Psychologically informed physiotherapy for chronic pain: patient experiences of treatment and therapeutic process

Relationships Between Socioecological Factors and Self-Efficacy to Participate in Physical Activity for Adults With Chronic Musculoskeletal Pain: An Integrative Review

OBJECTIVE

Self-efficacy for leisure-time or health-promoting physical activity (SEPA) is a psychosocial determinant of physical activity. The socioecological model can provide a robust perspective of SEPA. The objective of this study was to synthesize the evidence on multilevel correlates of SEPA among individuals with chronic musculoskeletal pain. The second aim examined the extent to which socioecological disparities are associated with SEPA among individuals with chronic musculoskeletal pain.

METHODS

An integrative review was conducted. Included studies needed to investigate the relationship between SEPA and socioecological factors at the interpersonal, institutional, community, and/or macrosystem level among adults with chronic musculoskeletal pain (≥3 months). Searches in PubMed, EMBASE, PsycINFO, and CINAHL were performed (December 30, 2020, and October 12, 2022), yielding 4047 records after duplicates were removed. Two independent reviewers completed screening, full-text reviews, and data extraction. After title and abstract screening and full-text reviews, 17 studies were included. The constant comparison method included: data reduction, data display, data comparison, and conclusion drawing/verification. Quality of evidence was assessed using the Joanna Briggs Institute appraisal tools.

RESULTS

Five themes emerged with respect to relationships between SEPA and socioecological factors: social relations, social comparisons, patient-provider relationship, organizational resources, and accessibility to physical activity. Relationships between interpersonal factors and SEPA were most prominently studied. One study examined and addressed potential disparities in SEPA at the macrosystem level.

CONCLUSION

A spectrum of relationships from supporting to straining SEPA were found at the interpersonal level. Relationships between institutional, community, and macrosystem factors and SEPA were comparably sparse. Gaps in the literature were identified regarding how health disparities present across the socioecological model with respect to SEPA.

IMPACT

Clinicians can use this review to evaluate how SEPA can be supported or threatened by factors across the socioecological model. This may be a preliminary step towards examining and addressing health disparities in SEPA.

Exploring the impact of physiotherapy on health outcomes in older adults with chronic diseases: a cross-sectional analysis

Objective

This study evaluates the impact of physiotherapy interventions on health outcomes and explores the correlation between physiotherapy session characteristics and improvements in health among older individuals.

Methods

In a cross-sectional design, 384 older adults with chronic conditions such as arthritis, osteoporosis, Chronic Obstructive Pulmonary Disease (COPD), diabetes, and hypertension were recruited.

Results

The proportion of arthritis (39.1%) and hypertension (45.8%) was notably high. Participants receiving physiotherapy showed significant improvements in pain levels (mean reduction from 5.09 to 2.95), mobility scores (improvement from 3.0 to 3.96), and functional independence. A positive correlation was identified between the frequency of physiotherapy sessions and pain reduction (r = 0.26, p = 0.035), and a stronger correlation between session duration and both pain reduction (r = 0.38, p = 0.002) and mobility improvement (r = 0.43, p = 0.001). High satisfaction rates with physiotherapy were reported, and age was found to be a significant negative predictor of health outcomes (Coef. = -0.3402, p = 0.0009).

Conclusion

Physiotherapy interventions significantly improve health outcomes in older adults with chronic diseases.

Headache diagnosis and treatment: A pilot knowledge and needs assessment among physical therapists

OBJECTIVE

The objective of this pilot study was to assess physical therapists' (PTs) knowledge and needs regarding headache diagnosis and management.

BACKGROUND

While there is significant research on physical therapy and cervicogenic headache, studies suggest that migraine is often under-recognized, misdiagnosed, and inadequately treated across society despite its high prevalence and burden. Because migraine commonly includes concurrent neck pain and/or vestibular symptoms, patients with migraine may present to PTs for treatment. Very little is known about PTs' headache and migraine education, knowledge, and clinical practices.

METHODS

A team of headache specialists and PTs adapted a previously used headache knowledge and needs assessment survey to help ascertain PTs' knowledge and needs regarding headache treatment. The cross-sectional survey was distributed online via Research Electronic Data Capture (REDCap) to PTs within a large healthcare system in Connecticut.

RESULTS

An estimated 50.5% (101/200) of PTs invited to complete the survey did so. Only 37.6% (38/101) of respondents reported receiving any formal headache or migraine education in their professional training, leading to knowledge gaps in differentiating and responding to headache subtypes. Only 45.5% (46/101) were able to identify that migraine is characterized by greater pain intensity than tension-type headache, and 22.8% (23/101) reported not knowing the duration of untreated migraine. When asked about the aspects of care they believe their patients with headache would like to see improved, PTs reported education around prevention and appropriate medication use (61/100 [61.0%]), provider awareness of the degree of disability associated with migraine (51/100 [51.0%]), and diagnostics (47/100 [47.0%]).

CONCLUSION

This sample of PTs from one healthcare system demonstrates knowledge gaps and variations in clinical practice for managing their patients with headache. Future research on integrating additional opportunities for headache education for physical therapists, including evidence-based behavioral therapies, is needed to ascertain whether it is likely to improve patient care.

Chronic Pain Management Approaches among Spanish Physiotherapists: Influences, Practices, Barriers, and Challenges

This study evaluated Spanish physiotherapists' orientations toward biopsychosocial and biomedical approaches in chronic pain management through a cross-sectional survey of 447 registered professionals. Validated questionnaires assessed knowledge, attitudes, and beliefs. Multivariate analysis of covariance (MANCOVA) identified influential factors and ordinal regression determined the frequency of biopsychosocial application. Content analysis of open-ended responses explored barriers to biopsychosocial implementation. Over 50% of physiotherapists favored the biopsychosocial model, influenced by interdisciplinary work settings, advanced pain knowledge, and specific training. Comprehensive pain knowledge significantly impacted both biomedical and biopsychosocial orientations inversely. The biomedical approach was more prevalent among those with lower education levels and less pain knowledge, particularly at the beginning or over 20 years into their careers. Despite the theoretical preference for biopsychosocial among Spanish physiotherapists, practical application was infrequent, with only 9.8% always using it and 40.7% frequently. Self-reported confidence and skills were crucial determinants of biopsychosocial implementation frequency. Significant barriers included inadequate psychological skills (63.6%), coordination challenges (47.6%), time constraints (43.6%), patient misconceptions (34.2%), and systemic issues. These findings align with international research, highlighting the need to bridge the gap between theoretical knowledge and clinical practice. Addressing these challenges through targeted training and systemic reforms is crucial for improving chronic pain management globally.

