“In the physio we trust”: A qualitative study on patients’ preferences for physiotherapy

The PREVSAM model, "prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders", is seen as beneficial for patients risking persistent musculoskeletal disorders but may be difficult to implement - a focus group study

PURPOSE

The rehabilitation model "Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders" (PREVSAM) was tested in a randomised controlled trial. This study aimed to explore participating healthcare professionals' experiences of working according to the PREVSAM model, and their perceptions of its clinical benefit and feasibility in primary care rehabilitation.

METHODS

A focus group study including 12 healthcare professionals from five primary care rehabilitation clinics was analysed according to the focus group methodology described by Krueger and Casey.

RESULTS

Four themes were identified. A clear framework describes how PREVSAM facilitates person-centred teamwork. The value of teamwork highlights benefits and challenges with teamwork. Through thick and thin discusses perceived patient benefits. In the ideal world focusses on feasibility of implementing the model.

CONCLUSIONS

The participants experienced that the PREVSAM model may be beneficial for the patients, for their own work situation and workplace, and for society. Identifying psychological risk factors was perceived as helpful, but not enough to capture patients in need of team-based rehabilitation. While considered feasible, barriers for implementing the model were identified. Managers and healthcare policy makers must prioritise and create appropriate conditions for team-based musculoskeletal rehabilitation in primary care.

Real-world implementation of pain science education and barriers to use in private practice physiotherapy settings: an Australia-wide cross-sectional survey

ABSTRACT

Physiotherapists are critically positioned to integrate education into patient care, including pain science education (PSE) to enhance management and outcomes. Anecdotally, many physiotherapists report difficulty providing PSE in private practice settings. Here, we aimed to explore current PSE use, knowledge, and barriers to implementation. A nationwide online (Qualtrics) survey of PSE-trained Australian private practice physiotherapists assessed use, knowledge (revised Neurophysiology of Pain Questionnaire [rNPQ]), concept application, implementation barriers, and resource awareness/use/preferences, exploring associations with individual/clinic-level factors (clinical experience, PSE training, work location). A total of 278 physiotherapists (62.9% female, 39.4 [11.8] years, 15.2 [11.6] years of experience, 37.2% rural/remote) completed the survey. Pain science knowledge (rNPQ: mean 10.4 [2.2]/13) and perceived PSE competence was high, although 30% supported inaccurate PSE concepts. Pain science education training via professional development course was associated with higher knowledge relative to university training (multivariable; β = 1.337, P < 0.001). Physiotherapists reported providing PSE to 61% of patients, with patient-related barriers (expecting other treatments: 94%; previous negative/contradictory PSE experiences: 89%), clinic-level barriers (time constraints: 77%; insufficient billing schedules: 57%), and clinician-specific barriers (difficulties identifying/addressing patient maladaptive beliefs/behaviours: 53%; cultural/demographic translation challenges: 46%) reported. Fewer years of clinical experience was associated with heightened worry that providing PSE might go wrong (multivariable; β = -0.034, P = 0.010) and/or damage therapeutic relationships (multivariable; β = -0.049, P < 0.001). Physiotherapists were aware of over 100 PSE resources, with varying levels of perceived use/effectiveness, yet were largely unaware of educational strategies. Physiotherapists called for reduced complexity and greater ability to individualise PSE resources. Findings will guide improvements in PSE training/resources, to maximise physiotherapists' confidence and preparedness to effectively implement PSE.

Enhancing Patient Choice Through the Development of Physical Therapist Online Biographies

Provider web profiles are becoming popular locations for patients to seek information before their visits. This industry insight assesses patients' utilization of a physical therapy clinic's website to determine the impact the addition of physical therapist biographies had on patient perceptions and physical therapist selection. Forty-six percent of first-time patients (n = 786) indicated visiting the clinic's website prior to their visit. After biographies were added, these website visitors rated the website as more helpful, and indicated a greater perception of certainty regarding the services the clinic provides. A greater percentage of website visitors made a purposeful selection of therapist after therapist biographies were posted online than prior to biographies being posted. These findings indicate that improvements to a clinic's website can positively impact patient empowerment in making personal healthcare decisions. Simply adding biographies of physical therapists to clinics' websites can have significant effects on reducing first-time patients' uncertainty, as well as providing a greater level of patient-centered care by offering information to empower patients to be more active participants in their healthcare choices.

They paid attention to the whole of me in some way, both physically, mentally, and everything in between: a qualitative study of patients' experiences of interdisciplinary rehabilitation (PREVSAM) in primary care for musculoskeletal disorders

PURPOSE

To explore and describe patients' experiences and perceptions of rehabilitation according to the rehabilitation model 'Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain' (PREVSAM).

METHOD

A qualitative study was conducted, with individual semi-structured interviews analysed using qualitative content analysis. Fifteen patients from three primary care rehabilitation clinics in Sweden who had undergone rehabilitation based on the PREVSAM model participated.

RESULTS

Four categories were identified from the participants' experiences: Gratitude for the holistic view, Challenging but clarifying to create a health plan, Different needs for addressing work-related factors, and Difficulties and negative experiences. From these categories, an overarching theme was conceptualised: Grateful for being seen for who I am and given the care I need.

CONCLUSION

Participants were generally positive towards the PREVSAM model. The addition of occupational therapy and psychological treatment to physiotherapy was seen by many, albeit not all, as enriching the rehabilitation. Collaboration with the workplace was mainly considered 'good in theory'. The wide variation in the need for support underscore the importance of person-centredness.

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.

