Sociocultural factors influencing physiotherapy management in culturally and linguistically diverse people with persistent pain: a scoping review

Pain neuroscience education for patients with chronic pain: A scoping review from teaching-learning strategies, educational level, and cultural perspective

OBJECTIVE

(1) To identify the characteristics of PNE programs in terms of teaching-learning strategies, session modality, content delivery format, number of sessions, total minutes and instructional support material used in patients with chronic musculoskeletal pain, (2) to describe PNE adaptations for patients with different educational levels or cultural backgrounds, and (3) to describe the influence of the patient's educational level or cultural background on the effects of PNE.

METHODS

The PRISMA guideline for scoping reviews was followed. Nine databases were systematically searched up to July 8, 2023. Articles that examined clinical or psychosocial variables in adults with chronic musculoskeletal pain who received PNE were included.

RESULTS

Seventy-one articles were included. Studies found benefits of PNE through passive/active teaching-learning strategies with group/individual sessions. However, PNE programs presented great heterogeneity and adaptations to PNE were poorly reported. Most studies did not consider educational level and culture in the effects of PNE.

CONCLUSIONS

Despite the large number of studies on PNE and increased interest in this intervention, the educational level and culture are poorly reported in the studies.

PRACTICAL IMPLICATIONS

It is recommended to use passive and/or active teaching-learning strategies provided in individual and/or group formats considering the patient's educational level and culture.

Use of implementation mapping in the planning of a hybrid type 1 pragmatic clinical trial: the BeatPain Utah study

BACKGROUND

Considerable disparities in chronic pain management have been identified. Persons in rural, lower income, and minoritized communities are less likely to receive evidence-based, nonpharmacologic care. Telehealth delivery of nonpharmacologic, evidence-based interventions for persons with chronic pain is a promising strategy to lessen disparities, but implementation comes with many challenges. The BeatPain Utah study is a hybrid type 1 effectiveness-implementation pragmatic clinical trial investigating telehealth strategies to provide nonpharmacologic care from physical therapists to persons with chronic back pain receiving care in ommunity health centers (CHCs). CHCs provide primary care to all persons regardless of ability to pay. This paper outlines the use of implementation mapping to develop a multifaceted implementation plan for the BeatPain study.

METHODS

During a planning year for the BeatPain trial, we developed a comprehensive logic model including the five-step implementation mapping process informed by additional frameworks and theories. The five iterative implementation mapping steps were addressed in the planning year: (1) conduct needs assessments for involved groups; (2) identify implementation outcomes, performance objectives, and determinants; (3) select implementation strategies; (4) produce implementation protocols and materials; and (5) evaluate implementation outcomes.

RESULTS

CHC leadership/providers, patients, and physical therapists were identified as involved groups. Barriers and assets were identified across groups which informed identification of performance objectives necessary to implement two key processes: (1) electronic referral of patients with back pain in CHC clinics to the BeatPain team and (2) connecting patients with physical therapists providing telehealth. Determinants of the performance objectives for each group informed our choice of implementation strategies which focused on training, education, clinician support, and tailoring physical therapy interventions for telehealth delivery and cultural competency. We selected implementation outcomes for the BeatPain trial to evaluate the success of our implementation strategies.

CONCLUSIONS

Implementation mapping provided a comprehensive and systematic approach to develop an implementation plan during the planning phase for our ongoing hybrid effectiveness-implementation trial. We will be able to evaluate the implementation strategies used in the BeatPain Utah study to inform future efforts to implement telehealth delivery of evidence-based pain care in CHCs and other settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04923334 . Registered June 11, 2021.

Effects of perceptive rehabilitation and mobilization methods on symptoms and disability in patients with fibromyalgia: A preliminary randomized control trial

BACKGROUND

Currently, there is no definitive cure for fibromyalgia. Instead, treatments focus of reducing symptoms and disability.

AIMS

This randomized controlled study aimed to evaluate the effectiveness of perceptive rehabilitation and soft tissue and joint mobilization on the severity of symptoms and disability in fibromyalgia compared with a control group.