Positive Association between Patients' Perception of Chronic Pain Rehabilitation as a Personally Meaningful Experience and the Flourishing Aspect of Well-Being

Chronic pain rehabilitation helps to reduce pain and restore valued life roles. Patients may have more positive outcomes when they perceive rehabilitation to be personally meaningful. This study examined associations between self-reported, personally meaningful rehabilitation and well-being. A pilot study was conducted using an online survey of people with chronic pain and experiences of rehabilitation. The PROMIS Pain Interference Short Form 8a and The Flourishing Scale were used to explore well-being. A modified self-report measure, the Meaningfulness in Rehabilitation Scale, was pilot-tested for construct validity and used in the survey. Of the 48 participants (81% female; 19% male), most attended a generalist therapy practice (62%) once per week (33%) or once per fortnight (29%). No statistically significant relationship was found between self-reported meaningfulness in rehabilitation and pain interference or other patient and therapy characteristics (duration of chronic pain category, type of therapy practice, resolution of rehabilitation category, and frequency of appointments). The nonparametric analysis identified a statistically significant moderate positive correlation between self-reported meaningfulness in rehabilitation and the flourishing aspect of well-being. This raises important questions and suggests that patients' perception of rehabilitation as meaningful warrants further research. This pilot study provides valuable guidance to inform a larger investigation.

[Management of chronic non-oncologic pain by multicomponent programs using non-pharmacologic therapies: A systematic review of the literature]

Chronic pain is a public health problem suffered by 20% of the world's population. Pharmacological approaches are insufficient, so a multi-therapeutic approach that also includes non-pharmacological therapies (psychological therapies, meditation, physical exercise, healthy habits, etc.) is proposed. The aim of this review was to review the existing scientific evidence on the effect of multicomponent programs with non-pharmacological therapies in people with chronic non-oncologic pain. To this end, a search for scientific articles was carried out in three databases (PubMed, Web of Science and PsycINFO) and 17 articles were selected, following the PRISMA recommendations. The patients who participated in these programs were mostly women, aged 18 to 80years, working or on sick leave due to pain, with secondary education or less and married. The most frequent pain was musculoskeletal, mainly low back pain. All the articles studied the effectiveness of two or more therapies, highlighting psychological therapies, physical exercise and education. Positive results were obtained in the reduction of different variables such as pain, pain catastrophizing, anxiety and depression, in addition to improving functionality and quality of life. It has also been shown that patients' prior expectations regarding the intervention influence its effectiveness. Although throughout the review there was great heterogeneity in the interventions, in the evaluation methods and in the results themselves, it can be concluded that multicomponent programs show positive results in the management of chronic pain, and should therefore be incorporated as a routine therapeutic treatment.

Empowering patients with persistent pain: The potential of cognitive functional therapy in interdisciplinary care: A single-case experimental design

INTRODUCTION AND PURPOSE

Persistent musculoskeletal pain (PMP) is multifactorial and causes both societal and financial burdens. Integration of multifactorial management in patients with PMP remains challenging. A single-case experimental design was performed on three patients suffering from high impact PMP (lumbar spine, shoulder and knee) to i) assess the potential for Cognitive Functional Therapy (CFT) in interdisciplinary care, ii) describe in detail the clinical journey patients experienced during the intervention, and iii) evaluate the changes and associations in relation to the outcome measures of pain, disability, maladaptive movement behavior, subjective overall improvement, health related quality of life and work status. These were monitored over one year, at the end of each of the six intervention modules.

RESULTS

After introducing the intervention systematic changes were seen, with medium to large changes (Non-overlap of All Pairs 0.67-1) for all outcome measures. Associations between changes of the outcome measures were large (r ≥ 0.50) and changes occurred concurrently. Minimally clinically important difference thresholds were exceeded for all outcome measures and two patients achieved relevant improvements related to work reintegration.

DISCUSSION

The positive results of this study are comparable with recent CFT studies. However, the difference regarding the number of sessions and duration of the intervention is evident. The length of the intervention in this study seemed to enable continuous significant improvements up until 12 months post onset and follow-up.

CONCLUSION

CFT in interdisciplinary care was effective for all measures. The detailed descriptions of the clinical processes aim to improve clinical care.

Identifying central elements of the therapeutic alliance in the setting of telerehabilitation: A qualitative study

INTRODUCTION

Therapeutic alliance is a relevant aspect of healthcare and may influence patient outcomes. So far, little is known about the therapeutic alliance in telerehabilitation.

PURPOSE

To identify and describe central elements of therapeutic alliance in the setting of telerehabilitation and compare it to those in conventional rehabilitation.

METHODS

In this qualitative study, a literature search and in-depth semi-structured interviews with rehabilitation and telerehabilitation experts were conducted from 15.5.-10.8.2020 on elements influencing the therapeutic alliance in rehabilitation and telerehabilitation. Using a combined deductive and inductive approach, qualitative content analysis was used to identify categories and derive central themes.

RESULTS

The elements bond, communication, agreement on goals and tasks and external factors were identified in the literature search and informed the development of the interview guide. Twelve purposively sampled experts from the fields of physiotherapy, occupational therapy, speech and language therapy, psychology, general medicine, sports science and telerehabilitation software development participated in the interviews. We identified three central themes: building effective communication; nurturing a mutual relationship of trust and respect; and agreement on goals and tasks and drivers of motivation.

CONCLUSIONS

In this qualitative study, key elements of therapeutic alliance in rehabilitation confirmed those reported in the literature, with additional elements in telerehabilitation comprising support from others for ensuring physical safety and technical connectedness, caregivers acting as co-therapists and applying professional touch, and promoting patient autonomy and motivation using specific strategies.

Guarding and flow in the movements of people with chronic pain: A qualitative study of physiotherapists' observations

BACKGROUND

Among the adaptations of movement consistently associated with disability in chronic pain, guarding is common. Based on previous work, we sought to understand better the constituents of guarding; we also used the concept of flow to explore the description of un/naturalness that emerged from physiotherapists' descriptions of movement in chronic pain. The aim was to inform the design of technical systems to support people with chronic pain in everyday activities.

METHODS

Sixteen physiotherapists, experts in chronic pain, were interviewed while repeatedly watching short video clips of people with chronic low back pain doing simple movements; physiotherapists described the movements, particularly in relation to guarding and flow. The transcribed interviews were analysed thematically to elaborate these constructs.