Do patients' preferences and expectations match clinical guidelines? A survey of individuals seeking private primary care for a musculoskeletal disorder

BACKGROUND

Physiotherapists often inconsistently adhere to clinical practice guidelines (CPGs) when managing musculoskeletal disorders (MSKDs), potentially due to discrepancies between patient-valued interventions and guideline recommendations. Since patients' expectations are important predictors of outcome, this disparity between CPGs recommendations and patient preferences could be problematic for the effective care of MSKDs.

OBJECTIVES

To assess patients' expectations and preferences for the interventions used in their MSKD management and to establish correspondence rates between patients' preferences and recommendations from CPGs.

DESIGN

Survey.

METHOD

This cross-sectional descriptive study included a survey on sociodemographics, preferences, and expectations towards interventions for their MSKD, acceptable cost of care, number of treatment sessions required, and their involvement in their MSKD management.

RESULTS

One hundred and fifty participants (94 women and 56 men; mean age: 51 ± 17) responded to the survey. Eighty percent of respondents expected their involvement in their MSKD management to be equal to or superior than that of the physiotherapist. Sixty-nine percent of respondents expected to receive exercises, and 67% expected to receive education. Based on preference ratings, 95% of respondents chose recommended interventions, 57% chose interventions with uncertain levels of recommendation, and 48% chose interventions not recommended by CPGs.

CONCLUSION

Less than 70% of participants expected to receive education and exercises, the two most frequently recommended interventions by CPGs. On the other hand, the majority of respondents indicated that their involvement should be equal to or superior than that of the physiotherapist. This aligns with CPGs, which advocate for active and self-management strategies.

Exploring Experiences of People With Knee Osteoarthritis Who Received a Physiotherapist-Delivered Dietary Weight Loss and Exercise Intervention: A Mixed Methods Study

OBJECTIVE

Explore the experiences of people with knee osteoarthritis (OA) who received a very low energy diet (VLED) and exercise program from a physiotherapist.

METHODS

Mixed methods study involving questionnaires (n = 42) and semistructured interviews (n = 22) with randomized control trial participants with knee OA who had received a 6-month physiotherapist-delivered VLED weight loss and exercise intervention. Questionnaires measured participant satisfaction and perceptions about physiotherapist's skills/knowledge in delivery of the dietary intervention (measured on 5-7 point Likert scales). Interviews explored participant's experiences and were analyzed based on the principles of reflexive thematic analysis.

RESULTS

Questionnaire response: 90%. Participants were satisfied with the program (95%), confident their physiotherapist had the required skills (84%) and knowledge (79%) to deliver the dietary intervention, felt comfortable talking to the physiotherapist about weight (74%), and would recommend others see a physiotherapist for the intervention they undertook (71%). The following four themes were developed from the interviews: (1) one-stop-shop of exercise and diet; (2) physiotherapist-delivered weight loss works (unsure initially; successfully lost weight); (3) physiotherapists knowledge and skills (exercise is forte; most thought physiotherapists had the necessary weight loss skills/knowledge, but some disagreed); and (4) physiotherapists have a role in weight loss (physiotherapists are intelligent, credible, and trustworthy; specific training in weight loss necessary).

CONCLUSION

This study provides, to our knowledge, the first documented perspectives from people with OA who have received a physiotherapist-delivered weight loss intervention. Findings suggest physiotherapists may have a role in delivering a protocolized dietary intervention for some people with knee OA with overweight and obesity.

Prescribing exercise therapy for the management of musculoskeletal pain: new-graduate physiotherapists' perceptions and perceived training needs

BACKGROUND

Pain management is a challenging area of practice for new-graduate physiotherapists during the transition from student to clinician. The attitudes and beliefs of new-graduate physiotherapists toward the use of exercise therapy as part of the management of musculoskeletal pain remain relatively unknown.

PURPOSE

The aim of the study was to investigate the perspectives of new-graduate physiotherapists toward prescribing exercise therapy in musculoskeletal pain management, and their perceptions of training and support needs in this area of practice.

METHODS

A qualitative study with a general inductive approach was used to investigate new-graduate physiotherapists' perspectives. Semi-structured interviews were conducted with 16 participants. Interview data was subjected to thematic analysis.

RESULTS

Four themes were generated following analysis: 1) Balancing the value of exercise with practical challenges; 2) Communication and education are inherent in exercise; 3) Influence of support and training; and 4) The benefits of direct experience.

CONCLUSION

New-graduate physiotherapists acknowledge the pivotal role of exercise in managing musculoskeletal pain. Direct learning experiences in pre-professional training that develop knowledge and skills required for delivering exercise therapy were highly valued. New-graduates recognize pain management as a skill that requires further development and identify the importance of opportunities for professional development in exercise therapy.

Survey of Confidence and Knowledge in Managing Patellofemoral Pain among Physical Therapists in Saudi Arabia

BACKGROUND

This study assessed the beliefs and knowledge of physical therapists in Saudi Arabia regarding the management of patellofemoral pain (PFP) and their alignment with current Clinical Practice Guidelines (CPGs).

METHODS

A cross-sectional survey was conducted, involving 111 licensed physical therapists actively treating PFP patients. The survey included questions about PFP risk factors, prognosis, diagnosis, and treatment, using a Likert scale to measure confidence and knowledge.

RESULTS

Readers have significantly greater confidence in the knowledge of managing patients with PFP following current CPGs (p < 0.01). No significant differences were observed between groups in the other items (p > 0.01). However, over 70% of respondents, irrespective of guideline familiarity, held beliefs about risk factors, prognosis, diagnosis, and treatment that were inconsistent with CPGs.

CONCLUSIONS

These discrepancies highlight a significant knowledge gap that may affect patient care quality. Enhancing education and dissemination efforts regarding CPGs is essential to improve adherence to evidence-based practices among physical therapists in Saudi Arabia. To change practitioners' preferences, attitudes, and beliefs, more targeted programs and interventions for knowledge dissemination and implementation should be provided.

