Weight stigma in physiotherapy practice: Patient perceptions of interactions with physiotherapists

Does dissection influence weight bias among doctor of physical therapy students?

Anatomy with human dissection may help to develop respect for the human body and professionalism; however, dissection may worsen students' attitudes about body weight and adiposity. The purpose of this study was to measure weight bias among Doctor of Physical Therapy (DPT) students enrolled in gross anatomy and determine if, and how the experience of dissection impacts weight bias. Ninety-seven DPT students (70 University of Colorado [CU], 27 Moravian University [MU]) were invited to complete a survey during the first and final weeks of their anatomy course. The survey included demographic items, two measures of weight bias-the Modified Weight Bias Internalized Scale (M-WBIS) and the Attitudes Towards Obese Persons (ATOP) Scale-and open-ended questions for the students who participated in dissection (CU students) that explored attitudes about body weight and adiposity. At baseline, there were no significant differences (p > 0.202) in ATOP, M-WBIS, or BMI between the two universities. The mean scores on both the ATOP and M-WBIS indicated a moderate degree of both internalized and externalized weight bias. There were no significant changes in ATOP (p = 0.566) or M-WBIS scores (p = 0.428). BMI had a low correlation with initial M-WBIS scores (⍴ = 0.294, p = 0.038) and a high correlation with change scores in CU students (⍴ = 0.530, p = 0.011). Future studies should utilize the same measures of weight bias in other healthcare trainees to facilitate comparison and incorporate larger populations of DPT students.

"It's just as remarkable as being left-handed, isn't it?": exploring normativity through Australian physiotherapists' perspectives of working with LGBTQIA+ patients

INTRODUCTION

Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual and other related identities (LGBTQIA+) experience challenges with healthcare, including physiotherapy. To understand potential contributions to poor experiences, this study explored physiotherapists' experiences and perspectives about working with members of LGBTQIA+ communities.

METHODS

This study employed a qualitative research design, suitable for exploring the experiences and perspectives of individuals within the physiotherapy context. The sample consisted of physiotherapists working in Australia who participated in a larger survey study. Data were collected via semi-structured interviews which were audio-recorded and transcribed verbatim. Data analysis was conducted using a relativistic and queer theoretical framework with a reflexive thematic approach.

RESULTS

Eighteen physiotherapists with diverse sexual orientations participated in the interviews. While all participants identified as women or men, not all used binary gender pronouns. Five key themes were developed: 1) "anti-discrimination" regarding choice of language and providing safe environments; 2) "current and historical discrimination" against LGBTQIA+ individuals; 3) "taking an equality approach" when working with LGBTQIA+ patients; 4) "knowledge of LGBTQIA+ health" in a broad sense and specifically with transgender and gender-diverse people; and 5) "managing own reactions" with respect to individual biases and discomfort.

CONCLUSION

Underpinning all themes was the overarching concept of cis/hetero/endonormativity. Assuming normativity when working with LGBTQIA+ patients, is likely to have negative effects on patients' mental health, the therapeutic relationship and quality of care. In order to improve diversity, safety, inclusion and equity of care for LGBTQIA+ individuals, it is vital that normativity within physiotherapy is challenged.

Patient Perceptions of Weight Stigma Experiences in Healthcare: A Qualitative Analysis

BACKGROUND

Weight stigma is the social devaluation and denigration of individuals because of their excess body weight, resulting in poorer physical and mental health and healthcare avoidance. Attribution Theory and Goffman's theory of spoiled identity provided a general overarching framework for understanding weight stigma experiences.

OBJECTIVE

Our purpose was to explore weight stigma experiences from a broad range of perspectives emphasizing identities typically excluded in the weight stigma literature.

DESIGN

We conducted a qualitative descriptive study with data drawn from 73 substantive narrative comments from participants who responded to a larger survey.

RESULTS

Analysis developed five themes: Working on weight, Not being overweight, Lack of help and empathy, Exposure and embarrassment and Positive experiences. Individuals who would be clinically assessed as overweight, especially men, often did not identify with having a weight problem and found the framing of personal responsibility for weight empowering. Participants with larger body sizes more often attributed embarrassment and shame about weight to treatment in the clinical setting. Older participants were more likely to have positive experiences.

CONCLUSIONS

The findings suggest ongoing tension between the framing of weight as a personal responsibility as opposed to a multifactorial condition with many uncontrollable aspects. Gender, age and body size shaped respondent perspectives, with some young male respondents finding empowerment through perceived personal control of weight. The healthcare system perpetuates weight stigma through lack of adequate equipment and excessively weight-centric medical counselling. Recommending a healthy lifestyle to patients without support or personalized medical assessment may perpetuate weight stigma and associated detrimental health outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients with obesity and overweight were integral to this study, providing comments for our qualitative analyses.

Determining Associations Among Health Orientation, Fitness Orientation, and Attitudes Toward Fatness in Physiotherapists and Physiotherapy Students Using Structural Equation Modeling

Purpose

Research suggests physiotherapists hold negative attitudes and beliefs toward fatness and fat people. Physiotherapists are also health-conscious, and invested in healthy lifestyle behaviours including physical activity. Our purpose was to describe relationships between health orientation, fitness orientation, and fat attitudes.

