy of a multidimensional versus usual care physiotherapy on pain and electroencephalography (EEG) spectrum in chronic nonspecific low back pain: study protocol for a randomized controlled trial

BACKGROUND

Non-specific chronic low back pain (NSCLBP) is a major public health and global socioeconomic burden associated with a complex interplay of biopsychosocial factors. Despite scientific signs of progress, treatment of NSCLBP often tends to stick to a biomechanical model, without targeting psychological and social factors. To enhance the clinical efficacy of usual physiotherapy for NSCLBP, the development of clinical strategies is to be pursued. This study aims to assess the effectiveness of multidimensional physiotherapy based on a biopsychosocial approach compared to usual care physiotherapy, on clinical findings and electroencephalography spectrum in non-specific chronic low back pain.

METHODS

This study is a triple-blind, two-arm (1:1) randomized controlled trial with a 4 months follow-up. Seventy NSCLBP patients will be randomly allocated to either the experimental (multidimensional physiotherapy) or the active control group (usual physiotherapy); each group will receive 6 weeks of physiotherapy. The main outcome is pain and secondary outcomes are brain function, quality of life, disability, lumbar flexion range of motion, and psychosocial correlates. Assessment will be performed at baseline, post-treatment, and at 1 and 4 months follow-up.

DISCUSSION

Findings may provide evidence on the effectiveness of multidimensional physiotherapy on clinical findings and brain characteristics and might provide evidence towards showing the role of brain and biopsychosocial factors on chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04270422 , Registered on 17 February 2020, IRCT Identifier: IRCT20140810018754N11.

A cross-sectional study on fear-avoidance beliefs and chronic low back pain in fighter pilots

Background

Chronic low back pain (CLBP) is considered a serious complaint among fighter pilots because the vertebrae of these pilots are exposed to high compression forces from prolonged sitting on a hard ejection seat and frequent sudden fighter aircraft maneuvers. It is yet unknown whether a correlation exists between CLBP and psychosocial/behavioral performance of fighter pilots.

Methods

This was a cross-sectional study of 66 fighter pilots with nonspecific CLBP voluntarily participated in this study. Self-efficacy was measured based on the degree of physical activity and work performance using the fear-avoidance beliefs questionnaire (FABQ).

Results

A significant inverse correlation was found between the work subscale of the FABQ (FABQw) (mean score: 27.4 ± 8.4) and both age (mean: 35 ± 4.9 years) and flying experience (mean: 13.2 ± 4.4 years) among fighter pilots with nonspecific CLBP. In contrast, there was no significant correlation between physical activity subscale of the FABQ (mean score: 12.3 ± 6.4) and both age and flying experience.

Conclusions

An inverse correlation was observed between FABQw and both age and flying experience among fighter pilots with nonspecific CLBP. It is important for rehabilitation specialists to understand the role of cognitive/affective components of a pain from tissue injury and nociception to prevent occupational disability and enhance occupational performance.

Improving Cultural Knowledge to Facilitate Cultural Adaptation of Pain Management in a Culturally and Linguistically Diverse Community

Purpose: Health care disparities exist for people from culturally and linguistically diverse (CALD) communities. Addressing the cultural competence of health care providers could limit these disparities. The aim of this study was to improve cultural knowledge of and humility regarding pain in a CALD community. Method: This interpretive description qualitative study used focus group discussions (FGDs) to generate ideas about how South Asian culture could influence how health care providers manage pain. A total of 14 people with pain and of South Asian background (6 women and 8 men, aged 28–70 y) participated. Two investigators independently analyzed the data. This process involved repeatedly reading the transcripts, then manually sorting the key messages into categories. The investigators compared their categorizations and resolved differences through discussion. Next, similar categories and concepts were grouped into ideas (potential themes). These ideas, along with supporting categories and verbatim quotes, were presented to the full research team for feedback. After compiling the feedback, the ideas formed the thematic representation of the data. Results: The data from the FGDs revealed how pain management could be culturally adapted. The FGDs generated four themes about South Asian cultural perspectives that could influence the pain management experience for people living with pain: (1) cultural and linguistic impediments to communication, (2) understanding of pain in terms of the extent to which it interferes with function and work, (3) nurturing or personal attention as a marker of good care, and (4) value attributed to traditional ideas of illness and treatment. Conclusion: This study demonstrates how engaging with CALD people living with pain can lead to improved cultural knowledge and humility that can form the basis for adapting pain management. Through this process, it is more likely that a meaningful and client-centred pain management plan can be developed.