METHODS

A total of 55 fibromyalgia patients were randomized into three groups: perceptive rehabilitation, mobilization, and control. The impact of fibromyalgia was evaluated using the Revised Fibromyalgia Impact Questionnaire (FIQR; primary outcome). Pain intensity, fatigue severity, depression, and sleep quality were secondary outcome measures. Data were collected at baseline (T0), the end of treatment (8 weeks; T1), and the end of 3 months (T2).

RESULTS

Statistically significant differences were found in between-groups comparisons at T1 for primary and secondary outcome measurements (p < .05), except for sleep quality. Both the perceptive rehabilitation and mobilization groups had statistically significant differences at T1 over the control group (p < .05). Between-group pairwise comparisons showed statistically significant differences between the perceptive and control groups for all outcome measures at T1 (p < .05). Similarly, statistically significant differences existed between the mobilization and control groups for all outcome measures at T1 (p < .05), except the FIQR overall impact scores. All other variables except depression were statistically similar between groups at T2.

CONCLUSION

This study shows that perceptive rehabilitation and mobilization therapy are similarly effective in improving fibromyalgia symptoms and disability, but the effects disappear within 3 months. Further research is needed to understand how the improvements could be maintained longer.

TRIAL REGISTRATION

Clinical Trial Registration number, ClinicalTrials.gov Identifier: NCT03705910.

Use of implementation mapping in the planning of a hybrid type 1 pragmatic clinical trial: the BeatPain Utah study

Background

Considerable disparities in chronic pain management have been identified. Persons in rural, lower income and minoritized communities are less likely to receive evidence-based, nonpharmacologic care. Telehealth delivery of nonpharmacologic, evidence-based interventions for persons with chronic pain is a promising strategy to lessen disparities, but implementation comes with many challenges. The BeatPain Utah study is a hybrid type I effectiveness-implementation pragmatic clinical trial investigating telehealth strategies to provide nonpharmacologic care from physical therapists to persons with chronic back pain receiving care in Community Health Centers (CHCs). CHCs provide primary care to all persons regardless of ability to pay. This paper outlines the use of implementation mapping to develop a multifaceted implementation plan for the BeatPain study.

Methods

During a planning year for the BeatPain trial we developed a comprehensive logic model including the 5-step implementation mapping process informed by additional frameworks and theories. The five iterative implementation mapping steps were addressed in the planning year; 1) conduct needs assessments for involved groups; 2) identify implementation outcomes, performance objectives and determinants; 3) select implementation strategies; 4) produce implementation protocols and materials; and 5) evaluate implementation outcomes.

Results

CHC leadership/providers, patients and physical therapists were identified as involved groups. Barriers and assets were identified across groups which informed identification of performance objectives necessary to implement two key processes; 1) electronic referral of patients with back pain in CHC clinics to the BeatPain team; and 2) connecting patients with physical therapists providing telehealth. Determinants of the performance objectives for each group informed our choice of implementation strategies which focused on training, education, clinician support and tailoring physical therapy interventions for telehealth delivery and cultural competency. We selected implementation outcomes for the BeatPain trial to evaluate the success of our implementation strategies.

Conclusions

Implementation mapping provided a comprehensive and systematic approach to develop an implementation plan during the planning phase for our ongoing hybrid effectiveness-implementation trial. We will be able to evaluate the implementation strategies used in the BeatPain Utah study to inform future efforts to implement telehealth delivery of evidence-based pain care in CHCs and other settings.

Trial registration

Clinicaltrials.gov Identifier: NCT04923334. Registered June 11, 2021 (https://clinicaltrials.gov/study/NCT04923334.

UK physiotherapists delivering physical activity advice: what are the challenges and possible solutions? A qualitative study

OBJECTIVES

Despite the known health benefits of physical activity (PA), PA levels are in decline. Healthcare professionals, including physiotherapists, have been identified as ideal conduits to promote PA, yet their knowledge and awareness of PA guidelines are poor. The aims of this study were to explore current knowledge of PA guidelines among UK physiotherapists and identify barriers and possible solutions to delivering PA advice.

DESIGN

A qualitative approach using semistructured interviews that took place between March and May 2021. Data were analysed with a thematic approach using Braun and Clarke's six steps.

SETTING

Various inpatient and outpatient clinical settings across six UK regions.