Methods

Physiotherapists (n = 187) and physiotherapy students (n = 34) completed an online survey (Health Orientation Scale, Multidimensional Body-Self Relations Questionnaire, Fat Attitudes Assessment Toolkit). Structural equation modeling estimated associations between fat attitudes (dependent variable) and health and fitness orientation (independent variables).

Results

Participants scored high in orientation toward fitness and health. We found strong positive associations between fitness orientation and health orientation (p < 0.001). Health orientation was not significantly associated with fat attitudes (p = 0.075), whereas increased age was associated with more positive fat attitudes (p < 0.01). Although most participants acknowledged that factors outside an individual's control contribute to body weight, many also agreed with normative negative perspectives.

Conclusions

Physiotherapists are highly oriented toward fitness and health. This may underlie beliefs in the controllability of body weight and contribute to negative attitudes toward fatness and fat people. Further research, with greater sample sizes is necessary to further investigate associations between health orientation and fat attitudes.

Putting weight-related conversations into practice: Lessons learned from implementing a knowledge translation casebook in a disability context

BACKGROUND

Due to reported challenges experienced by healthcare providers (HCPs) when having weight-related conversations with children with disabilities and their families, a knowledge translation (KT) casebook was developed, providing key communication principles with supportive resources. Our aim was to explore how the KT casebook could be implemented into a disability context. Study objectives were to develop and integrate needs-based implementation supports to help foster the uptake of the KT casebook communication principles.

METHODS

A sample of nurses, physicians, occupational therapists and physical therapists were recruited from a Canadian paediatric rehabilitation hospital. Informed by the Theoretical Domains Framework, group interviews were conducted with participants to understand barriers to having weight-related conversations in their context. Implementation strategies were developed to deliver the KT casebook content that addressed these identified barriers, which included an education workshop, simulations, printed materials, and a huddle and email strategy. Participant experiences with the implementation supports were captured through workshop evaluations, pre-post surveys and qualitative interviews. Post-implementation interviews were analysed using descriptive content analysis.

RESULTS

Ten HCPs implemented the KT casebook principles over 6 months. Participants reported that the workshop provided a clear understanding of the KT casebook content. While HCPs appreciated the breadth of the KT casebook, they found the abbreviated printed educational materials more convenient. Strategies developed to address participants' need for a sense of community and opportunities to learn from each other did not achieve their aim. Increased confidence in integrating the KT casebook principles into practice was not demonstrated, due, in part, to having few opportunities to practice. This was partly because of the increase in competing clinical demands at the onset of the COVID-19 pandemic.

CONCLUSIONS

Despite positive feedback on the product itself, changes in the organisational and environmental context limited the success of the implementation plan. Monitoring and adapting implementation processes in response to unanticipated changes is critical to the success of implementation efforts.

Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis

Weight stigma research is largely focused on quantifiable outcomes with inadequate representation of the perspectives of those that are affected by it. This study offers a comprehensive systematic review and synthesis of weight stigma experienced in healthcare settings, from the perspective of patients living with obesity. A total of 1340 studies was screened, of which 32 were included in the final synthesis. Thematic synthesis generated three overarching analytical themes: (1) verbal and non-verbal communication of stigma, (2) weight stigma impacts the provision of care, and (3) weight stigma and systemic barriers to healthcare. The first theme relates to the communication of weight stigma perceived by patients within patient-provider interactions. The second theme describes the patients' perceptions of how weight stigma impacts upon care provision. The third theme highlighted the perceived systemic barriers faced by patients when negotiating the healthcare system. Patient suggestions to reduce weight stigma in healthcare settings are also presented. Weight stigma experienced within interpersonal interactions migrates to the provision of care, mediates gaining equitable access to services, and perpetuates a poor systemic infrastructure to support the needs of patients with obesity. A non-collaborative approach to practice and treatment renders patients feeling they have no control over their own healthcare requirements.

Integrating person-centred care and social justice: a model for practice with larger-bodied patients

Person-centred care (PCC) has been touted as a promising paradigm for improving patients' experiences and outcomes, and the overall therapeutic environment for a range of health conditions, including obesity. While this approach represents an important shift away from a paternalistic and disease-focused paradigm, we argue that PCC must be explicitly informed by a social justice lens to achieve optimal conditions for health and well-being. We suggest that existing studies on PCC for obesity only go so far in achieving social justice goals as they operate within a biomedical model that by default pathologises excess weight and predetermines patients' goals as weight loss and/or management, regardless of patients' embodied experiences and desires. There remains a dearth of empirical research on what social justice-informed PCC looks like in practice with larger patients. This interview study fills a research gap by exploring the perspectives of 1) health practitioners (n=22) who take a critical, social justice-informed approach to weight and 2) larger patients (n=20) served by such practitioners. The research question that informed this paper was: What are the characteristics of social justice-informed PCC that play out in clinical interactions between healthcare practitioners and larger-bodied patients? We identified five themes, namely: 1) Integrating evidence-based practice with compassionate, narrative-based care; 2) Adopting a curious attitude about the patient's world; 3) Centring patients' own wisdom and expertise about their conditions; 4) Working within the constraints of the system to advocate for patients to receive equitable care; 5) Collaborating across professions and with community services to address the multifaceted nature of patient health. The findings illustrate that despite participants' diverse perspectives around weight and health, they shared a commitment to PCC by upholding patient self-determination and addressing weight stigma alongside other systemic factors that affect patient health outcomes.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia

OBJECTIVES

To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.