Biomedical Beliefs Explain the Clinical Decisions Made by Exercise-Based Practitioners for People With Chronic Low Back Pain

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

This study surveyed the attitudes and beliefs of physiotherapists and accredited exercise physiologists (AEP) toward chronic low back pain (CLBP), in Australia. The objective of this study was to investigate the effect of biomedical and biopsychosocial attitudes and beliefs toward CLBP on clinical decision making in exercise-based practitioners.

SUMMARY OF BACKGROUND DATA

The attitudes and beliefs of AEPs toward CLBP have not been studied. Literature regarding physiotherapists suggests a biomedical approach leading to more conservative treatment and on occasion, treatment going against practice guidelines.

METHODS

Seventy five AEPs and 75 physiotherapists were surveyed using the pain attitudes and beliefs scale for physiotherapists, which consists of both a biomedical and biopsychosocial subscale. Clinical decision making was assessed using two patient vignettes.

RESULTS

AEPs held higher biomedical beliefs compared with physiotherapists. No between-group differences were observed on the biopsychosocial subscale. Indeed, biomedical attitudes and beliefs did explain clinical decision making with higher scores reflecting a more conservative approach. However, biomedical beliefs influenced decision making regardless of profession.

CONCLUSION

Biomedical attitudes and beliefs regarding CLBP influence clinical decision making in exercise-based practitioners, regardless of profession. AEPs reported higher biomedical scores, suggesting more frequent choice of conservative care. Thus, patients may receive inconsistent care and advice from practitioners within the same field. Based on clinical practice guidelines and the positive associations on clinical decision making of the biopsychosocial model, it is necessary to understand how best to provide exercise-based practitioners with education on how to apply a biopsychosocial approach to CLBP.Level of Evidence: 3.

Pain Education in the Context of Non-Specific Low Back Pain: The Lived Experience of the Physiotherapist. An Interpretive Phenomenological Analysis

OBJECTIVES

The aim of this study was to explore the physiotherapists' lived experiences of providing pain education (PE), to people living with non-specific low back pain (NSLBP). In previous studies, PE has been associated with positive clinical outcomes within the physiotherapeutic management of NSLBP. However, the meaning of providing PE, as experienced by physiotherapists, has not been specifically explored.

METHODS

This study adopted a hermeneutic phenomenological approach to explore PE experiences. Six semi-structured interviews were conducted, interviews were transcribed and analysed in line with the 'interpretative phenomenological analysis' framework.

RESULTS

Five main thematic meaning structures emerged: Experienced significance of assessment in understanding NSLBP, PE as explaining the nature of NSLBP, Experienced challenges in providing PE, individualisation as key to PE for NSLBP and Reassurance as central to PE for people living with NSLBP.

CONCLUSIONS

The significance of subjective assessment, was a key component of PE, as experienced by participants. However, differences were noted between participants in addressing the sense of assessment; in seeking a physiotherapeutic understanding of the NSLBP, and in seeking to understand the situation of those who are in pain. Within the participant experience, the significance of 'patient' reassurance was highlighted, related to the individualisation and outcome of PE. Reassurance, as described by participants, was emotive and practically grounded and linked with physical activity promotion. Individualisation in PE was meaningfully related to language modification and developing positive therapeutic relationships. Physiotherapists described PE particularly challenging related to pain chronicity and psychosocial factors, which may have significant implications to practice.

Psychological Distress among Patients Attending Physiotherapy: A Survey-Based Investigation of Irish Physiotherapists' Current Practice and Opinions

Purpose: The primary purpose of this study was to investigate the current practice and opinions of members of the Irish Society of Chartered Physiotherapists (ISCP) with respect to the care of patients in psychological distress. Method: This was a cross-sectional, survey-based investigation of Irish physiotherapists. An electronic survey was sent by email to the ISCP membership. It consisted of closed- and open-ended questions, as well as opinion questions with Likert scale responses. Results: More than 80% of the respondents reported that they encountered patients with psychological distress at least once a week. A lack of education in the area of mental health emerged as a predominant theme. Reflecting on current practice, many discussed the importance of addressing underlying psychological issues before or in tandem with physical issues. Respondents who had engaged in further education in mental health, psychology, or both rated their confidence in recognizing the signs and symptoms of psychological distress higher (p < 0.001). Moreover, a greater proportion of these respondents routinely assessed for psychological distress in their clinical practice (p < 0.001). Conclusion: Physiotherapists regularly encounter patients whom they perceive to have high levels of psychological distress. Irish physiotherapists displayed positive attitudes toward patients' psychological well-being. However, additional education in mental health was a recognized need in the profession.