RESULTS

Moderate agreement emerged on the extent of guarding in the videos, with good agreement that guarding conveyed caution about movement, distinct from biomechanical variables of stiffness or slow speed. Physiotherapists' comments on flow showed slightly better agreement, and described the overall movement in terms of restriction (where there was no flow or only some flow), of tempo of the entire movement, and as naturalness (distinguished from normality of movement).

CONCLUSIONS

These qualities of movement may be useful in designing technical systems to support self-management of chronic pain.

SIGNIFICANCE

Drawing on the descriptions of movements of people with chronic low back pain provided by expert physiotherapists to standard stimuli, two key concepts were elaborated. Guarding was distinguished from stiffness (a physical limitation) or slowness as motivated by fear or worry about movement. Flow served to describe harmonious and continuous movement, even when adapted around restrictions of pain. Movement behaviours associated with pain are better understood in terms of their particular function than aggregated without reference to function.

Holding space and sitting with emotions: the lived experiences of physiotherapists using psychological strategies in pain care

BACKGROUND

Persistent pain is the biggest global cause of years lived with disability. Physiotherapists working in pain care aim to take a holistic perspective helping persons to gain a multidimensional understanding of their condition and achieve meaningful goals despite their symptoms. In recent years there has been a paradigm shift in physiotherapeutic pain care toward a psychologically informed physiotherapy approach. Physiotherapists have incorporated principles of strategies such as: cognitive behavioral therapy (CBT); acceptance and commitment therapy (ACT); psychological flexibility; or mindfulness-based therapies in helping persons move forwards despite their pain.

OBJECTIVES

The purpose of this study was to explore the lived experience of physiotherapists using psychological strategies in pain care.

METHODS

Seven participants were purposefully recruited for this study and data was collected through semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Master themes were developed to help express the qualitative meanings of the lived experiences.

FINDINGS

Seven master themes were identified: 1) Trust; 2) Active listening; 3) Developing understanding; 4) Exploring the journey; 5) Making it meaningful; 6) Being held; and 7) Holding space and sitting with emotions. All themes are interwoven and profoundly connected in the essence of a safe "space."

CONCLUSION

Participants described a journey toward holding space and sitting with emotions. All themes were interwoven and profoundly connected in the essence of a safe "space," where persons can voice their emotions in a non-judgmental environment. The themes may represent a pathway for the physiotherapist to facilitate a person on their journey of healing.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

OBJECTIVE

To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy.

METHODS

We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized.

RESULTS

Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.

CONCLUSION

Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain.

STUDY REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Do baseline patient reported outcome measures predict changes in self-reported function, following a chronic pain rehabilitation programme?

Background

Interdisciplinary pain management programmes, based on cognitive-behavioural principles, aim to improve physical and psychological functioning and enhance self-management in people living with chronic pain. Currently there is insufficient evidence about whether psychological, biological or social factors are predictive of positive outcomes following pain rehabilitation. This study aims to evaluate predictors of change in Brief Pain Inventory - pain interference score (BPI) in a clinical data set to determine whether age, sex and baseline outcome measures are predictive of improvement in pain interference following pain rehabilitation.

Methods

A retrospective, pragmatic observational analysis of routinely collected clinical data in two pain rehabilitation programmes, Balanced Life Programme (BLP) and Get Back Active (GBA) was conducted. Standard regression and hierarchical regression analyses were used to identify predictors of change to assess temporal changes in BPI. Responder analysis was also conducted.

Results

Standard regression analyses of 208 (BLP) and 310 (GBA) patients showed that higher baseline BPI and better physical performance measures predicted better improvement in BPI across both programmes. Hierarchical regression showed that age and sex accounted for 2.7% (BLP) and 0.002% (GBA) of the variance in change in BPI. After controlling for age and sex, the other measures explained an additional 23% (BLP) and 19% (GBA) of the variance, p = < .001 where BPI and physical performance measures were consistently statistically significant predictors, p < .05. Responder analysis also showed that pain interference and physical performance were significantly associated with improvement (p = < .0005).

Conclusions

The combination of high self-reported pain interference and better physical performance measures may be a useful indicator of who would benefit from interdisciplinary rehabilitation. Further validation of the results is required.

[Efectividad de una intervención multimodal para la mejora de la atención al dolor crónico.]

OBJECTIVE

The prevalence of chronic pain in Spain is 17%, which causes suffering and significant loss of quality of life. Therapies should not focus only on pain reduction, to improve function and quality of life are necessary. Currently, it is committed to combining drugs and other therapies such as relaxation, meditation, cognitive behavioral therapy, targeted exercises, healthy lifestyles and techniques to increase self-esteem and motivation for change. These therapies can be used as part of a multimodal approach, forming part of multicomponent programs or workshops. In this paper we proposed to evaluate the effectiveness of a workshop developed from the Hospital San Juan de Dios del Ajarafe, that integrated different non-pharmacological therapies in the control of chronic non-oncologic pain and to analyze patients' perceptions of the techniques applied and how they affected pain and lifestyles.

METHODS

An intragroup before-after study (beginning-end of the workshop) was carried out, comparing pain, well-being, drug use, quality of life, and self-esteem. Surveys were conducted to deepen more qualitative aspects and identify improvements. The workshop consisted of psychoeducational action and training for the mental control of pain and emotions, based on the active participation of the patient in the management of his disease, promoting self-care and self-esteem, and aiming to improve well-being and quality of life. It consisted of 5 sessions of 3 hours (1 per week); of a group, interactive and practical nature. Statistical analysis was performed with SPSS vs.27.0. To compare related measures (before-after) we used Student's T tests for paired samples and Wilcoxon's test and to compare independent groups, Student's T and Mann Whitney's U; for the qualitative variables, we used Chi-Square and Fisher's test.

RESULTS

Four workshops were evaluated in which 63 patients participated, with a mean age of 57.6 (SD:11.37) years, 60 (95.2%) of them were women. At the end of the workshop pain decreased 1.5 median (-2.0-0) and well-being increased 2.0 (0-2.0); quality of life increased a median of 0.121 (SD: 0.209), health status 16.8 (23.78) and self-esteem 2.74 (4.73); [p<0.001]. The best valued techniques were meditations, mainly mental analgesia, affirmations in the mirror and self-esteem techniques.

CONCLUSIONS

Overall satisfaction with the workshop is 9.8 out of 10. There is a pain control and improvement in quality of life, self-perception of health status, well-being and self-esteem.