DESIGN

We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.

SETTING

Australian primary care.

PARTICIPANTS

Registered physiotherapists who are members of a practice-based research network (n=31).

RESULTS

The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.

CONCLUSION

High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Impact of obesity on the use of healthcare resources by young adults aged 18-45 years: Results of the 2017 National Health Survey

INTRODUCTION

Excess weight is a public health problem associated with a greater burden of chronic diseases and increased use of health resources.

MATERIAL AND METHODS

A subsample of Spanish adults aged 18-45 from the 2017 Spanish National Health Survey (N=7081) was used. The odds ratios of service utilisation of the group with BMI≥30kg/m² were compared to the normal-weight group, using a model adjusted for sex, age, education, socioeconomic level, perceived health status and the presence of comorbidities.

RESULTS

In all, 12.4% of the sample had obesity. Of these, 24.8% visited their general physician, 37.1% attended emergency services and 6.1% were hospitalised during the last 12 months, which were significantly higher rates than in the normal-weight population (20.3%, 29.2%, 3.8%, respectively). However, 16.1% visited a physiotherapist and 3.1% used alternative therapies, compared to 20.8% and 6.4% in the healthy weight group. After adjusting for confounding factors, people with obesity were more likely to visit emergency services (OR: 1.225 [1.037-1.446]) and less likely to visit a physiotherapist (OR: 0.720 [0.583-0.889]) or use alternative therapies (OR: 0.481 [0.316-0.732]).

CONCLUSIONS

Spanish young adults suffering from obesity are more likely to use some health resources than those of normal weight, even after adjusting for socioeconomic variables and comorbidities, but they are less likely to attend physical therapy. The literature shows that these differences are less marked than in older ages, so this stage of life could be a window of opportunity for prevention to achieve better resource management.

Understanding the Impact and Tackling the Burden of Osteoarthritis for Aboriginal and Torres Strait Islander People

OBJECTIVE

The aim of this study was to understand and describe the lived experience of Aboriginal and Torres Strait Islander people with osteoarthritis.

METHODS

Qualitative study guided by cultural security, which ensures that research is conducted in a way that will not compromise the cultural values, beliefs, and expectations of Aboriginal and Torres Strait Islander people. Participants were purposively sampled through the networks of project staff. Research yarns (a cultural form of conversation used as a data gathering tool) were conducted with 25 Aboriginal and Torres Strait Islander adults with self-reported osteoarthritis in Western Australia and Victoria, Australia. Data were analyzed using a framework approach and presented through composite storytelling (hypothetical stories representing an amalgam of participants' experiences).

RESULTS

Two composite stories were constructed to reflect themes relating to beliefs and knowledge, impact, coping, and health care experiences. Common beliefs held by participants were that osteoarthritis is caused by previous physically active lifestyles. Many participants feared for their future, increasing disability and needing a wheelchair. Pain associated with osteoarthritis impacted daily activities, sleep, work, family, and social life and cultural activities. Multidimensional impacts were often experienced within complex health or life circumstances and associated with increased anxiety and depression. Most participants reported negative health care experiences, characterized by poor patient-provider communication.

CONCLUSION

Our findings highlight that osteoarthritis is a multidimensional issue for Aboriginal and Torres Strait Islander people that permeates all aspects of life and highlights the need for integrated, multidisciplinary care that is culturally informed and individualized to patient need.

Perceptions of practising physiotherapists in Saudi Arabia about their role in the health promotion of patients with musculoskeletal conditions: a qualitative study

OBJECTIVE

This study aimed to explore physiotherapists' perceptions in Saudi Arabia about their understanding and role in health promotion through lifestyle behaviours and risk factors assessment and management of patients with musculoskeletal pain and disabilities.

STUDY DESIGN

Qualitative study.

METHOD

One-to-one interviews with 12 physiotherapists (six females; mean age 34.5 ± 8) within a constructivist framework. Interviews were recorded, transcribed verbatim, and analysed using a thematic analysis approach.

RESULT

Three themes were identified: (1) the physiotherapists' awareness and knowledge of health promotion; (2) current practice of physiotherapists to implementing health promotion practice; and (3) the physiotherapists' perceived barriers to implementing health promotion practice. Participants generally perceived health promotion to be within their scope of practice. However, their understanding and approaches to deliver this practice were varied and non-standardised. Some barriers to routine engagement in health promotion were identified, including time constraints, the beliefs of healthcare practitioners, and limited education and training.

CONCLUSION

This study highlighted that physiotherapists acknowledged the role of health promotion in their practice. However, there were different explanations of the concept and it was informally practised.

An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, and Professional Roles

OBJECTIVE

The purpose of this study was to explore physical therapy through the stories of physical therapists who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) to consider how the profession enacts and constructs gender and sexual orientation.

METHODS

Physical therapists with clinical, academic, and professional roles who identify as LGBTQIA+ were recruited from Australia, the United Kingdom, Canada, and the United States. In-depth data were collected via narrative interviews. An iterative group discourse analysis was used to examine key discourses underpinning interview narratives and how these relate to the physical therapy profession.