Physiotherapists' pain attitudes and beliefs towards chronic low back pain and their association with treatment selection: a cross-sectional study

OBJECTIVES

The main aim of this study was to investigate physiotherapists' pain attitudes and beliefs towardss non-specific chronic low back pain (NSCLBP) and identify whether they are associated with treatment selection.

DESIGN

Cross-sectional study.

SETTING

Saudi Arabia (SA).

PARTICIPANTS

An online survey was distributed to physiotherapists from April 2018 to January 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Biomedical and biopsychosocial treatment orientations were assessed using the Pain Attitudes and Beliefs Scale for Physiotherapists. (2) Frequent potential treatments used by physiotherapists for individuals with NSCLBP were identified through a 20-item survey. (3) The association between physiotherapists' pain attitudes and beliefs and treatment selection was investigated. Descriptive analysis, Pearson's correlation and multinomial logistic regression were used to analyse the data using SPSS (V.26).

RESULTS

A total of 304 responses were included in the analysis. The biomedical (34.45±7.84) and biopsychosocial (31.74±5.67) treatment orientations were relatively low. The most frequent treatments used by physiotherapists were home exercises (87.1%), patient education (82.0%), specific back exercises (80.6%), electrotherapy (61.9%), soft tissue release (58.8%) and spinal mobilisation or manipulation (57.8%). Physiotherapists with a stronger biomedical treatment orientation were more likely to use treatments (p<0.05) such as specific back exercises, electrotherapy, soft tissue release, hydrotherapy, massage, lumbar supports and acupuncture. However, physiotherapists with a stronger biopsychosocial treatment orientation were more likely to use cognitive functional therapy (p<0.01).

CONCLUSIONS

Biomedical and biopsychosocial treatment orientations were relatively low among physiotherapists in SA. Although treatments such as home exercises and patient education were frequently used, some passive and traditional treatments not recommended by clinical practice guidelines continue to be commonly used by physiotherapists in SA. This study has confirmed that physiotherapists' pain attitudes and beliefs are significantly associated with treatment selection when managing individuals with NSCLBP.

TRIAL REGISTRATION NUMBER

Researchregistry3944.

How do physiotherapists understand and interpret the "Pain Attitudes and Beliefs Scale"? A cognitive interview study

Background: The Pain Attitudes and Beliefs Scale (PABS) for physiotherapists aims to differentiate between clinicians' biomedical and biopsychosocial treatment orientations regarding nonspecific low back pain (LBP). Objective: To study the content validity of the Norwegian PABS by following international guidelines: exploring its relevance, comprehensibility and comprehensiveness. Methods: Cognitive interviews were performed using the Three-Step Test Interview, consisting of think-aloud techniques, retrospective probing and in-depth interviews. Eleven Norwegian physiotherapists with a diversity of professional backgrounds participated. Results: The participants encountered little difficulty in completing the PABS. All items were deemed relevant and important but five items had ambiguous formulations which can easily be handled. The biomedical subscale appeared to be a comprehensive representation of biomedical treatment orientation. The biopsychosocial subscale was found to lack items concerning cognitive behavioral aspects of LBP management, such as patient education, therapeutic alliance, shared decision making and graded exposure. Conclusions: This study provides empirical evidence that the Norwegian version of the PABS-PT is relevant and comprehensible, provided some minor adjustments. The biopsychosocial subscale, however, lacks comprehensiveness, as it is not able to capture important aspects of contemporary biopsychosocial best practice care. Measurement of biopsychosocial treatment orientation may therefore be incomplete.

Confidence, attitudes, beliefs and determinants of implementation behaviours among physiotherapists towards clinical management of low back pain before and after implementation of the BetterBack model of care

BACKGROUND

Implementing clinical guidelines is challenging. To facilitate uptake, we developed a model of care (BetterBack Model of Care) and an implementation strategy to support management of low back pain in primary care. The aim of this study was to evaluate physiotherapists´ confidence, attitudes and beliefs in managing patients with low back pain before and after a multifaceted implementation of the BetterBack Model of Care. A further aim was to evaluate determinants of implementation behaviours among physiotherapists.