'Going through the motions'; a rich account of the complexity of the anterior cruciate ligament reconstruction pathway, a UK qualitative study

OBJECTIVES

This study aimed to understand the lived experiences of patients on the anterior cruciate ligament reconstruction (ACLR) pathway up to 3 months before, 3 months after and 1 year after surgery. Study objectives were to explore (1) patient experiences of preoperative and postoperative treatment, (2) views of/involvement in prehabilitation and (3) sources and consistency of healthcare advice.

DESIGN

Semi-structured interviews analysed using reflexive thematic analysis.

SETTING

Midlands, England.

PARTICIPANTS

Purposive sample of 18 participants aged 18-45. Three identified as female and 15 as male. Participants' ethnic origin was white (n=14), Indian (n=2), British Asian (n=1) and Pakistani (n=1). 10 participants were awaiting ACLR, six were 3months postsurgery and two were 1 year postsurgery.

RESULTS

Participants gave a rich account of ACLR pathway experiences discussing negative impacts of the injury, difficulties with navigating the pathway and making decisions about surgery. Interacting with healthcare professionals and managing the variety of resources, advice and opinions were also highlighted as challenges. Participants reflected on their preoperative journey accounting a wide spectrum of expectations and realities of returning to work and physical activity postoperatively. Prehabilitation was perceived to offer an advantage to recovery, mental well-being, injury knowledge, postoperative rehabilitation and supports a faster return to physical activity. Five themes were identified:Injury experience, impact and support.Navigating the treatment pathway.Sense making in the preoperative period.Uncertainty, expectations and reality of the postsurgical period.Balancing resources, advice and opinions.

CONCLUSION

This study has illuminated patient experiences of the National Health Service (NHS) ACLR pathway, novel to the evidence base.The results highlight the perceived shortcomings in patient support. They also demonstrate the difficulty patients face when navigating the NHS system, communicating with clinicians, making decisions about treatment and managing conflicting sources of healthcare advice. These problems are more prominent than previously recognised in the literature.

REGISTRATION

ClinicalTrials.gov Identifier: NCT05529511.

Unravelling interacting barriers and facilitators to adherence and delivery of exercise-based care in the treatment of Subacromial Pain Syndrome - an exploratory qualitative study

PURPOSE

Subacromial Pain Syndrome (SAPS) is a common persistent pain condition. Exercise-based care is first-line recommendation, but an insufficient exercise dose hampers effectiveness. This study explores individual and contextual barriers and facilitators for delivery of and adherence to exercise-based care in people with SAPS.

MATERIALS AND METHODS

Participants in this exploratory qualitative study were involved in the management of SAPS in Denmark. Triangular interviews and analyses were conducted within 3 themes (delivery of recommended services, adherence to recommendations, and frames of the clinical pathways) using the Theoretical Domains Framework (TDF) and the Behavioural Change Wheel model (BCW) to map barriers and facilitators into the Capability, Opportunity, Motivation and Behaviour (COM-B) model.

RESULTS

From interviews with 10 persons with SAPS and 37 healthcare practitioners and double-deductive analyses, 30 subjects of target behaviour within 13 TDF domains emerged across perspectives and COM-B components. Central barriers to delivery and adherence were inconsistencies in diagnostic terminology, cross-professional disagreements, beliefs, and expectations towards pathway services.

CONCLUSION

We identified interrelated individual and contextual barriers to delivery and adherence across all aspects of the BCW, underpinning the complexity of the subject. Findings support that effectiveness of exercise-based care is linked to contextual barriers to delivery and adherence.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain

BACKGROUND

Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings.

PURPOSE

This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy.

METHODS

An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices.

RESULTS

Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices.

CONCLUSION

Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

Patients' expectations of physiotherapists before and after an intensive chronic low back pain rehabilitation programme: a qualitative study based on semi-structured interviews and observations

PURPOSE

To investigate the expectations regarding physiotherapists of patients attending an interdisciplinary CLBP rehabilitation programme and the response to these expectations.

MATERIALS AND METHODS

A thematic analysis was conducted, based on interviews of working-age patients with CLBP and without significant comorbidities.

RESULTS

Twenty patients participated (9 male, 11 female, aged 21-58 years; symptoms duration 4.3 ± 3.0 years; pain VAS 53 ± 21 mm). Patients expected to learn pain and activity management. Expected outcomes were a reduction of pain, increased well-being and a return to normality. A collaborative approach involving therapeutic and relational adaptation was expected. Despite divergences concerning emotional aspects, patients expected a large range of applied psychosocial skills.The programme met the expectations of most patients, especially when its goals matched those reported by the individuals. For most participants, the pain relief was below expectations. Active therapies were valued. After the programme, patients felt more ready to take responsibility for their back.

CONCLUSION

The expectation of developing self-management skills was prevalent. Expected treatments were mostly compatible with recommendations. Expectations to resume activities and decrease pain were in line with the rehabilitation goals, although the expected reduction in pain was overestimated. Relational expectations converged towards patient-centred care.

What are patients' perspectives on the value of physical therapy? A prospective cohort study

PURPOSE

To assess and identify patients' perceptions about the overall value of physical therapy services for musculoskeletal conditions and how these values were associated with their outcomes.

METHODS

The association between the perceived value of physical therapy (as a score) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and physical function at 6-weeks was assessed in a prospective cohort. Generalised linear models were used to identify relationships between the value of physical therapy score and PROMIS outcomes. Kendall's tau was used to identify correlations between responses and outcomes.