RESULTS

Twenty-two physical therapists were interviewed. Participants had between 1.5 and 40 years of experience across various clinical areas and settings. Participants identified with varying sexual orientations and gender identities. Analysis identified discourses discussed under the following headings: (1) normativity, which related to hetero-normative assumptions about sexual orientation and cisnormative assumptions about gender identity and the intersectionality among sexual orientation, gender identity, and other forms of marginalization; (2) stress and labor, which explored the stress experienced by physical therapists who are LGBTQIA+ (due to fear of discrimination or actual discrimination) and additional emotional and other types of labor or work done in the workplace to hide aspects of their lives to feel safe, educate colleagues, and be a role model; and (3) professionalism, which related to the heterosexual/cisnormative (and other) "norms" that comprised participants' ideas of presenting as "professional" and positioning physical therapists who are LGBTQIA+ as "unprofessional."

CONCLUSION

Findings suggest that cultural norms may need to be reconceptualized in physical therapy to promote inclusion and belonging of individuals who identify as LGBTQIA+. Approaches to upskill new and existing physical therapists may include elements such as individual and institutional reflexivity, learning and implementing appropriate terminology, displaying indicators of inclusivity, and cultural safety training. These elements may provide the first steps to promote inclusive and culturally safe environments for individuals who identify as LGBTQIA+ within the profession.

IMPACT

This is the first known study to explore the lived experiences of those who identify as LGBTQIA+ in the physical therapy profession. The findings highlight how prevailing normative discourses in Western society are also present in physical therapy and impact those who identify as LGBTQIA+.

Stigmatizing effects of weight status on lay perceptions of eating disorder-related distress

The present study examined how weight status would affect lay perceptions of a White female student presenting signs of eating disorder-related distress. We recruited a mixed-gender, weight-diverse U.S. community sample through Mechanical Turk (N = 130; 49.2% female) to complete an online survey. Participants were randomly assigned to one of two conditions in which they read a personal statement section of a college application revealing eating disorder-related distress from a student who was either 'overweight' or 'underweight.' Participants evaluated the student on need for support, behavioural prescriptions for eating and exercise, and personal qualities. Although participants recognized a serious mental health concern in both conditions, they were more likely to prescribe eating disorder behaviors to the higher weight student. Findings suggest that weight stigma may bias lay perceptions of and even reinforce an eating disorder when exhibited by higher weight individuals.

"I've learned to look at things in a different way": exploring patients' perspectives on participation in physiotherapist delivered integrated stress inoculation training and exercise for acute whiplash

PURPOSE

To explore patient perspectives of the integrated intervention (intervention arm) of a recent randomised clinical trial that found clinically relevant and sustained benefits of a physiotherapist delivered integrated stress inoculation training (SIT) and exercise for people with acute whiplash-associated disorders (WAD) and at risk of poor recovery.

MATERIAL AND METHODS

Twelve patients from the 53 who participated in the SIT and exercise arm of a randomised controlled trial (StressModex RCT) participated in semi-structured interviews. Data were analysed using inductive thematic analysis.

RESULTS

Five main themes were identified: "balance between the physical and psychological components," "dealing with stress," "coping with the injury," "pain relief and return to function," and "elements enhancing therapeutic alliance."

CONCLUSIONS

The majority of patients found the SIT techniques to be helpful in managing stress and pain, coping with their injury, and returning to function. The patients also found the exercises useful and acknowledged the importance of both the physical and the psychological aspects of whiplash injury.IMPLICATIONS FOR REHABILITATIONPatients with acute WAD at risk of poor recovery welcomed the inclusion of psychological strategies as part of physiotherapy treatment.The patients nominated both the psychological (SIT) component and exercise as assisting them with their stress, pain, and recovery.Physiotherapists could consider including strategies targeting early stress responses in their management of patients with acute WAD.

Knee Osteoarthritis: An Investigation into the Clinical Practice of Physiotherapists in Canada

Purpose: The purpose of this study was to establish the clinical practice of physiotherapists who treat people with knee osteoarthritis (OA) in Canada and examine their knowledge, awareness, use of, and attitudes toward clinical practice guidelines (CPGs). Method: We conducted a cross-sectional survey of physiotherapists who are licensed to practise in Canada and who treat people with knee OA. Results: A total of 388 physiotherapists completed our survey. Approximately two-thirds of them (271) were aware of CPGs. Out of all CPG recommendations, most respondents provided leg strengthening exercises (380) and education (364). More than 80% believed that CPGs improved patient care and enhanced decision making and were confident in their ability to interpret CPGs. More physiotherapists (204) identified barriers to the use of CPGs than facilitators of their use (117). Physiotherapists who were employed in private practice were substantially more likely to use interventions such as acupuncture (odds ratio [OR] 5.98; 95% CI: 2.92, 12.23; p < 0.01) and joint mobilization and manipulation (OR 6.58; 95% CI: 3.45, 12.55; p < 0.01) than were physiotherapists employed in hospital settings. Conclusions: Two-thirds of respondents were aware of CPGs. Physiotherapists provided education and leg strengthening exercises more often than aerobic exercise and weight management advice. Physiotherapists employed in private practice were more likely to use adjunct interventions.

Challenges with strengthening exercises for people with knee osteoarthritis and comorbid obesity: a qualitative study with patients and physiotherapists

OBJECTIVE

Explore challenges associated with implementing a home-based strengthening exercise program for people with knee osteoarthritis and comorbid obesity.