METHODS

This clinical trial was an experimental before and after study within a hybrid type 2 effectiveness-implementation trial. The primary outcome was Practitioner Self-Confidence Scale (PCS), secondary outcomes were the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT) and Determinants of Implementation Behaviour Questionnaire (DIBQ). Data was analysed using repeated measures ANOVA and pairwise comparisons.

RESULTS

One hundred sixteen physiotherapists answered a questionnaire before, directly after, as well as 3 and 12 months after implementation of the Model of Care. PCS improved over time with a large effect size post implementation (ηp2 = 0.197, p < 0.001). Changes in PABS-PT were only significant after 12 months with higher biopsychosocial orientation, (ηp2 = 0.071, p < 0.01) and lower biomedical orientation, (ηp2 = 0.136, p < 0.001). Directly after the workshop, after 3 and 12 months, physiotherapists had high ratings on all DIBQ domains, (scores > 50) implying that all were potential facilitators of the implementation. However, after 3 months, all domains had significantly decreased except for organisation, social influence and patient expectation domains. However, after 12 months, organisation and social influence domains had significantly decreased while domains such as knowledge, skills and beliefs about capabilities returned to initial levels.

CONCLUSIONS

Physiotherapists´ confidence and biopsychosocial orientation increased after implementation and may have the potential to improve management of low back pain in primary care. The implementation behaviour showed mostly facilitating patterns but changed over time, pinpointing a need to repeatedly monitor these changes. This can inform the need for changes of implementation efforts in different phases and support sustainability strategies.

TRAIL REGISTRATION

ClinicalTrials.gov NCT03147300 3 May 2017, prospectivly registered.

An adventurous learning journey. Physiotherapists' conceptions of learning and integrating cognitive functional therapy into clinical practice

Background: Recent low back pain guidelines recommend a BPS approach to the management of disabling low back pain. However, the most effective way of teaching physiotherapists to implement these approaches remains unknown. The present qualitative study aimed to explore physiotherapists' conceptions of learning and integrating Cognitive Functional Therapy (CFT) into clinical practice in Finnish primary health care.Methods: We interviewed 22 physiotherapists, who participated in four to six days of CFT workshops. A phenomenographic approach was used to explore the variation in the physiotherapists' conceptions of this process.Results: Four themes emerged from the data: 1) membership of work community; 2) learning journey; 3) transition to new working methods; and 4) professional role as a physiotherapist. These themes varied in four categories of description: recognizing difference of the new approach, toward integrating the new approach, waking up to explore, commitment to new approach and expanding application of new approach. The critical aspects between the categories that enabled the integration of CFT into clinical practice were ability to overcome resistance and to change views, being shaken and ability to critically reflect on one's work, support from the work community and becoming convinced, creativity, multidisciplinary collaboration and continuous learning.Conclusion: The participants' responses to the training varied greatly, suggesting that for some, the training was insufficient to support adequate changes in their practice behavior; whereas for others, the training was a life changing experience.

An exploration of physiotherapists' perceived benefits and barriers towards using psychosocial strategies in their practice

BACKGROUND

This study aimed to determine what physiotherapists perceive are the benefits of using psychosocial strategies in their own practice, and whether perceived barriers extend beyond practitioner and contextual barriers.

METHODS

Content analysis of two open-ended questions was conducted. Australian physiotherapists (n = 206) provided written comments.

RESULTS

Three key categories of benefits emerged: patient benefits, shared patient and physiotherapist benefits, and physiotherapist benefits. Patient benefits included improved rehabilitation experience, improved patient wellbeing and improvement of psychosocial responses. Specifically, increased patient enjoyment, improved self-management and improved understanding of the links between their physical and psychological health. Therapeutic alliance appeared as a shared patient and physiotherapist benefit, with specific reference to enhanced partnerships and improved patient-centred practice. Physiotherapist benefits comprised of improved needs assessment and occupational benefits such as reduced load. Three key categories of physiotherapist barriers, contextual barriers, and patient barriers emerged. Time, knowledge, confidence, lack of expertise, and limited formal training, were the main barriers, specifically a lack of practical training, and for more complex strategies. Physiotherapists acknowledged patient barriers such as patient resistance, lack of understanding, and complex mental health needs.