RESULTS

A total of 133 participants met the final inclusion criteria. The majority of participants were female (63.9%) with a mean age of 55.53 (SD 15.36) years. A majority of participants (63.9%) reported a previous positive personal experience with physical therapy. There was no significant relationship between perceived value of physical therapy and pain interference (β -0.32, p = 0.07, 95% CI-0.67, 0.03) or physical function (β 0.19, p = 0.29, 95% CI-0.16, 0.54). Stronger beliefs in agreement with the value of non-invasive treatment were significant, but weakly correlated with lower pain interference (r = -0.18, p = 0.048) and higher physical function scores (r = 0.22, p = 0.03).

CONCLUSIONS

Participants had an overall positive perception of the value of physical therapy prior to initiating physical therapy, but this perception was not associated with 6-week pain and function outcomes. A better understanding of the driving factors encouraging patients to seek physical therapy services is needed to provide value-based care.

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).

Dry needling perceptions and experiences: A survey of Australian physiotherapists

BACKGROUND

There is a lack of information on the use of dry needling in Australian physiotherapy practice.

OBJECTIVES

Our primary aim was to enhance the understanding of why Australian physiotherapists use dry needling in clinical practice. The secondary aim was to explore Australian physiotherapists experiences with adverse events caused by dry needling.

DESIGN

Cross-sectional online survey.

METHOD

We developed a survey and disseminated it through email to physiotherapists from all states and territories in Australia. Participant demographics and responses were reported as frequencies and percentages.

RESULTS/FINDINGS

We invited 1006 Australian physiotherapists, of which 232 (23%) viewed the online survey and 203 (20%) consented to participate, of which nearly all completed the survey (n = 198, 98%). Most respondents worked in private practice (n = 164, 83%), with 127 (64%) reporting using dry needling as an intervention within the previous 12 months. Physiotherapists typically used dry needling to decrease pain intensity (n = 105, 85%) and reduce muscle tension (n = 100, 81%). Reports of minor adverse events were common and included discomfort during the treatment (n = 77, 62%) and bruising (n = 69, 56%). Some respondents reported experiencing major adverse events including prolonged aggravation of symptoms (n = 10, 8%) and syncope (n = 16, 13%).

CONCLUSIONS

We found that many Australian physiotherapists in private practice use dry needling, usually to decrease pain intensity and muscle tension. Minor adverse events were experienced by more than half the respondents and between 8 and 13% of the Australian physiotherapists surveyed reported experiencing a major adverse event due to dry needling.

The 'responsive' practitioner: physiotherapists' reflections on the 'good' in physiotherapy practice

BACKGROUND

Being 'responsive' is named as an element of ethic of care theories, yet how it is enacted is not clearly described in health professional practice. Being 'responsive' is implied within patient-centered approaches and promoted as important to health care practices, including physiotherapy. However, ways of being a responsive practitioner have not been explicitly examined. Practitioners' perspectives about how a 'good' physiotherapist enacts responsiveness have potential implications for the future practice of physiotherapy. Physiotherapists' perceptions may inform professional priorities including education curricula, professional practices, and patient interactions.

PURPOSE

The purpose of this research was to explore experienced musculoskeletal (MSK) practitioners' perceptions of 'responsiveness' in the practice of a 'good' physiotherapist.

METHODS

A secondary analysis of data arising from a hermeneutic phenomenological study into physiotherapists' perceptions of what constitutes a 'good' physiotherapist was undertaken. The secondary analysis focused on 'responsiveness,' which emerged as a major theme in the original study.

FINDINGS

Six themes were identified related to 'Being responsive' in a 'good' physiotherapist: Being person-centered, Being attentive, Being open, Being a listener, Being validating, and Being positive.

CONCLUSIONS

As a relational way of practicing, being responsive may facilitate person-centered approaches including a relational understanding of autonomy, inviting dialogue, and sharing power and decision-making with patients. Pivotal to the practice of a 'good' physiotherapist, being responsive in the ways underscored by participants suggests researchers, educators, and practitioners consider relational ways of practicing as a balance to the technical aspects of physiotherapy.

Barriers and facilitators of integrating physiotherapy into primary health care settings: A systematic scoping review of qualitative research

Purpose

This scoping review investigated the barriers and facilitators to integrating physiotherapy into primary health care (PHC).

Materials and methods

PubMed, Scopus, Web of Science, Embase, ProQuest, and REHABDATA were searched. Two independent reviewers were involved in screening, selecting, and extracting data. Data were synthesized using thematic analysis.

Results

Of the 483 screened documents, 44 qualitative studies, primarily from high-income countries, were included. All of the studies had good methodological quality. Barriers and facilitators of integrating physiotherapy into PHC were extracted within the WHO six building blocks framework. In total, 41 items were identified as barriers to the integration process. The studies included 49 recommendations to facilitate integrating physiotherapy services into PHC.

Conclusion

Integrating physiotherapy services into PHC faces many barriers. The most commonly suggested potential barriers are poor knowledge of physicians about physiotherapy, ineffective teamwork, physiotherapists' time constraints/workload, a lack of clarity over the role and knowledge of physiotherapists, unawareness of physiotherapy users about these services, and lack of intra- and inter-professional collaborations. The most commonly suggested recommendations to facilitate the integration process include: Clarifying the role of involved professionals, strengthening teamwork, improving intra- and inter-professional collaborations, and providing comprehensive training programs for physiotherapists.

Shared decision-making in physiotherapy: a cross-sectional study of patient involvement factors and issues in Japan

BACKGROUND

Evidence-based medicine education has not focused on how clinicians involve patients in decision-making. Although shared decision-making (SDM) has been investigated to address this issue, there are insufficient data on SDM in physiotherapy. This study aimed to clarify the issues concerning patient involvement in Japan, and to examine whether SDM is related to perceptions of patient involvement in decision-making.