METHODS

Qualitative study embedded within a randomised controlled trial comparing two home-based strengthening programs (weight bearing functional exercise versus non-weight bearing quadriceps strengthening exercise) for people with knee osteoarthritis and comorbid obesity. Patients in both exercise programs attended five consultations with a physiotherapist and undertook a home-based exercise program for 12 weeks. Semi-structured individual telephone interviews were conducted with 22 patients after trial completion, and all seven physiotherapists who delivered trial interventions. Interviews were recorded, transcribed verbatim, and thematically analysed using an inductive approach.

RESULTS

Three themes arose: i) psychological challenges (false assumptions about exercise; fear of pain; disliking exercise; mental effort of weight bearing functional program; underestimating capability) ii) physical challenges (complexity of weight bearing functional program; cuff weights and straight leg raise problematic in non-weight bearing quadriceps program; other health conditions), and; iii) overcoming challenges (incentives to exercise; accountability; education and reassurance; tailoring the exercise program).

CONCLUSION

Patients and physiotherapists experienced numerous psychological and physical challenges to exercise, including a fear of pain, having false assumptions about exercise, difficulties with exercise performance, application of cuff weights, and adverse impacts of other health conditions.

Weight Stigmatization among Physical Therapy Students and Registered Physical Therapists

INTRODUCTION

Weight stigmatization is reflected in anti-fat attitudes and stereotypical perceptions of people who are overweight; it has been demonstrated to be prevalent in many segments of society across multiple countries. Studies examining the prevalence of weight stigmatization use different research tools, which can hinder inter-study comparisons. There is also evidence indicating weight stigmatization among registered physical therapists, although its magnitude differs between studies. Limited information exists regarding the attitudes and beliefs of physical therapy (PT) students toward individuals with obesity. Examining weight stigmatization among PT students is particularly important for developing appropriate educational interventions that may influence the professional lives of future physical therapists.

OBJECTIVE

This study aims to characterize and compare the stigmatizing attitudes and beliefs of PT students and certified physical therapists regarding people with obesity in Israel. Its secondary objective is to translate three weight stigmatization questionnaires into Hebrew and determine their psychometric properties.

METHODS

A cross-sectional, anonymous, and computerized self-report survey was completed by 285 certified physical therapists (average age 39.6 ± 10.1 years) and 115 PT students (average age 26.4 ± 4.9 years). The study used three validated weight stigma questionnaires employed in earlier studies to determine different aspects of weight stigmatization: the Fat Phobia Scale (short form; FPS), Anti-Fat Attitudes (AFA) questionnaire, and Beliefs about Obese People (BAOP). These questionnaires were translated into Hebrew and their psychometric properties ascertained.

RESULTS

Similar to the original English versions, the translated versions of the three questionnaires demonstrated good internal consistency (Cronbach's α values of FPS = 0.77; AFA = 0.75; BOAP = 0.59). The three questionnaires showed a low correlation. No significant difference was noted in the FPS and AFA scores between groups, reflecting that both demonstrated average weight stigmatization (FBS in both groups: average score of 3.6 out of 5; AFA therapists: 3.3 ± 1.2, students: 3.0 ± 1.2 out of 9). However, significant between-group differences were observed for BOAP, which examines beliefs regarding individuals' control over their weight (therapists: 16.4 ± 5.6, students: 18.0 ± 5.7 out of 48; p < 0.01).

CONCLUSION

Student and certified physical therapists demonstrate average levels of weight stigmatization, as reflected in the FPS and AFA scores. Nevertheless, compared to certified physical therapists, physical therapist students believe more strongly that obesity cannot be controlled by the individual. The students' beliefs could affect their clinical judgment and behavior as health care professionals in the future. Therefore, anti-fat attitudes and stereotypical perceptions should be addressed and remediated early using educational interventions during the study period.

Addressing weight bias and stigma of obesity amongst physiotherapists

Backgound: Physiotherapists, as with all other healthcare professionals, report attitudes toward patients with obesity and beliefs about obesity that contribute to weight bias and stigma. Objectives: Determine if physiotherapists' attitudes and/or beliefs changed after attending an educational seminar that included content about the challenges faced by patients with obesity undergoing joint replacement and strategies on how to work effectively and sensitively with this population.Methods: Physiotherapists completed a survey before and after attending a one day seminar to evaluate attitudes (The Attitude Towards Obese Persons, ATOP) and beliefs (Beliefs About Obese Persons, BAOP) towards obesity. To provide a reference, the seminar group's attitudes and beliefs were compared to a provincial cohort of 383 physiotherapists who completed the online version of the survey.Results: The pre-seminar mean ATOP score (71.3 ± 19.3) was similar to the online mean score (72.6 ± 15.3) (p = .66). The post-seminar ATOP score decreased (63.6 ± 15.9) (p = .02) indicating greater negative attitudes. The mean difference of the seminar BAOP showed a modest increase (mean difference 4.6, p = .001) indicating that participants believed obesity was less in control of the individual.Conclusions: Seminar information presented by respected and trusted leaders did not challenge participants' implicit attitudes and beliefs towards obesity. Further evaluation of theory-driven approaches specifically targeting physiotherapists is needed to address stigmatization within the profession.