CONCLUSIONS

These findings contribute novel information with regard to the benefits and barriers of psychosocial approaches from a physiotherapist perspective. Physiotherapists may benefit from further support in their use of psychosocial approaches, to emphasize the benefits for their own practice. Furthermore, to potentially reduce patient barriers and improve outcomes, patient education concerning a biopsychosocial model of care could be valuable.

The impact of modified exercise and relaxation therapy on chronic lower back pain in office workers: a randomized clinical trial

This study aimed to evaluate the effectiveness of a modified package of exercise therapy combined with relaxation on pain intensity, range of motion (ROM), anxiety, and quality of life (QoL) in office workers with chronic lower back pain. In this clinical trial, 72 office workers aged 20 to 50 years with chronic low back pain were randomized to one of four groups including; group 1, exercise therapy; group 2, psychotherapy (relaxation therapy); group 3, modified protocol (exercise therapy followed by relaxation therapy); group 4, control group (no intervention). Participants exercised 3 times weekly for 6 weeks for 40-45 min of exercise/relaxation. Pain intensity, ROM, anxiety, and QoL were evaluated at baseline, 6 weeks, and 12 weeks after the end of the intervention. Results showed significant decreases in pain intensity and anxiety in the three experimental groups compared to the control group. The three intervention groups indicated a significant decrease in pain intensity and anxiety after 6 and 12 weeks. ROM significantly improved in the exercise therapy and the modified protocol over time (after 6 and 12 weeks). A significant difference in QoL was found between the groups, with the greatest improvement found in the psychotherapy and modified protocol groups. This therapeutic package (including exercise movements and psychological interventions) was found to have a superior effect on pain intensity, ROM, anxiety, and QoL after 6 and 12 weeks compared to other interventions (only exercise and psychotherapy).

In Theory, Yes; in Practice, Uncertain: A Qualitative Study Exploring Physical Therapists' Attitudes Toward Their Roles in Weight Management for People With Knee Osteoarthritis

BACKGROUND

Physical therapists are at the frontline of treatment for knee osteoarthritis (OA). International guidelines recommend weight loss for individuals with knee OA who are overweight, and research indicates that patients believe it is appropriate for physical therapists to address weight.

OBJECTIVES

The objective was to explore physical therapists' attitudes about their role in weight management for people with OA.

DESIGN

This was a qualitative semistructured telephone interview study.

METHODS

Participants included 13 purposively sampled physical therapists who had treated at least 1 patient with knee OA within the past 12 months. Each participated in a telephone interview exploring their perceptions and attitudes toward the role of physical therapists in providing weight management support for people with knee OA. Data were analyzed using a thematic approach.

RESULTS

Three main themes were identified, which highlighted that physical therapists: (1) believe they have a role in facilitating weight loss for people with knee OA; (2) are uncertain how to integrate weight loss into their management; and (3) are conscious of the psychosocial complexities and the need to tread cautiously around weight management.

CONCLUSIONS

Physical therapists are aware of the importance of weight loss in the management of knee OA, and believe weight management falls within their role and responsibilities; however, they do not feel equipped to fulfill this role. They also acknowledge the weight management conversation as potentially sensitive. This study highlights the need for training opportunities to develop physical therapists' skills and confidence in weight management for people with knee OA who are overweight, including consideration of the potential harms and benefits of this aspect of care.

Physiotherapists' views, perceived knowledge, and reported use of psychosocial strategies in practice

Background: Research has addressed the usefulness of psychosocial strategies within physiotherapy, as part of a biopsychosocial model. A lack of current research in Australia concerning the views of physiotherapists, from a range of practice areas, regarding a variety of strategies, suggests the need for broader exploration. Methods: This research employed a cross-sectional survey asking Australian physiotherapists (n = 251) to rate their perceived importance and perceived benefits of psychosocial strategies; perceived positive effects on rehabilitation outcomes and adherence; confidence in applying strategies, and perceived benefits of further training. Data were analyzed using descriptive statistics, Crosstabs with Chi-Squared Tests of Contingencies and Spearman's Rank-Order Correlations. Results: Physiotherapists reported that having knowledge of such strategies was important and considered them beneficial for practice. Respondents rated highly their perceived knowledge about goal setting and positive reinforcement, both of which were reported as most used in practice. Approximately one quarter of physiotherapists reported using cognitive behavioral therapy and motivational interviewing. Physiotherapists communicated a lack of confidence to apply psychosocial strategies in their practice, and desired further training. Conclusion: Physiotherapists could benefit from tailored instruction regarding psychosocial strategies at a level appropriate to, and within their scope of practice. This could enhance their practice from a biopsychosocial perspective, subsequently improving outcomes for their patients.