METHODS

The study participants were recruited from among acute and sub-acute inpatients and community residents receiving physiotherapy outpatient care, day care, and/or home rehabilitation. The Control Preference Scale (CPS) was used to measure the patients' involvement in decision-making. The nine-item Shared Decision-Making Questionnaire (SDM-Q-9) was used to measure SDM. In analysis I, we calculated the weighted kappa coefficient to examine the congruence in the CPS between the patients' actual and preferred roles. In analysis II, we conducted a logistic regression analysis using two models to examine the factors of patient involvement.

RESULTS

Analysis I included 277 patients. The patients' actual roles were as follows: most active (4.0%), active (10.8%), collaborative (24.6%), passive (35.0%), and most passive (25.6%). Their preferred roles were: most active (3.3%), active (18.4%), collaborative (39.4%), passive (24.5%), and most passive (14.4%). The congruence between actual and preferred roles by the kappa coefficient was 0.38. Analysis II included 218 patients. The factors for patient involvement were the clinical environment, the patient's preferred role, and the SDM-Q-9 score.

CONCLUSIONS

The patients in Japan indicated a low level of decision-making involvement in physiotherapy. The patients wanted more active involvement than that required in the actual decision-making methods. The physiotherapist's practice of SDM was revealed as one of the factors related to perceptions of patient involvement in decision-making. Our results demonstrated the importance of using SDM for patient involvement in physiotherapy.

Physiotherapists' ethical behavior in professional practice: a qualitative study

Background

In health professions, ethics is considered a fundamental competence. The increase in clinical autonomy in the field of physiotherapy is associated with an increase in ethical situations in their clinical practice.

Objective

To explore the ethics of the clinical relationship between physiotherapists and patients, the ethics training received by physiotherapists, and if in the clinical context, physiotherapists identify the necessary attitudes and apply the ethical recommendations of the profession for the ethical situations they experience.

Methods

A qualitative exploratory and descriptive study was performed with physiotherapists. Data were collected through semi-structured interviews. The data were analyzed using content analysis, as proposed by Krippendorf. The study protocol was approved by the University of Valencia Ethics Committee of Human Research.

Results

This study included 15 physiotherapists (66.66% women, average age = 42.2 years), which was sufficient to reach data saturation. We identified four categories: (i) Ethics of the clinical relationship (ethical values, principles, and norms; type of clinical relationship), (ii) Ethics training received (during the physiotherapy studies; current training of students; low importance of ethics in the curriculum), (iii) Necessary attitudes for professional ethical practice (main attitudes were identified: personal attitudes and professional attitudes); (iv) Experiences from professional practice (general; public sector vs. private sector).

Conclusion

The ethics of the clinical relationship between physiotherapists and patients is determined by the attitudes of the practitioner, which are the result of his or her values and previous experiences; and are very centered on ethics of indication (founded mainly on the principles of Beneficence and Non-Maleficence). It is necessary to improve the ethical training received by physiotherapists, which is poorly focused on professional attitudes.

Recruiting hand therapists improves disposal of unused opioid medication

BACKGROUND

Opioids often remain unused after upper extremity surgery, and leftover prescriptions are frequently diverted. When administered in a hand surgery clinic, an educational brochure outlining a simple method of opioid disposal has been shown to improve disposal rates after surgery.

PURPOSE

To understand whether administration of an opioid disposal educational brochure in a hand therapy clinic would increase opioid disposal rates, compared to a hand surgery clinic.

STUDY DESIGN

Prospective cohort study.

METHODS

Patients who presented to a hand therapy clinic postoperatively were recruited to participate in this prospective cohort study. An educational brochure outlining a simple method of opioid disposal was made available at the hand therapy and surgery clinics. A questionnaire was later issued to obtain: location of brochure receipt, demographic information, pre- and post-operative opioid use history, and opioid disposal patterns. Chi-square tests and multivariable binary logistic regression assessed associations between medication disposal and explanatory variables.

RESULTS

Patients who received the brochure were significantly more likely to dispose of excess opioid medication, compared to those who did not receive the brochure (57.1% vs 10.8%, p < .001). Patients who received the brochure at the hand therapy clinic were significantly more likely to dispose of excess opioids (86.4%) compared to those who received the brochure at the surgery clinic (25.0%). Older age was predictive of increased disposal (p =.028*). There were no significant associations between gender, length of follow-up, or surgery type with the incidence of opioid disposal.

CONCLUSION

Recruiting both hand therapists and surgeons in the distribution of a simple, educational brochure on opioid disposal can increase disposal rates. Patients who received the brochure from the hand therapist were more likely to dispose of excess opioids. The longstanding patient-therapist relationship creates an opportunity for educational initiatives and discussion of stigmatized topics, such as opioid use.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review

BACKGROUND

This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness.

METHODS

Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE.

RESULTS

Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment.

DISCUSSION

Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access.

TRIAL REGISTRATION

The review was registered in the PROSPERO database, CRD42021277624.

Expertise and individually tailored interventions are expected by pregnant women with pelvic girdle pain who seek physical therapy: a qualitative study

BACKGROUND

Pelvic girdle pain (PGP) in pregnancy may result in activity limitations and thus a negative impact on the individual woman's everyday life. Women's expectations when they seek physical therapy because of PGP are not yet known.

OBJECTIVE

To explore pregnant women's lived experience of PGP and what needs and expectations they express prior to a physical therapy consultation.

METHODS

A qualitative study using a descriptive phenomenological method. Interviews conducted with 15 pregnant women seeking physical therapy because of PGP, recruited through purposive sampling at one primary care rehabilitation clinic.