Beyond the pain: A qualitative study exploring the physical therapy experience in patients with chronic low back pain

BACKGROUND

Chronic low back pain (cLBP) is a complex condition that is physically and psychologically debilitating, with vulnerable populations experiencing more severe outcomes. Physical therapy (PT) includes evidence-based treatments that can reduce disability, however the experience of PT can vary amongst different populations. Empirical evidence is largely based on majority samples that are predominantly white with high educational attainment. Little is known regarding how people from vulnerable groups (e.g. low income and racial minority) experience physical therapy treatment for low back pain.

OBJECTIVE

To describe the experience of physical therapy in a predominantly low-income and minority population with cLBP.

METHODS

This qualitative study was embedded within a randomized controlled trial for patients with cLBP in urban, underserved communities. We used a convenience sample to interview 12 participants from the 102 who participated in the PT arm of the trial and then performed thematic analysis to describe their experience.

RESULTS

Three major themes emerged: 1) Empowerment through education and exercise; 2) Interconnectedness to providers and other patients; and 3) Improvements in pain, body mechanics, and mood. Divergent cases were few however centered around a lack of improvement in pain or an absence of connection with the therapist. Within the first theme a prevailing sub-theme emerged that aligned with Bandura's theory of self-efficacy: 1) Mastery of experience; 2) Verbal persuasion; 3) Vicarious experience; and 4) Physiological state.

CONCLUSIONS

Our participants' insight highlighted the value of cognitive-emotional and interpersonal dimensions of PT. These may be particularly important components of PT in populations that have experienced systemic distrust in providers and disparities in services. Future work could use Bandura's model of self-efficacy to build a PT intervention comprised of fear-based movement exercises, interconnectedness, a strong therapeutic alliance, and mindfulness techniques.

Therapeutic touch and therapeutic alliance in pediatric care and neonatology: An active inference framework

Therapeutic affective touch has been recognized as essential for survival, nurturing supportive interpersonal interactions, accelerating recovery-including reducing hospitalisations, and promoting overall health and building robust therapeutic alliances. Through the lens of active inference, we present an integrative model, combining therapeutic touch and communication, to achieve biobehavioural synchrony. This model speaks to how the brain develops a generative model required for recovery, developing successful therapeutic alliances, and regulating allostasis within paediatric manual therapy. We apply active inference to explain the neurophysiological and behavioural mechanisms that underwrite the development and maintenance of synchronous relationships through touch. This paper foregrounds the crucial role of therapeutic touch in developing a solid therapeutic alliance, the clinical effectiveness of paediatric care, and triadic synchrony between health care practitioner, caregiver, and infant in a variety of clinical situations. We start by providing a brief overview of the significance and clinical role of touch in the development of social interactions in infants; facilitating a positive therapeutic alliance and restoring homeostasis through touch to allow a more efficient process of allostatic regulation. Moreover, we explain the role of CT tactile afferents in achieving positive clinical outcomes and updating prior beliefs. We then discuss how touch is implemented in treatment sessions to promote cooperative interactions in the clinic and facilitate theory of mind. This underwrites biobehavioural synchrony, epistemic trust, empathy, and the resolution of uncertainty. The ensuing framework is underpinned by a critical application of the active inference framework to the fields of pediatrics and neonatology.

'Thinking about pain in a different way': Patient perspectives of a neuroscience-informed physiotherapy programme for rotator cuff-related shoulder pain

BACKGROUND

Rotator cuff-related shoulder pain (RCRSP) is a common musculoskeletal problem. The multi-factorial contributors to persistent pain are often overlooked during treatment. Pain neuroscience education (PNE) contributes to a holistic approach for patients with persistent pain but has not yet been researched for patients with RCRSP.

OBJECTIVE

To explore the perspectives and experiences of participants with RCRSP who had completed a programme of PNE-informed pragmatic physiotherapy.

DESIGN

A qualitative study using semi-structured interviews.

METHODS

We included a sub-group of five males and five females, aged 46-75 years, with persistent RCRSP of at least three months. They had undertaken a three-month pragmatic physiotherapy integrated with PNE. Individual semi-structured interviews were recorded, transcribed verbatim, and analysed using the General Inductive Approach.

RESULTS

Four themes emanated from the interviews. The first two themes were named 'Patient Beliefs' and overall 'Rapport and Relationship'. Another theme, 'Perspective and Understanding of the Resources', indicated diverse uptake of the resource information. The participants reported developing self-management skills, active coping strategies and a reduction in fear of pain described by the theme: 'Empowerment: My Shoulder into the Future'.

CONCLUSIONS

Participants experienced a change in their beliefs, which were enhanced by an individualised delivery and a strong therapeutic relationship through the course of the physiotherapy care. The participants appeared to value when the physiotherapist listened to and understood their beliefs. This required a shift in the patient-therapist relationship from the physiotherapist being the 'expert' to facilitating the patient's ability to take control of their shoulder health.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

Background

While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020.

Objective

This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program.

Methods

Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming.

Discussion/Results

Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement.

Conclusion

TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

The experience of meaningful rehabilitation as perceived by people with chronic pain: A phenomenological study

BACKGROUND: People with chronic pain may seek rehabilitation to reduce pain and restore productivity and valued roles. Theoretically, a biopsychosocial approach makes rehabilitation more meaningful, however, the limited research on meaningful rehabilitation predominantly describes the perspective of therapists and researchers. The client’s perspective of meaningfulness in rehabilitation is lacking. OBJECTIVE: To investigate the experience of meaningfulness in rehabilitation from the perspective of people with chronic pain. METHOD: Qualitative, semi-structured interviews were conducted with Australian adults who had chronic pain and recent experience of occupational therapy or physiotherapy. Sampling continued until thematic saturation occurred. Transcripts were coded and analyzed using theory-driven and data-driven thematic analysis. RESULTS: Ten participants (four males; six females) were interviewed. Pain histories ranged from nine months to 20+ years, with conditions such as fibromyalgia or trauma. Three themes from a prior concept analysis were upheld, and a further three data-driven themes emerged. Results indicate that people with chronic pain seek a “genuine connection”; from a therapist who is “credible”; and can become a “guiding partner”, and they find rehabilitation meaningful when it holds “personal value”; is “self-defined”; and relevant to their sense of “self-identity”. CONCLUSIONS: The genuine connection and guiding partnership with a credible therapist, that is sought by people with chronic pain, may be at odds with aspects of contemporary rehabilitation. Client-defined meaningfulness is an important construct to engage clients in treatment and improve work and other occupational outcomes for people with chronic pain.