Caring in and for physiotherapy through stewardship

Care is central to many health professions, including physiotherapy. Different forms of care are enacted as part of being a caring professional. For example, a practitioner who provides good service to others and upholds standards while doing so is in-grained in education for professional formation. However, there are other topics and aspects of care that are not as well attended to, and that is care for the future of the profession. This too is an aspect of care, and it is an urgent objective in an era where societies and healthcare are changing at rapid rates. In this paper, I argue that Golde and Walker's (2006) idea of stewardship can help health professionals think about this often overlooked aspect of care. Stewardship adds a perspective that is centered on a deep authentic care for and responsibility towards the ongoing relevance of the profession. Stewardship keeps the question of what the profession is, and what a professional does, alive as part of its present and future practice.

A qualitative study exploring the views of individuals with knee osteoarthritis on the role of physiotherapists in weight management: A complex issue requiring a sophisticated skill set

OBJECTIVES

The aim of the present study was to explore the attitudes of individuals with knee osteoarthritis (OA) towards the role of physiotherapists in weight management in knee OA.

METHODS

The study took the form of a qualitative semi-structured telephone interview study. Participants included 13 purposively sampled individuals with symptomatic knee OA who were overweight or obese by body mass index. Each participated in a semi-structured telephone interview exploring their perspectives regarding the potential role of physiotherapists in weight management in knee OA. Data were transcribed and analysed using a thematic approach.

RESULTS

Three main themes were identified, which highlighted that individuals with knee OA: (a) recognize that weight management is complex; (b) consider that a special skill set is required by clinicians for weight management; and (c) expressed ambivalence towards physiotherapists' role in weight management, with a focus on the role of exercise prescription.

CONCLUSIONS

Although participants were open to physiotherapists taking on a weight management role within a multidisciplinary team, they were uncertain about whether physiotherapists had the skills and scope of practice needed to address this complex issue. The findings highlight the importance of engagement by physiotherapists in meaningful dialogue with patients, to understand better their experiences, expectations and preferences, and establish if, when and how to integrate patients in weight management discussions in the treatment plan for their knee OA.

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.

People who identify as LGBTIQ+ can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey

QUESTIONS

What are the experiences of people who identify as lesbian, gay, bisexual, transgender, intersex, queer or related identities (LGBTIQ+) and attend physiotherapy? How could those experiences of physiotherapy be improved?

DESIGN

Primarily qualitative design using a purpose-built online survey.

PARTICIPANTS

People aged 18 years or older, who self-identified as LGBTIQ+, and had attended physiotherapy in Australia.

METHODS

Open responses were analysed with thematic analysis and quantitative responses with descriptive statistics.

RESULTS

One hundred and fourteen participants responded to the survey, with 108 meeting all eligibility criteria. Four main themes were identified in the analysis, with almost all participants reporting experiences during physiotherapy interactions relating to at least one of the following themes: 'assumptions' about participants' sexuality or gender identity; 'proximity/exposure of bodies', including discomfort about various aspects of physical proximity and/or touch and undressing and/or observing the body; 'discrimination', including reports of overt and implicit discrimination as well as a fear of discrimination; and 'lack of knowledge about transgender-specific health issues'. Positive experiences were also evident across the first, third and fourth themes. Participants suggested or supported a number of ways to improve LGBTIQ+ experiences with physiotherapy, including: LGBTIQ+ diversity training for physiotherapists, education specific to the LGBTIQ+ population (particularly transgender health), and open options for gender provided on forms.

CONCLUSION

People who identify as LGBTIQ+ can experience challenges when attending physiotherapy, including: erroneous assumptions by physiotherapists, discomfort, explicit and implicit discrimination, and a lack of knowledge specific to their health needs. Positive findings and participant-suggested changes offer ways to improve physiotherapy for LGBTIQ+ people across educational and clinical settings.

Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: a mixed methods systematic review

Worldwide prevalence of adult overweight and obesity is a growing public health issue. Adults with overweight/obesity often have chronic musculoskeletal pain. Using a mixed-methods review, we aimed to quantify the effectiveness and explore the appropriateness of weight loss interventions for this population. Electronic databases were searched for studies published between 01/01/90 and 01/07/16. The review included 14 randomized controlled trials that reported weight and pain outcomes and three qualitative studies that explored perceptions of adults with co-existing overweight/obesity and chronic musculoskeletal pain. The random-effects pooled mean weight loss was 4.9 kg (95%CI:2.9,6.8) greater for intervention vs control. The pooled mean reduction in pain was 7.3/100 units (95%CI:4.1,10.5) greater for intervention vs control. Study heterogeneity was substantial for weight loss (I²  = 95%, tau = ±3.5 kg) and pain change (I²  = 67%, tau = ±4.1%). Meta-regression slopes for the predictors of study quality, mean age and baseline mean weight on mean study weight reduction were shallow and not statistically significant (P > 0.05). The meta-regression slope between mean pain reduction and mean weight lost was shallow, and not statistically significant, -0.09 kg per unit pain score change (95%CI:-0.21,0.40, P = 0.54). Meta-synthesis of qualitative findings resulted in two synthesized findings; the importance of healthcare professionals understanding the effects of pain on ability to control weight and developing management/education programmes that address comorbidity.