RESULTS

PGP was described by four themes; An experience with larger impact on life than expected, A time for adjustments and acceptance, A feeling of insecurity and concern, A desire to move forward. PGP had a large impact on the pregnant women´s life. Thoughts of PGP as something to be endured was expressed, the women therefore accepted the situation. Finding strategies to manage everyday life was hard and when it failed, the women described despair and a need for help. They expected the physical therapist to be an expert who would see them as individuals and provide advice that could make their everyday life easier.

CONCLUSION

Our results reveal that pregnant women with PGP delay seeking physical therapy until their situation becomes unmanageable and they run out of strategies for self-care. The women express, in light of their individual experiences, needs and expectations for professional management and advice tailored to their individually unique situation.

Beyond guidelines: A qualitative clinical stakeholder study of optimal management of anterior cruciate ligament rehabilitation

AIMS

This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies.

MATERIALS AND METHODS

This was a qualitative semi-structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach.

RESULTS

Results included 24 interviews that were conducted with 19 physiotherapists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self-management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location 'lottery' that significantly varied for patients across the UK.

CONCLUSIONS

Stakeholders identified that optimal management should be patient centred and incorporate adequate equipment, specific training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.

Barrieren und Förderfaktoren für die Implementierung eines Konzepts zur Förderung evidenzbasierten Arbeitens in der Physiotherapie – Eine Mixed-Methods-Studie

Hintergrund In der Physiotherapie in Deutschland besteht Bedarf an theoretisch und wissenschaftlich fundierten Implementierungsstrategien zur Förderung des evidenzbasierten Arbeitens (EBP). Bei der Entwicklung solcher Strategien ist es notwendig, die Rahmenbedingungen und Einflussfaktoren im individuellen Kontext zu erfassen und zu berücksichtigen. In diesem Zusammenhang wurde das „science4practice“-Konzept mit dem Ziel entwickelt, die Umsetzung von EBP in physiotherapeutischen Einrichtungen zu fördern.

Ziel Erhebung von Barrieren und Förderfaktoren für die Implementierung des „science4practice“-Konzepts.

Methode Im Rahmen einer Mixed-Methods-Studie wurden qualitative, semistrukturierte Interviews sowie eine quantitative Erhebung anhand eines Online- und Papierfragebogens durchgeführt. An den Interviews nahmen Geschäfts- und Therapieleitungen therapeutischer Einrichtungen sowie Physiotherapeut*innen ohne Leitungsverantwortung teil. An der quantitativen Befragung nahmen Physiotherapeut*innen ohne Leitungsverantwortung teil. Die Daten der Interviews wurden mittels thematischer Inhaltsanalyse ausgewertet. Die Daten der quantitativen Erhebung wurden deskriptiv analysiert.

Ergebnisse Aus den 15 durchgeführten Interviews konnten die mangelnden Fähigkeiten zur Literaturrecherche und -bewertung, negative Erfahrungen mit Veränderungsprozessen sowie unzureichende Zugangsmöglichkeiten zu wissenschaftlicher Literatur als Barrieren abgeleitet werden. Als Förderfaktoren wurden die Unterstützung durch Vorgesetzte sowie die Verfügbarkeit von Ressourcen für die Implementierung des Konzepts identifiziert. Die Umfrageergebnisse von 47 Physiotherapeut*innen ohne Leitungsverantwortung zeigen kumulierte Zustimmungswerte („trifft voll zu“ und „trifft eher zu“) von 83–91 % für die Bereitschaft zur Umsetzung des „science4practice“-Konzepts. Durch die Zusammenführung der quantitativen und qualitativen Daten konnte die Bereitschaft des Teams zur Konzeptumsetzung abschließend als Förderfaktor eingeordnet werden.

Schlussfolgerung Die Studie identifiziert Barrieren und Förderfaktoren aus Sicht der Teilnehmenden mit und ohne Leitungsverantwortung. Einerseits unterstreichen die Daten national und international identifizierte Barrieren wie mangelnde wissenschaftliche Kompetenzen oder unzureichende Zugänge zu wissenschaftlicher Literatur. Andererseits zeigen die Ergebnisse das Potential des Konzepts als EBP-Implementierungsvorhaben in der Physiotherapie in Deutschland. Im nächsten Schritt sollten Studien durchgeführt werden, um die Machbarkeit des Konzepts zu überprüfen.

An integrative review of the qualities of a 'good' physiotherapist

INTRODUCTION

Qualities of a physiotherapist may influence the therapeutic alliance and physiotherapy outcomes. Understanding what qualities constitute a 'good' physiotherapist has yet to be systematically reviewed notwithstanding potentially profound implications for the future practice of physiotherapy.

PURPOSE

The primary purpose of this review was to critically examine how physiotherapists and their patients describe the qualities of a 'good' musculoskeletal physiotherapist as depicted in peer-reviewed literature. The secondary aim was to synthesize qualities represented in the literature, and to compare patient and physiotherapist perspectives.

METHODS

An integrative review methodology was used to undertake a comprehensive literature search, quality appraisal of studies, and thematic analysis of findings. An electronic search of CINAHL, EMBASE, Nursing and Allied Health, PsycINFO, PubMed, and Scopus databases was conducted within a time range from database inception to June 14, 2019.

RESULTS

Twenty-seven studies met the inclusion criteria. Six qualities of a 'good' musculoskeletal physiotherapist were identified as: responsive, ethical, communicative, caring, competent, and collaborative.

CONCLUSIONS

The qualities of a 'good' physiotherapist identified in the review emphasize the human interaction between physiotherapists and patients and point to the centrality of balancing technical competence with a relational way of being.