The experiences and acceptability of a novel multimodal programme for the management of fibromyalgia: A qualitative service evaluation

Introduction

Fibromyalgia guidelines recommend multi‐modal, non‐pharmacological interventions but there is limited evidence on the optimal programme. The Fibromyalgia Active Management and Exercise programme (FAME) aimed to improve function and quality of life. It consisted of 12 sessions delivered by a multidisciplinary team and incorporated education, exercise, Cognitive Behavioural Therapy and mindfulness approaches.

This qualitative service evaluation explored the experience and acceptability of FAME from the perspective of the patients' and healthcare practitioners' (HCP).

Methods

All patients and HCP involved in the first FAME programme were invited to attend either one audio‐recorded focus group or an individual semi‐structured interview. Topic guides were developed a priori. Data were transcribed verbatim and analysed thematically.

Results

Thirteen participants (six HCP (three physiotherapists, two nurses, one psychologist)) and seven patients (mean age 46 (7.5) years, all female,) were enroled. FAME was acceptable to HCP participants but not to all patient participants. Where patient participants understood and anticipated the aims of FAME, the programme was found to be acceptable. Whereas, patient participants who did not fully understand the aims of the programme reported lower acceptability. Three themes were generated: expectations and preparation for FAME, the value of socialsupport, and FAME as a learning opportunity. The themes could be explained by five constructs of the Theoretical Framework of Acceptability.

Conclusion

FAME was acceptable to HCPs but not to all patient participants. Patient and HCP participants valued social support and regarded this as central to their learning. Further adaptation of FAME is required to optimise acceptability.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care

Touch is recognised as crucial for survival, fostering cooperative communication, accelerating recovery, reducing hospital stays, and promoting overall wellness and the therapeutic alliance. In this hypothesis and theory paper, we present an entwined model that combines touch for alignment and active inference to explain how the brain develops "priors" necessary for the health care provider to engage with the patient effectively. We appeal to active inference to explain the empirically integrative neurophysiological and behavioural mechanisms that underwrite synchronous relationships through touch. Specifically, we offer a formal framework for understanding - and explaining - the role of therapeutic touch and hands-on care in developing a therapeutic alliance and synchrony between health care providers and their patients in musculoskeletal care. We first review the crucial importance of therapeutic touch and its clinical role in facilitating the formation of a solid therapeutic alliance and in regulating allostasis. We then consider how touch is used clinically - to promote cooperative communication, demonstrate empathy, overcome uncertainty, and infer the mental states of others - through the lens of active inference. We conclude that touch plays a crucial role in achieving successful clinical outcomes and adapting previous priors to create intertwined beliefs. The ensuing framework may help healthcare providers in the field of musculoskeletal care to use hands-on care to strengthen the therapeutic alliance, minimise prediction errors (a.k.a., free energy), and thereby promote recovery from physical and psychological impairments.

Physiotherapy informed by Acceptance and Commitment Therapy for chronic low back pain: A mixed-methods treatment fidelity evaluation

OBJECTIVES

A randomized controlled trial of a new type of Physiotherapy informed by Acceptance and Commitment Therapy (PACT), found that it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment fidelity including delivery, receipt, and enactment.

DESIGN

A mixed-methods study nested within a randomized controlled trial was conducted.

METHODS

A total of 72 (20% of total) PACT treatment audio files were independently assessed by two raters, according to a novel framework developed to measure PACT treatment content adherence, therapeutic alliance, ACT competence, and treatment enactment. Interview transcripts from 19 trial participants randomized to PACT were analysed thematically for evidence of treatment receipt and enactment.

RESULTS

PACT physiotherapists delivered treatment as intended with high content adherence and satisfactory therapeutic alliance, but ACT competence was low. Qualitative findings indicated participant receipt of 11/17 and enactment of 3/17 components; 89% (n = 17) and 47% (n = 9) of participants reported treatment receipt and enactment of at least one component, respectively.

CONCLUSIONS

This mixed-methods study of PACT treatment demonstrated high fidelity reflecting treatment content delivery and receipt, and therapeutic alliance. There was some evidence of treatment enactment in participants with chronic low back pain. Low ACT competence could be addressed through additional support and adaptations to therapeutic processes for delivery by physiotherapists.

Physiotherapists perceived role in managing anxiety in patients with relapsing-remitting multiple sclerosis: a mixed-methods study

Background

Anxiety is common for people with Multiple Sclerosis (PwMS) and is higher in those with relapsing-remitting MS (RRMS) and in community-based samples. Anxiety can impact self-efficacy, pain, fatigue, engagement in physical activity and treatment adherence, all of which influence the rehabilitation process. Little is known about how physiotherapists manage anxiety in PwMS and the challenges associated with anxiety throughout the rehabilitation process, in community and outpatient settings.

Methods

A mixed-methods design, combining a cross-sectional survey and semi-structured interviews with UK-physiotherapists, was used to answer the research question. To inform the qualitative study, a cross-sectional survey collected data from physiotherapists working in neurology to understand the impact and management of anxiety in people with MS (PwMS) during rehabilitation. Analysis used descriptive statistics and the findings formed the interview guide. Semi-structured interviews with specialist physiotherapists explored barriers and facilitators to managing anxiety in PwMS in community and outpatient settings, identified perceived physiotherapy training needs and offered suggestions to develop physiotherapy research and practice. Themes were derived inductively.

Results

The survey suggested how PwMS present with anxiety, its impact during rehabilitation, physiotherapy management practices, and physiotherapist skills and training needs. Five semi-structured interviews with specialist physiotherapists expanded on the survey findings and identified five main themes: Understanding the MS journey, modifying assessment and treatment, anxiety management toolbox, lagging behind Musculoskeletal Physiotherapy, and gaining knowledge and skills.

Conclusion

Physiotherapists encounter anxiety in PwMS in community and outpatient rehabilitation and perceive they have a role in managing it as it presents. Facilitators included communication, listening skills and opportunities to develop strong therapeutic relationships. Poor training and support, lack of clinical guidelines and limited research evidence were considered barriers. Clinically relevant learning opportunities, interprofessional working, and greater support through clinical supervision is recommended to better develop physiotherapy practice.

Rethinking pain education from the perspectives of people experiencing pain: a meta-ethnography to inform physiotherapy training

BACKGROUND

Pain is a complex, global and multidimensional phenomena that impacts the lives of millions of people. Chronic pain (lasting more than 3 months) is particularly burdensome for individuals, health and social care systems. Physiotherapists have a fundamental role in supporting people who are experiencing pain. However, the appropriateness of pain education in pre-registration physiotherapy training programmes has been questioned.Recent research reports identify the need to integrate the voice of patients to inform the development of the pre-registration curriculum. The aim of this meta-ethnography was to develop new conceptual understanding of patients' needs when accessing physiotherapy for pain management. The concepts were viewed through an educational lens to create a patient needs-based model to inform physiotherapy training.