Discriminative Validity of the Pain Attitudes and Beliefs Scale for Physical Therapists

BACKGROUND

The Pain Attitudes and Beliefs Scale (PABS) for Physical Therapists aims to measure clinicians' biomedical and biopsychosocial treatment orientations regarding nonspecific low back pain.

OBJECTIVE

The objective of this study was to assess whether the PABS can differentiate between subgroups of physical therapists hypothesized to differ in treatment orientations.

DESIGN

This study was a cross-sectional survey.

METHODS

The PABS was completed by 662 Norwegian physical therapists with a diversity of professional backgrounds. Twenty-four a priori hypotheses on expected differences in PABS scores were formulated. Sufficient discriminative ability was defined as a minimum of 75% confirmed hypotheses. Hypotheses on differences in scores were tested for the biomedical and biopsychosocial subscales separately as well as for combinations of the 2 subscales, representing responders with high biomedical and low biopsychosocial PABS scores and vice versa.

RESULTS

Of the 24 hypotheses, only 15 (62.5%) were confirmed. Between-group differences concerning the separate subscales were small, varying from -0.63 to 1.70 scale points, representing values up to 6.0% of the total subscale ranges. Between-group differences were larger when combined subscales were used, varying from 1.80 to 6.70 points, representing values up to 25.1% of the total subscale ranges. Despite little spread in scores, 24% of respondents demonstrated extreme attitudes.

LIMITATIONS

The lack of convincing scientific evidence from previous research on differences in attitudes and beliefs between physical therapists was a limitation for the formulation of hypotheses.

CONCLUSIONS

Discriminative validity of separate subscales of the PABS was not supported. Combining the 2 subscales into global treatment attitudes enabled better discrimination. Little spread in biomedical and biopsychosocial orientations explains why more than one-third of the hypotheses were not confirmed. Either Norwegian physical therapists are basically similar in their treatment orientation or the PABS is not able to detect any differences between them.

Physiotherapist-delivered Stress Inoculation Training for acute whiplash-associated disorders: A qualitative study of perceptions and experiences

BACKGROUND

Formally trained and accredited physiotherapists delivered Stress Inoculation Training (SIT) integrated with guideline-based physiotherapy management to individuals with acute whiplash associated disorders (WAD) as part of a randomised controlled trial. The delivery of SIT by physiotherapists is new.

OBJECTIVES

To investigate physiotherapists' perspectives on delivering SIT as part of the trial and in routine practice.

DESIGN

Qualitative descriptive.

METHOD

Physiotherapists (n = 11) participated in semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Findings were triangulated against an audit of physiotherapists' adherence to the SIT protocol.

RESULTS

Three themes were identified: perceived value; capacity to deliver; and adaptation and implementation. Physiotherapists' saw value in SIT in that they perceived the program to have improved patient outcomes, enhanced their therapeutic alliance, and provided new skills to manage psychological contributors to WAD. Physiotherapists' capacity to deliver the program was facilitated through the development of confidence in their ability to deliver sessions, viewing SIT as falling within their current professional identity, and having confidence in their ability to manage mismatches in patients' expectations of care. All physiotherapists reported having used SIT to some extent in routine practice, by selectively delivering sessions and/or integrating the content with other management. Physiotherapists were able to deliver SIT as was intended (94.6% adherence).

CONCLUSIONS

Physiotherapists' supported adding SIT to usual management of individuals with acute WAD. Education on SIT principles is recommended during pre-professional training to facilitate future implementation.

The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study

BACKGROUND

It has long been acknowledged that nonspecific chronic low back pain (NSCLBP) is associated with a complex combination of biopsychosocial (BPS) factors, and recent guidelines advocate that the management of back pain should reflect this multidimensional complexity. Cognitive functional therapy (CFT) is a behaviourally oriented intervention that targets patients' individual BPS profiles. Although the efficacy of CFT has been demonstrated in primary care, little evidence exists about the training requirements of this approach.