PARTICIPANTS

Eighteen UK-based physiotherapists managing National Health Service patients were recruited through volunteer sampling in March 2021.

RESULTS

Five themes and 16 subthemes (shown in parenthesis) were identified as barriers and solutions to delivering PA advice: physiotherapist intrinsic barriers (knowledge, fear/confidence); a lack of emphasis and priority given to PA (time constraints, minimal educational and staff training); patient barriers (compliance, expectations and fear of doing PA); increasing awareness of the PA guidelines (staff training, signposting awareness, use of social media and television campaigns); and optimising delivery (use of visual resources, good communication and approaches involving being individualised and gradual for patients with chronic conditions).

CONCLUSIONS

In this study, physiotherapist participants seemed to have limited awareness of the PA guidelines despite recent updates and were faced with similar barriers to those previously reported in the literature. The solutions suggested could guide strategies to support physiotherapists being able to deliver PA advice. Further research is needed to evaluate the efficiency of any implemented solutions supporting the delivery of PA advice.

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.

A qualitative study to explore the acceptability and feasibility of implementing person-focused evidence-based pain education concepts in pre-registration physiotherapy training

Objectives

The purpose of this study was to engage with physiotherapy clinicians, academics, physiotherapy students and patients to explore the acceptability, feasibility, and practical considerations of implementing person-focused evidence-based pain education concepts, identified from our previous research, in pre-registration physiotherapy training.

Design

This qualitative study took a person-focused approach to ground pain education in the perspectives and experiences of people who deliver and use it. Data was collected via focus groups and in-depth semi-structured interviews. Data was analysed using the seven stage Framework approach.

Setting

Focus groups and interviews were conducted either face to face, via video conferencing or via telephone. This depended on geographical location, participant preference, and towards the end of data collection the limitations on in-person contact due to the Covid-19 pandemic.

Participants

UK based physiotherapy clinicians, physiotherapy students, academics and patients living with pain were purposively sampled and invited to take part.

Results

Five focus groups and six semi-structured interviews were conducted with twenty-nine participants. Four key dimensions evolved from the dataset that encapsulate concepts underpinning the acceptability and feasibility of implementing pain education in pre-registration physiotherapy training. These are (1) make pain education authentic to reflect diverse, real patient scenarios, (2) demonstrate the value that pain education adds, (3) be creative by engaging students with content that requires active participation, (4) openly discuss the challenges and embrace scope of practice.

Conclusions

These key dimensions shift the focus of pain education towards practically engaging content that reflects people experiencing pain from diverse sociocultural backgrounds. This study highlights the need for creativity in curriculum design and the importance of preparing graduates for the challenges that they will face in clinical practice.

Back pain beliefs among Indian migrants in Australia: a cross-sectional study

PURPOSE

One of the largest migrant communities in Australia is the Indian migrant community. Current back pain guidelines recommend assessment of patients' beliefs; however, little is known about these beliefs in Indian communities. We aimed to investigate beliefs about back pain among Indian migrants living in Sydney.

MATERIAL AND METHODS

An online questionnaire with demographic information, participant characteristics, the Back Beliefs Questionnaire (BBQ) and open-ended questions relating to beliefs about causes of back pain and treatment preferences was completed by 386 Indian migrants in Sydney.

RESULTS

The overall BBQ score was 25.1 ± 6.7. We found significant but slightly more positive beliefs among Indian females than Indian males (standardized regression coefficient, β = 0.134, p = 0.014). Presence and severity of pain did not affect back pain beliefs. There seemed to be a belief in physical and structural/anatomical causes of back pain, and a belief in the effectiveness of exercise, medications, and Indian traditional approaches for pain management.

CONCLUSIONS

Beliefs of Indian migrants aligned with a "western traditional" biomedical model for the cause of pain, but with a belief in the effectiveness of both Indian traditional and western treatment approaches. Awareness of these beliefs could enable an effective therapeutic alliance between clinicians and Indian patients.IMPLICATIONS FOR REHABILITATIONBack pain beliefs of Australian Indian migrants are similar to their western counterparts, so the current guidelines for back pain can potentially be implemented without too much adjustment for this migrant community.Awareness of these beliefs is likely to improve the therapeutic alliance between clinician and an Indian migrant patient.