METHODS

Noblit and Hare's seven-stage meta-ethnography was used to conduct this qualitative systematic review. Five databases (MEDLINE, CINAHL Complete, ERIC, PsycINFO and AMED) were searched with eligibility criteria: qualitative methodology, reports patient experience of physiotherapy, adult participants with musculoskeletal pain, reported in English. Databases were searched to January 2018. Emerge reporting guidelines guided the preparation of this manuscript.

RESULTS

A total of 366 citations were screened, 43 full texts retrieved and 18 studies included in the final synthesis. Interpretive qualitative synthesis resulted in six distinct categories that represent patients' needs when in pain. Analysing categories through an education lens resulted in three overall lines of argument to inform physiotherapy training. The categories and lines of argument are represented in a 'needs-based' model to inform pre-registration physiotherapy training.

DISCUSSION

The findings provide new and novel interpretations of qualitative data in an area of research that lacks patient input. This is a valuable addition to pain education research. Findings support the work of others relative to patient centredness in physiotherapy.

Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework

BACKGROUND

Psychological factors influence or are associated with physical function, pain, and health care costs among individuals with musculoskeletal pain conditions. Recent clinical practice guidelines recommend screening for psychological factors (also referred to as "yellow flags") in physical therapy practice to help understand prognosis and inform shared decision making for treatment.

CLINICAL QUESTION

Despite the urgings of clinical practice guidelines and evidence of the influence of psychological factors on clinical outcomes, screening for yellow flags is uncommon in clinical practice. Clinicians may feel uncertain about how to integrate screening tools into clinical practice, and how screening results might inform decision making and care coordination.

KEY RESULTS

We outline a 3-step framework for routine yellow flag screening in physical therapy practice: (1) establish a standard first-line screening instrument and process, (2) interpret the results to inform shared decision making, and (3) monitor treatment progress. Four case examples illustrate how yellow flag screening can help clinicians and patients decide whether the patient might benefit most from standard physical therapy, psychologically informed physical therapy, psychologically informed physical therapy with referral to another health care provider, or immediate referral.

CLINICAL APPLICATION

Consider incorporating a standard yellow flag screening process into usual musculoskeletal health care. We present a framework to guide yellow flag screening in practice (1) to help inform treatment pathway selection and (2) to enhance interdisciplinary communication. J Orthop Sports Phys Ther 2021;51(9):459-469. doi:10.2519/jospt.2021.10570.

Patients' conceptions of undergoing physiotherapy for persistent low back pain delivered in Finnish primary healthcare by physiotherapists who had participated in brief training in cognitive functional therapy

PURPOSE

To explore the conceptions of patients with persistent low back pain (LBP) of undergoing physiotherapy delivered in Finnish primary healthcare by physiotherapists who had participated in brief training in Cognitive Functional Therapy (CFT).

METHODS

As part of a feasibility implementation study exploring CFT in management of LBP in the Finnish primary healthcare system, we interviewed nine patients from four geographical areas in Finland after receiving care. We used a phenomenographic approach to explore the variation in their conceptions.

RESULTS

The analysis revealed four descriptive categories: "hung out to dry," "stuck," "making sense and taking control," and "holistic approach to care and living," that varied based on six themes.

CONCLUSIONS

Although the participants accepted this approach to care well, there was significant variation in patients' conceptions. Restricted access to care within the healthcare system and a lack of social support led some of them to feel they had been left alone to suffer with their pain. On the other hand, based on the results of this study, positive experiences of physiotherapy and good collaboration with the physiotherapist, wider social support outside of physiotherapy, a better understanding of the multidimensional nature of pain and the acquisition of self-management skills were reported as positive aspects of undergoing physiotherapy that may be related to positive treatment outcomes.Implications for rehabilitationThe participants of this study saw undergoing physiotherapy delivered within biopsychosocial framework as different from their previous physiotherapy experiences and for some the process ended with feeling empty-handed and for others it could be a turning point in their lives.This study encourages the health care providers to create flexible care pathways and ongoing support for more vulnerable individuals so that they don't feel abandoned by the system.Professionals could also pay attention to building strong therapeutic alliance, help patients understand pain in biopsychosocial framework, take into consideration social support networks of the patients, and support patients toward effective self-management strategies.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

Psychosocial strategies for physiotherapy: A qualitative examination of physiotherapists' reported training preferences

Physiotherapists report using a range of psychosocial strategies in their practice, yet, barriers to implementation include lack of time, limited knowledge, and minimal training. This research aimed to establish what training physiotherapists have had with regards to psychosocial strategies, why they think they would benefit from more training, what training they want, and delivery preferences. Content analysis of answers to four open-ended, online survey questions collected from Australian physiotherapists (N = 208) was conducted. Physiotherapists reported having minimal training specific to psychosocial strategies. Physiotherapists reported wanting training in assessment and management of psychosocial issues, and practical application of specific psychosocial strategies. Didactic and interactive training delivered by experts who understand the psychosocial needs of their patients, and the constraints of physiotherapy practice was preferred. These findings suggest that training in psychosocial strategies at the undergraduate level and continued professional development are necessary. Specifically, training in the assessment and management of psychosocial factors, and in referral processes is warranted, and should be applicable and appropriate for rehabilitation settings. Training should be both didactic and interactive as outlined in the proposed framework.

Functional Limitations and Disability in Persons Living with HIV in South Africa and United States: Similarities and Differences

Persons living with HIV (PLHIV) may experience disability. We compared disability among PLHIV in the United States and South Africa and investigated associations with health and demographic characteristics. Secondary analysis of cross-sectional data using medical records and questionnaires including the World Health Organization Disability Assessment Schedule (WHO-DAS) 2.0 12-item version (range: 0-36, with higher scores indicative of more severe disability). Between-country differences for the presence of disability were assessed with logistic regression and differences in severity using multiple regression. Eighty-six percent of US participants reported disability, compared to 51.3% in South Africa. The mean WHO-DAS score was higher in the United States (12.09 ± 6.96) compared to South Africa (8.3 ± 6.27). Participants with muscle pain, depression, or more years since HIV diagnosis were more likely to report disability. Being female or depressed was associated with more severity. Being adherent to anti-retroviral therapy (ART) and employed were associated with less severity. Because muscle pain and depression were predictive factors for disability, treatment of those problems may help mitigate disability in PLHIV.

Conceptualisation of the therapeutic alliance in physiotherapy: is it adequate?