METHODS

Qualitative semistructured interviews were conducted with 10 physiotherapists working in primary care, who had undergone a formal training programme in CFT. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes.

RESULTS

Five main themes emerged: (i) the learning challenge; (ii) self-reported changes in confidence; (iii) self-reported changes in communication practice; (iv) self-reported changes in attitudes and understanding; (v) the physiotherapists felt that CFT was more effective than their usual approach for NSCLBP but identified barriers to successful implementation, which included a lack of time and difficulties in engaging patients with strong biomedical beliefs.

CONCLUSIONS

The study suggested that training in CFT has the capacity to produce self-reported changes in physiotherapists' attitudes, confidence and practice. The provision of such training has implications in terms of time and costs; however, this this may be warranted, given the physiotherapists' strong allegiance to the approach compared with their usual practice.

Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual's disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.

Physiotherapists' views of implementing a stratified treatment approach for patients with low back pain in Germany: a qualitative study

Background

The STarT-Back-Approach (STarT: Subgroups for Targeted Treatment) was developed in the UK and has demonstrated clinical and cost effectiveness. Based on the results of a brief questionnaire, patients with low back pain are stratified into three treatment groups. Since the organisation of physiotherapy differs between Germany and the UK, the aim of this study is to explore German physiotherapists’ views and perceptions about implementing the STarT-Back-Approach.

Methods

Three two-hour think-tank workshops with physiotherapists were conducted. Focus groups, using a semi-structured interview guideline, followed a presentation of the STarT-Back-Approach, with discussions audio recorded, transcribed and qualitatively analysed using content analysis.

Results

Nineteen physiotherapists participated (15 female, mean age 41.2 (SD 8.6) years). Three main themes emerged, each with multiple subthemes: 1) the intervention (15 subthemes), 2) the healthcare context (26 subthemes) and 3) individual characteristics (8 subthemes). Therapists’ perceptions of the extent to which the STarT-Back intervention would require changes to their normal clinical practice varied considerably. They felt that within their current healthcare context, there were significant financial disincentives that would discourage German physiotherapists from providing the STarT-Back treatment pathways, such as the early discharge of low-risk patients with supported self-management materials. They also discussed the need for appropriate standardised graduate and post-graduate skills training for German physiotherapists to treat high-risk patients with a combined physical and psychological approach (e.g., communication skills).

Conclusions

Whilst many German physiotherapists are positive about the STarT-Back-Approach, there are a number of substantial barriers to implementing the matched treatment pathways in Germany. These include financial disincentives within the healthcare system to early discharge of low-risk patients. Therapists also highlighted the need for solutions in respect of scalable physiotherapy training to gain skills in combined physical and psychological approaches.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2991-3) contains supplementary material, which is available to authorized users.

Understanding Adolescent Low Back Pain From a Multidimensional Perspective: Implications for Management

Synopsis Low back pain (LBP) is the leading cause of disability worldwide. It often begins in adolescence, setting a course for later in life. We have tracked the course of LBP in the Raine Study cohort from the age of 14 years into early adulthood. Our work has found that LBP is already prevalent in individuals at 14 years of age and increases throughout adolescence and into early adulthood. It is often comorbid with other musculoskeletal pain. For some adolescents, LBP has little impact; for others, its impact includes care seeking, taking medication, taking time off from school and work, as well as modifying physical and functional activity. Of concern is the increasing prevalence of LBP with impact across adolescence, reaching adult rates by 22 years of age. The predictors of disabling LBP in adolescence are multidimensional. They include female sex, negative back pain beliefs, poor mental health status, somatic complaints, involvement in sports, and altered stress responses. Genetics also plays a role. Ironically, the factors that we have historically thought to be important predictors of LBP, such as "poor" spinal posture, scoliosis, carrying school bags, joint hypermobility, and poor back muscle endurance, are not strong predictors. This challenges our clinical beliefs and highlights that adolescent LBP needs a flexible and targeted multidimensional approach to assessment and management. In most cases, we recommend a cognitive functional approach that challenges negative LBP beliefs, educates adolescents regarding factors associated with their LBP, restores functional capacity where it is impaired, and encourages healthy lifestyle habits. J Orthop Sports Phys Ther 2017;47(10):741-751. Epub 12 Sep 2017. doi:10.2519/jospt.2017.7376.