Effectiveness of a telehealth physiotherapist-delivered intensive dietary weight loss program combined with exercise in people with knee osteoarthritis and overweight or obesity: study protocol for the POWER randomized controlled trial

BACKGROUND

Obesity is associated with knee osteoarthritis (OA). Weight loss, alongside exercise, is a recommended treatment for individuals with knee OA and overweight/obesity. However, many patients cannot access weight loss specialists such as dietitians. Innovative care models expanding roles of other clinicians may increase access to weight loss support for people with knee OA. Physiotherapists may be well placed to deliver such support. This two-group parallel, superiority randomized controlled trial aims to compare a physiotherapist-delivered diet and exercise program to an exercise program alone, over 6 months. The primary hypothesis is that the physiotherapist-delivered diet plus exercise program will lead to greater weight loss than the exercise program.

METHODS

88 participants with painful knee OA and body mass index (BMI) > 27 kg/m² will be recruited from the community. Following baseline assessment, participants will be randomised to either exercise alone or diet plus exercise groups. Participants in the exercise group will have 6 consultations (20-30 min) via videoconference with a physiotherapist over 6 months for a strengthening exercise program, physical activity plan and educational/exercise resources. Participants in the diet plus exercise group will have 6 consultations (50-75 min) via videoconference with a physiotherapist prescribing a ketogenic very low-calorie diet with meal replacements and educational resources to support weight loss and healthy eating, plus the intervention of the exercise only group. Outcomes are measured at baseline and 6 months. The primary outcome is percentage change in body weight measured by a blinded assessor. Secondary outcomes include self-reported knee pain, physical function, global change in knee problems, quality of life, physical activity levels, and internalised weight stigma, as well as BMI, waist circumference, waist-to-hip ratio, physical performance measures and quadriceps strength, measured by a blinded assessor. Additional measures include adherence, adverse events, fidelity and process measures.

DISCUSSION

This trial will determine whether a physiotherapist-delivered diet plus exercise program is more effective for weight loss than an exercise only program. Findings will inform the development and implementation of innovative health service models addressing weight management and exercise for patients with knee OA and overweight/obesity.

TRIAL REGISTRATION

NIH US National Library of Medicine, Clinicaltrials.gov NCT04733053 (Feb 1 2021).

How Individuals With Low Back Pain Conceptualize Their Condition: A Collaborative Modeling Approach

Low back pain (LBP) is complex. This study aimed to use collaborative modeling to evaluate conceptual models that individuals with LBP have of their condition, and to compare these models with those of researchers/clinicians. Twenty-eight individuals with LBP were facilitated to generate mental models, using "fuzzy cognitive maps," that represented conceptualization of their own LBP and LBP "in general." "Components" (ie, causes, outcomes and treatments) related to pain, disability and quality of life were proposed, along with the weighted "Connections" between Components. Components were classified into thematic categories. Weighting of Connections were summed for each Component to judge relative importance. Individual models were aggregated into a metamodel. When considering their own condition, participants' models included 19(SD = 6) Components and 43(18) Connections with greatest weight on "Biomechanical" components. When considering LBP in general, models changed slightly. Patient models contrasted the more complex models of researchers/clinicians (25(7) Components; 77(42) Connections), with most weight on "Psychological" components. This study provides unique insight into how individuals with LBP consider their condition, which is largely biomedical and narrower than clinician/researcher perspectives. Findings highlight challenges for changing public perception of LBP, and provide a method with potential utility to understand how individuals conceptualize their condition. PERSPECTIVE: Collaborative modeling was used to understand how individuals with low back pain conceptualize their own condition, the condition in general, and compare this with models of expert researchers/clinicians. Data revealed issues in how individuals with back pain conceptualize their condition, and the method's potential utility for clinical evaluation of patients.

Patients' Perceptions and Outcome Measures after Undergoing the Enhanced Transtheoretical Model Intervention (ETMI) for Chronic Low Back Pain: A Mixed-Method Study

This study aimed to evaluate the outcome measures and perceptions of patients with chronic low back pain (CLBP) after being treated with the Enhanced Transtheoretical Model Intervention (ETMI). In this process evaluation mixed-methods study, 30 patients with CLBP electronically completed self-reported measures (function, pain, and fear-avoidance beliefs) before and after ETMI treatment. Subsequently, each patient participated in one-on-one, semi-structured interviews, which were audio-recorded, transcribed, coded, and analyzed thematically. Quantitative analysis showed significant improvements in function (p < 0.001), pain (p < 0.001), and fear-avoidance beliefs (p < 0.001) after receiving ETMI treatment, with a large effect size (Cohen’s d = 1.234). Moreover, the average number of physiotherapy sessions was 2.6 ± 0.6 for the ETMI intervention, while the annual average number in Maccabi is estimated at 4.1 ± 1.5. Three main themes emerged from the thematic analysis: (1) communication between the patient and the practitioner; (2) psychosocial treatment elements, and (3) ETMI as a long-term solution for CLBP. The findings of the current study highlight patients’ perceived need for an open and sincere dialogue and for receiving reassurance and encouragement about their LBP. Notably, they had no problem with the fact that they did not receive passive treatment. Accordingly, together with the significant improvement in post-treatment outcome measures, patients perceived the ETMI method as a practical tool for self-managing their back problems in the long term.