What factors predict outcome from an inpatient multidisciplinary chronic pain service? A prospective cohort study

Objective To identify baseline factors associated with outcomes from an inpatient multidisciplinary pain management program (PMP) located in a bicultural area of Aotearoa New Zealand. Methods A prospective cohort study was undertaken involving 164 people with chronic pain who attended the PMP. Demographic, clinical, and psychosocial measures were obtained at baseline, whereas clinical and psychosocial outcome measures were also obtained at program discharge and 3-month follow up (N  = 100). Multivariate analyses were used to determine baseline demographic variables that were associated with outcomes at discharge and follow up. Results Being male and working full-time were associated with poorer outcomes in select measures at discharge. At the 3-month follow up, Māori ethnicity, working full-time, being retired or unemployed, or having chronic widespread pain were associated with poorer outcomes for some measures, whereas those with rheumatoid arthritis had greater self-efficacy. Conclusions Sex, ethnicity, employment status, and patient condition impact clinical outcomes from the program and in the time from discharge to follow up. Program content and/or delivery should be altered to promote more equitable outcomes for all patients in the long term.

Patterns of patient outcomes following specialist pain management in Australasia: a latent class analysis using the ePPOC database

ABSTRACT

The increasing demand for pain management and limited resources available highlight the need to measure treatment effectiveness. We analysed data collected at 75 specialist persistent pain services located in Australia and New Zealand to calculate overall treatment outcome for patients receiving care during 2014-2020. Socio-demographic and clinical information was provided for 23,915 patients, along with patient-reported measures assessing pain, pain interference, depression, anxiety, stress, pain catastrophizing and pain self-efficacy. Latent Class Analysis identified four distinct outcomes based on patients' pattern of responses across the assessment tools at treatment end. Group 1 (n=8,369, 35%) reported low/mild severity across all clinical domains at the end of care, while Group 4 (n= 7,081, 30%) were more likely to report moderate/high severity on all domains. Group 2 (n=1,991, 8%) reported low/mild pain with moderate/high psychological distress at treatment end, and Group 3 (n=6,474, 27%) reported moderate/high pain with low/mild psychological distress. Multi-variable logistic regression identified those factors associated with the different groups. In particular, factors most predictive of a poor (Group 4) vs. good outcome (Group 1) were unemployment (due to pain or other reasons), requiring an interpreter, widespread pain, pain of longer duration and attributing the pain to an injury at work. The results may allow identification of those most likely to benefit from the services currently provided, and inform development of alternative or enhanced services for those at risk of a poor outcome.

Facing symptoms and limitations: a qualitative study of women with carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a neuropathic pain condition characterised by pain, paresthesia, loss of strength and disability.

OBJECTIVE

To explore the experiences of women with CTS regarding the management of symptoms and limitations.

METHODS

A qualitative phenomenological study was conducted. Women with a clinical and electromyographic diagnosis of CTS recruited from the Neurology Department of a Public Hospital were included. Purposeful sampling was performed. Data were collected using in-depth interviews and researchers' field notes. Analysis proposed by Giorgi was used.

RESULTS

A total of 18 women with CTS were included. Two themes emerged: a) Living with CTS symptoms and limitations: describing the symptoms experienced, triggers of their symptoms and how they define CTS. Also, describing the difficulties that they experience on a daily basis, at home when handling tools, communicating, driving, and at work; and b) developing daily strategies for managing limitations: developing potential daily strategies to overcome daily limitations and/or compensate for them, and seeking professional help.

CONCLUSIONS AND SIGNIFICANCE

Current results provide insight on how symptoms and daily limitations are experienced by a group of women with CTS. These findings could help occupational therapists to understand the day-to-day difficulties and the reasons for developing certain strategies.