Knowledge, Attitudes, and Practice of In-Patient Physiotherapists in Ontario Regarding Patients Who Are Super-Morbidly Obese

Purpose: This article describes the knowledge, attitudes, and practice of in-patient physiotherapists in Ontario regarding the treatment of patients who are super-morbidly obese (SMO; i.e., those whose BMI is >50). Method: A 62-item questionnaire was developed to assess demographics, sources of knowledge, current practice, and attitudes such as confidence, willingness, and the perceived effectiveness of treatment. It was distributed electronically using FluidSurveys. All physiotherapists working in a clinical role with adults in an in-patient setting in Ontario were eligible to participate. Results: A total of 276 physiotherapists completed the survey. Most of them had learned about the treatment from non-structured sources such as clinical experience. More than half (52%) of the participants disagreed that their place of employment was well prepared to facilitate the treatment of patients who are SMO. The majority of respondents were confident in treating these patients, were willing to treat them (82%), and believed that physiotherapy would improve at least one health outcome (96%) for them; however, 46% were reluctant to treat for fear of personal injury. Participants most commonly felt limited by lack of equipment and lack of staff to assist. Conclusions: Physiotherapists have positive attitudes toward treating patients who are SMO, and increased equipment and staff to assist, as well as appropriate education, may decrease the fear of injury for physiotherapists while treating these patients and improve health outcomes for them.

Physiotherapists' encounters with "obese" patients: Exploring how embodied approaches gain significance

BACKGROUND

Obesity is regarded as a modern lifestyle problem, causing illness, stigma, discrimination, and psychological problems. To help patients avoid these problems, physiotherapists increasingly engage in lifestyle programs specialized in weight loss.

OBJECTIVE

To explore how physiotherapists' encounters with patients diagnosed as "obese" acquire significance for their development as clinicians.

METHOD

The material draws on semi-structured interviews with eight physiotherapists. We conducted a thematic analysis inspired by van Manen's hermeneutic-phenomenological approach combined with Kvale and Brinkman's critical approach.

FINDINGS

The analysis identified the following four themes: 1) Striving to find one's own style of communication; 2) Relating to bodily discrepancies; 3) Developing clinical competence through bodily encounters; and 4) Gaining insight into the dilemmas of group-based lifestyle programs. Taken together, our findings highlight bodily encounters between patients and physiotherapists as an invaluable source of insight. Such insight can shape physiotherapists' development as clinicians inspiring them to develop their unique ways of communicating so that patients diagnosed as obese can feel empowerment rather than failure and shame. At the same time, our findings point to the need of critically reflecting on ones' own approach entering a double role of both controller and supporter. As such, our findings complicate and extend previous work on stigma and shame.

CONCLUSION

Our research leads us to conclude that more emphasis on critical thinking in physiotherapy is necessary. We suggest that this should be given more priority in research, education, as well as in clinical practice.

An Examination of Women's Self-Presentation, Social Physique Anxiety, and Setting Preferences during Injury Rehabilitation

Objectives. This study investigated whether women experience self-presentational concerns related to rehabilitation settings and explored preferences for characteristics of the social and physical treatment environment in relation to women's Social Physique Anxiety (SPA). Methods. Two cross-sectional studies were conducted. In Study 1, female undergraduate students (n = 134) completed four questionnaires (Social Physique Anxiety Scale; three bespoke questionnaires assessing self-presentation in rehabilitation and social and physical environment preferences) with respect to hypothetical rehabilitation scenarios. Study 2 recruited injured women who were referred for physiotherapy (n = 62) to complete the same questionnaires regarding genuine rehabilitation scenarios. Results. Women with high SPA showed less preference for physique salient clothing than women with low SPA in both hypothetical (p = 0.001) and genuine settings (p = 0.01). In Study 2, women with high SPA also preferred that others in the clinic were female (p = 0.01) and reported significantly greater preference for private treatment spaces (p = 0.05). Conclusions. Self-presentational concerns exist in rehabilitation as in exercise settings. Results indicated inverse relationships between women's SPA and preference for the presence of men, physique-enhancing clothing, and open-concept treatment settings. Future studies to determine the effect of self-presentational concerns on treatment adherence are needed.

Objecting: Multiplicity and the practice of physiotherapy

Drawing from Annemarie Mol’s conceptulisation of multiplicity, we explore how health care practices enact their object(s), using physiotherapy as our example. Our concern is particularly to mobilise ways of practicing or doing physiotherapy that are largely under-theorised, unexamined or marginalised. This approach explores those actions that reside in the interstitial spaces around, beneath and beyond the limits of established practices. Using Mol’s understanding of multiplicity as a theoretical and methodological driver, we argue that physiotherapy in practice often subverts the ubiquitous reductive discourses of biomedicine. Physiotherapy thus enacts multiple objects that it then works to suppress. We argue that highlighting multiplicities opens up physiotherapy as a space which can broaden the objects of practice and resist the kinds of closure that have become emblematic of contemporary physiotherapy practice. Using an exemplar from a rehabilitation setting, we explore how physiotherapists construct their object(s) and consider how multiplicity informs an otherwise physiotherapy that has broader implications for health care and rehabilitation.