OBJECTIVE

The Therapeutic Alliance (TA) is an emerging concept within physiotherapy practice, reflecting the ongoing paradigm shift from a biomedical- (BMM) towards a biopsychosocial model (BPSM) of care. Current conceptual understanding of the TA is commonly based on Bordin's (1979) definition, developed within a psychotherapy context. A concept analysis was conducted in order to provide conceptual clarity of the TA within physiotherapy literature.

METHOD

An evolutionary method of concept analysis was followed. An extensive literature search was conducted, and eligible articles were submitted to inductive, semantic thematic analysis.

FINDINGS

A total of 14 articles were included within this concept analysis. 5 master attribute themes, and 4 corresponding sub-themes were identified following thematic analysis. The master attribute themes were: 'Seeing the person', 'Sharing the journey', 'Communication', 'Therapeutic space' and 'Fostering autonomy'. The 4 Sub-themes were: 'Giving of self', 'Legitimising the experience', 'Physiotherapist characteristics matter' and 'Interpersonal collaboration'.

CONCLUSION

A heuristic interpretation of the TA within a physiotherapy context is offered. The TA is a dynamic construct within the clinical encounter and is influenced reciprocally between the person seeking care and the physiotherapist by biological, social and psychological contributing factors. 'Communication' may act as a catalyst in operationalising the TA in a physiotherapy context. Continued efforts are needed in physiotherapy education and training in both enhancing theoretical awareness of the role of the TA within physiotherapy practice, as well as guidance on its implementation in clinical practice.

The prevalence of fear avoidance and pain catastrophising amongst patients with chronic neck pain

Background

Cognitive factors impact chronic pain, but the prevalence of fear avoidance (FA) and pain catastrophising (PC) in individuals suffering from chronic neck pain (CNP) has not been investigated in South Africa.

Objectives

To determine the prevalence of FA and PC in patients with CNP at private physiotherapy practices in Johannesburg.

Method

The Tampa Scale for Kinesiophobia-11 (TSK-11) (α = 0.80) and Pain Catastrophising Scale (α = 0.87) self-report questionnaires were used in a cross-sectional study to determine the prevalence of FA and PC, respectively. Descriptive statistics and correlations using Pearson’s or Spearman’s coefficient were conducted between demographic variables and FA and PC. Non-parametric data were tested using the Wilcoxon rank-sum or Kruskal–Wallis test. Cohen’s d-value or r-value measured strength of associations.

Results

A sample of 106 CNP patients with a mean age of 48.7 years (± 14.8) from 25 randomly selected private practices participated in the study. Of the participants, 81% were women (n = 86). Fear avoidance and PC had a prevalence of 25.5% (n = 27) and 15.1% (n = 16), respectively. A positive correlation was found between FA-11-Total and PC-Total (r = 0.684; p = 0.0001) and between FA (TSK-11-Total and TSK-SF (somatic focus)) and PC and its subscales (r ≥ 0.602; p = 0.0001). Participants with a secondary education (26.0 ± 3.4) showed a higher FA than those with tertiary education (21.9 ± 1.5). Effect size was moderate (Cohen’s d = 0.60). Pain intensity correlated positively with both FA (Pearson’s correlation: r = 0.33; p = 0.001) and PC (Spearman’s correlation; r = 0.39; p = 0.0001).

Conclusion

FA and PC affect a number of patients with CNP. A lower level of education was associated with FA and a higher pain intensity was associated with higher FA and PC.

Clinical implications

Identifying FA and PC in patients with CNP is important to facilitate holistic management.

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.

Adolescent and Parent Experiences of Acceptance and Commitment Therapy for Pediatric Chronic Pain: An Interpretative Phenomenological Analysis

Pediatric chronic pain is common and can be related to reduced functioning in many domains for the young person and their parents. Existing psychological treatments such as Acceptance and Commitment Therapy (ACT) have shown to be effective, but improvements are needed. Qualitative approaches can help improve our understanding of treatment processes and outcomes. The aim of the present qualitative interview study was to explore the lived experiences of young people and parents who had participated in ACT for pediatric chronic pain. Four young persons and four parents were interviewed, and data was analyzed using Interpretative Phenomenological Analysis (IPA). Three themes were generated, each comprising two subthemes: (1) 'Warning system', which included experiences from being offered this psychological intervention, and the alternative explanations provided for pain; (2) 'Change and challenges', which suggested the importance of the values-based work, and of individual adaptation; and (3) 'A common language' in which the interaction with others and new ways to communicate around the pain experience were described. Findings highlight the importance of pain education, formulating and acting in line with personal values, and communication around the pain experience, as well as the need for developmental and individual adaptations of interventions.

Physiotherapy treatment experiences of persons with persistent musculoskeletal pain: A qualitative study

The aim of this study was to explore and describe the physiotherapy treatment experiences of persons with persistent musculoskeletal pain. Eleven participants with persistent musculoskeletal pain in the back, neck, or shoulders were included in the study. Data was collected via semi-structured interviews and were analysed with qualitative content analysis. The analysis resulted in the theme "Towards acceptance and management of pain", comprising four sub-themes: 1) Establishing and maintaining a therapeutic alliance; 2) Being active, taking initiative and facing challenges; 3) Appreciating guidance, incentive and having a sounding board; and 4) Acquired knowledge and new body awareness change behaviours. The theme and sub-themes describe how the participants used increased knowledge, awareness, movements and exercises learned from the physiotherapy treatment to develop strategies for managing pain and the process of acceptance. A trusting relationship and continual dialogue with the physiotherapist was considered to be important. The participants were actively involved in the process as exercises, activities and other treatment modalities were individualized. This was rewarding but also challenging and required effort on their part. The physiotherapist's initiatives and actions were an important incentive and means of support.

The impact of health literacy on health outcomes in individuals with chronic pain: a cross-sectional study

OBJECTIVE

To establish if health literacy (HL) is linked to poorer outcomes and behaviours in patients with chronic pain.

DESIGN

A prospective cross-sectional observational study.

SETTING

Multidisciplinary out-patient pain clinics in three university teaching hospitals.

PATIENTS

New patients (n=131) referred to the pain clinic with a history of chronic pain (>12 weeks).

METHODS

A questionnaire was distributed to chronic pain patients attending their first appointment. Those eligible for inclusion were newly referred patients who had pain lasting longer than three months. The questionnaire comprised the following sections: demographics, chronic pain status and disease-related knowledge, quality of life (SF-36), beliefs (Beliefs About Pain Control Questionnaire), and a validated HL tool (Newest Vital Sign).