Profile, attitudes and beliefs of physiotherapists in the management of chronic nonspecific low back pain

Abstract Introduction: About 84% of the population have had some low back symptom during their lifetime; where 23% of cases become chronic pain. It is observed that in around 85% of cases of chronic low back pain, there is no specific cause or diagnosis, where it is referred to as chronic nonspecific low back pain. Given its disabling potential, the comprehensive assessment, attitudes and beliefs of the physiotherapist in clinical management become essential to the prognosis. Objective: To evaluate the relationship between sociodemographic/socioeducational and work profile and the attitudes and beliefs of physiotherapists in the management of chronic nonspecific low back pain treatment. Methods: This was a cross-sectional quantitative study. For data collection, two questionnaires were used, one referring to the sociodemographic/socioeducational profile information and the other referring to attitudes and beliefs determined by the Pain Attitudes and Beliefs Scale for Physiotherapists. Data were analyzed using the BioEstat 5.0 program using descriptive statistics, t-test and Pearson correlation (p < 0.05). Results: Fifty-seven physical therapists were analyzed, where most were women (61.4%), had specialization (56.2%), worked in private clinics (63.2%) and used specific methods in the management of chronic nonspecific low back pain (84.2%). Biomedical belief was predominant (70.2%) and showed a significant relationship with age (p = 0.0006). Conclusion: The biomedical model is still predominantly used, which is related to the age of the professionals surveyed.

Do Limited English Proficiency and Language Moderate the Relationship Between Mental Health and Pain?

AIM

To explore whether the relationship between mental health diagnosis (i.e., mood or neurotic, stress-related, or somatoform disorder) and pain is moderated by language in patients with limited English proficiency (LEP). Southeast Asian languages (i.e., Hmong, Lao, Khmer) and Spanish were compared with English.

METHOD

A retrospective data mining study was conducted (n = 79,109 visits). Pain scores, language, mental health diagnoses, age, sex, race, ethnicity, and pain diagnosis were obtained from electronic medical records. Cragg two-equation hurdle regression explored: (1) the effect of patient language and mental health diagnosis on pain and (2) the interaction between language and mental health diagnosis on pain.

RESULTS

Visits were primarily for female (62.45%), White (80.10%), not Hispanic/Latino (96.06%), and English-speaking (97.85%) patients. Spanish or Southeast Asian language increased chances of reporting any pain (i.e., pain score of 0 versus ≥1) and pain severity in visits with pain scores ≥1, whereas mental health diagnosis decreased chances of reporting any pain and pain severity. The combination of Southeast Asian language and mood disorder contributed to higher chances of reporting any pain (odds ratio [OR] = 1.78, p<.001) but no difference in severity. A similar trend was observed for Southeast Asian language and neurotic disorder (OR = 1.29, p=.143). In contrast, the combination of Spanish language and mood (p = .066) or neurotic (p = .289) disorder contributed to lower pain severity but did not change the chances of reporting any pain.

CONCLUSIONS

LEP and patient language should be considered during pain assessment within the context of mental health.

Gender matters in physiotherapy

The World Health Organization states that gender has implications for health across the course of a person's life in terms of norms, roles and relations. It also has implications in rehabilitation. In this article, we argue the need of gender perspectives in the field of physiotherapy; gender matters and makes a difference in health and rehabilitation. We highlight a number of central areas where gender may be significant and give concrete examples of social gender aspects in physiotherapy practice and in diverse patient groups. We also discuss why it can be important to consider gender from an organizational perspective and how sociocultural norms and ideals relating to body, exercise and health are gendered. Further we present useful gender theories and conceptual frameworks. Finally, we outline future directions in terms of gender-sensitive intervention, physiotherapy education and a gendered application of the ICF model. We want to challenge physiotherapists and physiotherapy students to broaden knowledge and awareness of how gender may impact on physiotherapy, and how gender theory can serve as an analytical lens for a useful perspective on the development of clinical practice, education and research within physiotherapy.

Management strategies to improve French language service coordination and continuity for official language Francophone seniors in Canada

Evidence suggests that language barriers present obstacles to healthcare access and quality for Francophone seniors in official language minority communities across Canada. Addressing language barriers and providing continuity is challenging, as French language services (FLSs) rely heavily on bilingual providers and the practice of active offer by all staff. This qualitative research used semi-structured group and individual interviews to explore mechanisms supporting FLS coordination and continuity in two Canadian provinces. Identification of the language variable in health records, virtual healthcare, and FLS directories are conducive to FLS continuity, but financial and resource limitations present major obstacles. Management strategies to facilitate continuity of FLS across health organizations are discussed.