Stigma in Practice: Barriers to Health for Fat Women

In this paper, we explore barriers to health for fat people. By shifting the focus from what fat people do or do not do, neoliberal principles are replaced by a focus instead on structural and institutional policies, attitudes, and practices. This includes the impact of stigma on the health treatment and health-seeking behavior of fat people. For example, we consider the role that provider anti-fat attitudes and confirmation bias play in the failure to provide evidenced-based healthcare to fat patients. This is an autoethnographic paper, which provides the opportunity to read research from the perspective of fat scholars, framed by questions such as: can fat people have health? Is health itself a state of being, a set of behaviors, a commodity, a performance; perhaps the new social contract? As a co-written autoethnographic paper, one aspect of the evidence provided is the recorded experiences of the two fat authors. This includes writing from notes, journals, compiled and repeated experiences with medical professionals, family, and the community. Framed by feminist standpoint and supported by literature drawn from Fat Studies, Public Health, Obesity Research, and other interdisciplinary fields, this is a valuable opportunity to present an extended account of fat discrimination and the impact of the stigma fat people face through the medical profession and other sectors of the community, written by fat individuals. The paper concludes by considering the health pathways available to fat people. Special attention is paid to whether Bacon and Aphramor's Health at Every Size paradigm provides a path to health for fat individuals.

Physical Therapists' Ways of Talking About Overweight and Obesity: Clinical Implications

BACKGROUND

How people think and talk about weight is important because it can influence their behavior toward people who are overweight. One study has shown that physical therapists have negative attitudes toward people who are overweight. However, how this finding translates into clinical practice is not well understood. Investigating physical therapists' ways of thinking and speaking about overweight and obesity in the context of their work can provide insight into this underresearched area.

OBJECTIVES

The purpose of this study was to investigate physical therapists' ways of talking about overweight individuals and discuss clinical implications.

DESIGN

An interpretive qualitative design was used.

METHODS

The research team used discourse analysis, a type of inductive qualitative methodology, to guide data collection and analysis. The data came from 6 focus groups of 4 to 6 physical therapists in Queensland, Australia, who discussed weight in a physical therapy environment. Participants (N=27) represented a variety of physical therapy subdisciplines.

RESULTS

Data analysis identified 4 main weight discourses (ways of thinking and speaking about weight). Participants described patients who are overweight as little affected by stigma and difficult to treat. Furthermore, participants portrayed weight as having simple causes and being important in physical therapy. Alternate weight discourses were less frequent in these data.

CONCLUSIONS

The results indicated that some physical therapists' understandings of weight might lead to negative interactions with patients who are overweight. The findings suggest physical therapists require more nuanced understandings of: how patients who are overweight might feel in a physical therapy setting, the complexity of causes of weight, and possible benefits and disadvantages of introducing weight-management discussions with patients. Therefore, education should encourage complex understandings of working with patients of all sizes, including knowledge of weight stigma.

An ethical approach to health promotion in physiotherapy practice

ISSUE ADDRESSED

With increased emphasis on reducing the global burden of non-communicable disease, health professionals who traditionally focused on the individual are being encouraged to address population-level health problems. While physiotherapists are broadening their clinical role to include health promotion strategies in their clinical practice, the ethical foundations of this practice focus have received less attention.

METHODS

We use a physiotherapy clinical scenario to highlight different physiotherapeutic approaches and to analyse underpinning ethical values and implications for practice.

RESULTS

We suggest there are potential harms of incorporating health promotion into physiotherapy management of individuals if the population-based research does not resonate with an individual's particular circumstances, capacity to change or view of what counts as important and meaningful. We propose that critical reasoning and ethical judgment by the physiotherapist is required to determine how health promotion messages applied in primary care settings might work to benefit and enhance a client's well being rather than impose burdens or cause harm.

CONCLUSION

We suggest four ethical reasoning strategies designed to assist physiotherapists to frame and understand fundamental ethical principles of beneficence, harm, autonomy and justice when implementing health promotion and self-management approaches in clinical practice.

A qualitative examination of women's self-presentation and social physique anxiety during injury rehabilitation

OBJECTIVE

To understand women's self-presentation experiences in the rehabilitation setting, and their attitudes and preferences toward the social and physical features of the rehabilitation environment.

DESIGN

Qualitative study.

SETTING

Outpatient physiotherapy clinic.

PARTICIPANTS

Ten women (age 18 to 64) with high social physique anxiety (Social Physique Anxiety Scale score ≥25) referred for physiotherapy following acute injury.

MAIN OUTCOME MEASURES

Semi-structured interviews were conducted prior to commencement of treatment, and again after a third treatment session.

RESULTS

Participants experienced extensive self-presentational concerns that were intensified due to the nature of the physiotherapy environment. The women reported that their self-presentational anxiety did not diminish over time, and was related to others' negative perceptions regarding their physical appearance and inability to perform exercises as well as expected. The presence of men or younger women in the clinic was identified as a barrier to appointment attendance, along with open concept clinic settings, which were associated with the most potential for evaluation. Mirrors and windows in the physiotherapy clinic were highlighted as anxiety provoking. The women suggested that they would feel apprehensive about advocating for themselves if they felt uncomfortable with the area in which they were receiving treatment, and instead used avoidance coping strategies (e.g., hiding behind equipment, preventing eye contact) to manage their anxiety.

CONCLUSIONS

Physique-anxious women experience extensive self-presentational concerns in the rehabilitation environment, which could affect treatment adherence. Modifying the treatment setting, providing protective self-presentational strategies such as positive self-talk, and open patient-therapist communication could be implemented to help mitigate these concerns.