RESULTS

Of the 131 participants recruited, 54% had inadequate HL. The group was subsequently stratified according to HL level. In bivariate analysis, inadequate HL was associated with older age (p<0.001), being unemployed or retired (p=0.005), less education (p<0.001), lower income, increased comorbidities (p=0.038), being less likely to utilise allied health services (p=0.001), poorer disease-related knowledge (p=0.002), and poorer beliefs about pain (p<0.05). In multivariate analysis, disease-related knowledge (OR 2.5, 95%CI 1.0 to 6.3, p=0.05) and beliefs about pain (B=-2.3, S.E=0.9, p=0.01) remained independently associated with HL.

CONCLUSION

Inadequate HL is prevalent in chronic pain patients, and may impact on the development of certain characteristics necessary for effective self-management.

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.

The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature

OBJECTIVE

To systematically determine the specific impact of therapeutic alliance (TA) on chronic musculoskeletal pain, identify factors influencing TA between physical therapists and patients with chronic musculoskeletal pain, and determine the working definition of TA across studies. Data Sources: Databases, including PubMed, CINHAL, and Embase, were searched from inception to January 2017. Study Selection: The initial search resulted in 451 papers. After screening, seven studies were identified that examined the role of TA on chronic pain (> 12 weeks) management in physical therapy settings. Data Extraction: Authors extracted data into tables. Risk of bias was assessed using Cochrane Collaboration methodology. Data Synthesis: Three studies examined the influence of a strong TA coupled with physical therapy on pain outcomes. Four studies identified factors that positively and negatively influenced TA. The working definition of TA was identified in each study. Conclusions: Emerging evidence suggests that for individuals participating in physical therapy for chronic musculoskeletal pain, a strong TA may improve pain outcomes. In order to facilitate a strong TA, physical therapists must understand factors that positively and negatively influence the relationship. Studies demonstrate that the definition of TA remains consistent as it transitions to the physical therapy setting.

Development and validation of the Working Alliance Inventory Dutch version for use in rehabilitation setting

Background: In rehabilitation, therapeutic alliance is associated with improvements in clinical outcomes. The Working Alliance Inventory (WAI) measures therapeutic alliance and is frequently used in rehabilitation research; however, it has not been validated for rehabilitation. Objectives: To determine content validity, internal consistency and construct validity of the Working Alliance Inventory Rehabilitation Dutch Version (WAI-ReD). Methods: In phase 1, content and face validity of the WAI-ReD was judged by professionals (n = 15) and in phase 2 by patients (n = 22). In phase 3, 14 hypotheses were tested in patients (n = 138) regarding: content validity (i.e., missing items, floor, and ceiling effects); internal consistency; and construct validity (i.e., factor structural testing correlations of WAI-ReD scores with Session Rating Scale (SRS), the Helping Alliance Questionnaire II (HAQ-II), and Visual Analog Scale of Pain (VAS_pain)). Results: After phase 1 and phase 2, the WAI-ReD was formulated and tested. Content validity; missing items were negligible. Ceiling effects were present in all domains. Internal consistency; Cronbach's α ranged between 0.804 and 0.927. Construct validity; correlations between WAI-ReD, SRS, HAQ-II, and VAS_pain fell within the hypothesized ranges. Conclusion: Eleven of the 14 hypotheses were not rejected confirming good clinimetric properties of the WAI-ReD. The WAI-ReD can be used in rehabilitation to measure therapeutic alliance.

The psychological features of patellofemoral pain: a cross-sectional study

Background and aims:

Patellofemoral pain (PFP) is a prevalent and debilitating musculoskeletal condition, considered to have a mechanical aetiology. As such, the physical impairments associated with PFP are well documented and have helped characterise different physical phenotypes. But little is known about the relationship between PFP and psychological well-being. In this study, we aimed to: (1) compare psychological profiles between groups with and without PFP; (2) compare psychological profiles and condition severity between PFP subgroups; and (3) explore relationships between psychological factors and their contribution to disability. We expected to find higher levels of psychological impairment, especially kinesiophobia and catastrophizing in the PFP group. We also expected to identify a sub-group for who worsening levels of disability correspond with worsening psychological well-being.

Methods:

One hundred participants with PFP (72 females, mean±SD age 27±5 years, BMI 25.3±4.8 kg/m2) completed measures of pain, disability, and psychological features (kinesiophobia, catastrophizing, anxiety and depression). Fifty controls, matched by sex, age and activity level (36 females, age 27±5 years, BMI 22.9±4.5 kg/m2) also completed psychological measures. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to cluster PFP participants (K-means cluster analysis) into more and less severe sub-groups. Differences between the control and PFP groups were analysed using t-tests, analysis of variance, Mann-Whitney U-tests or χ 2 tests as appropriate (p<0.05). Pearson correlations were used to explore relationships between psychological measures. Backward stepwise regression (p out >0.05) evaluated how the psychological factors potentially relate to disability.

Results:

Psychological features did not differ between PFP and pain-free groups. But differences were apparent when the PFP cohort was subgrouped. Compared to controls, the more-severe group had significantly higher levels of depression (MD 1.8, 95% CI 0.8–2.8; p≤0.001) and catastrophizing (MD 5.7, 95% CI 2.4–9; p≤0.001). When compared to less-severe cases, the more-severe group also demonstrated significantly higher levels of kinesiophobia (MD 4.3, 95% CI 2.1–6.5; p≤0.001), depression (MD 1.5 95% CI 0.5–2.6; p=0.01) and catastrophizing (MD 4.9, 95% CI 1–8.8; p=0.01). The weakest relationship between psychological factors was found between kinesiophobia and anxiety (r=0.29; p=0.02). While the strongest relationship existed between depression and anxiety (r=0.52; p≤0.001). Both kinesiophobia (β −0.27, 95% CI −0.265 to −0.274) and depression (β −0.22, 95% CI −0.211 to −0.228) were associated with disability as defined by the KOOS in the regression model (R 2=0.17, p≤0.001).

Conclusions:

Those with more-severe PFP-related disability have higher levels of psychological impairment than less-severe cases. Kinesiophobia seems to stand as an important factor in the experience of PFP, because it was elevated in the PFP group, significantly differed between the PFP sub-groups and contributed to explaining disability. Contrary to our hypothesis, levels of catastrophizing in the PFP group and severe sub-group were low and seemingly not important.

Implications:

These findings draw attention to psychological factors to which clinicians assessing PFP should show vigilance. They also highlight psychological impairments that might be worthwhile targets in optimising PFP management.