People's Experience of Shared Decision Making in Musculoskeletal Physiotherapy: A Systematic Review and Thematic Synthesis

(1) Shared decision making (SDM) has been advocated as a way of improving prudency in healthcare and has been linked to self-efficacy and empowerment of service users. The evaluation of its use in musculoskeletal (MSK) physiotherapy has been vague, but articles suggest that trust and communication are integral. (2) ENTREQ guidelines informed this systematic review and thematic synthesis. PRISMA recommendations steered a systematic literature search of AHMED, CINAHL, MEDLNE, EMBASE and Cochrane databases from inception to September 2021. COREQ was used for quality appraisal of articles alongside critical discussions. Analysis and synthesis included five stages: outlining study characteristics, coding of data, development of descriptive themes, development of analytical themes and integration and refinement. The review aim was to explore people’s experiences of SDM in MSK physiotherapy and to inform our understanding of the conditions needed for successful SDM. (3) Out of 1508 studies, 9 articles were included. Four main themes (trust, communication, decision preferences and decision ability) demonstrated that the majority of people want to participate in decision-making. As described in the capacity and capability model, three core conditions were needed to facilitate someone’s’ ability to participate. (4) People want to be involved in SDM in MSK physiotherapy. For successful SDM, physiotherapists should look to develop mutual trust, utilise two-way communication and share power.

Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study

BACKGROUND

Achilles tendinopathy (AT) is common, and can be traumatic or insidious in onset and short-lasting or persistent in nature. Factors influencing the experience of pain are poorly understood; little is known about mechanisms driving pain and the response (or lack of) to rehabilitation. Despite this, there is a growing body of evidence supporting the use of exercise to manage AT. Interestingly, variation in exercise approach does not appear to significantly impact outcome. Patients' perceptions of factors related to rehabilitation that may influence outcome could provide a valuable addition to help guide future research and practice.

OBJECTIVES

The aim of this study is to gain an insight into patients' experiences of participating in an exercise-based rehabilitation programme for AT.

METHOD

A qualitative interpretive description design. Data generated from semi-structured interviews were analysed thematically using the guidelines set out by Braun and Clarke.

FINDINGS

This is the first study to use a qualitative method of inquiry to gain data on the experiences of people undertaking exercise-based rehabilitation for AT. The four major themes that were identified from the data were: (1) 'understanding the impact' (2) 'expectations' (3) 'what matters' and (4) 'the burden of exercise'.

CONCLUSIONS

Given the uncertainty surrounding the mechanisms of effect of our treatments, the insights provide a platform from which researchers and clinicians can consider further in the management of people with Achilles tendinopathy. Specifically, it has highlighted that patients value a flexible, supportive approach embracing the biopsychosocial impact of AT on the individual.

Patients' prior perceptions and expectations of the Enhanced Transtheoretical Model Intervention for chronic low back pain: A qualitative study

BACKGROUND

The Enhanced Transtheoretical Model Intervention (ETMI) is an approach for treating chronic low back pain (CLBP), which demonstrated clinical and cost-effectiveness outcomes. ETMI highlights reassurance, return to normal activities and encouragement of recreational physical activity. In order to optimally implement ETMI, it is important to gain an understanding of the expectations and perceptions of patients before they engage with the intervention.

OBJECTIVES

To explore CLBP patients' perceptions and expectations of the ETMI method prior to their first consultation with physiotherapist.

METHODS

Qualitative semi-structured interviews were conducted with 30 CLBP patients. The interviews were audio-recorded, transcribed, coded, and analysed thematically. Patients were first asked about their expectations of treatment, then they were asked to comment on the ETMI method.

RESULTS

Three main themes emerged from the interviews: (1) Patient's perceptions of LBP; (2) patient's expectations from current physiotherapy and (3) Patient's expectations from ETMI method. The patients' perceptions of back pain centred on biomechanical causal factors, a desire for diagnostic tests and beliefs that rest cures the pain. Their expectations from current physiotherapy included pain reduction, passive treatment, a structured exercise program and clear information about LBP. In reference to the ETMI method, patients expected pain reduction, practical tools to self-manage, and a combination of ETMI with passive treatment.

CONCLUSION

addressing issues around patient's perceptions and expectations of current physiotherapy and of the ETMI method, prior to their first consultation with physiotherapist, could be beneficial for understanding how to improve the ETMI implementation in the health care system.

Patients' experiences of the BetterBack model of care for low back pain in primary care - a qualitative interview study

Purpose: The aim of this study was to describe patient experiences of received primary care for low back pain (LBP) according to the BetterBack Model of Care (MoC) with a focus on illness beliefs and self-management enablement.

Methods: Individual interviews were conducted with 15 adults 4–14 months after receiving treatment according to the BetterBack MoC for LBP in primary care in Sweden. Data were analysed using content analysis.

Results: When analysing the data, the following theme emerged; “Participant understanding of their treatment for low back pain and self-management strategies—a matter of support systems”, comprising the following categories: “Knowledge translation”, “Interaction and dialogue”, “The health care professional support” and “Form organization”. Participants experienced that they had better knowledge about their LBP and received tools to better manage their health condition. The participants expressed good communication with the treating physiotherapist and provided suggestions to further improve the treatment of LBP.

Conclusions: Participants experienced that they had gained new knowledge about their health problems and after the treatment they had the tools to handle their back problems. This suggests that the BetterBack MoC may be used as a basis for a support system to provide valuable tools for self-management for patients with low back pain.

Exploring factors influencing physiotherapists' perceptions of measuring reactive balance following a theory-based multi-component intervention: a qualitative descriptive study

Purpose: Reactive balance is a critical consideration for mobility and fall avoidance, but is under-assessed among physiotherapists. The objective of this study was to explore factors influencing physiotherapist perceptions about measuring reactive balance upon completion of a 12-month theory-based, multi-component intervention to increase use of a measure of reactive balance.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 28 physiotherapists treating adults with balance impairment in three urban Canadian rehabilitation hospitals that participated in the intervention. Interviews explored perceptions of reactive balance measurement and perceived changes in clinical behavior. Thematic analysis involved multiple rounds of coding, review and discussion, theme generation, and interpretation of findings through individual analysis and team meetings.Findings: Participants expressed contrasting views about integrating reactive balance measurement in their practice, despite consistent acknowledgement of the importance of reactive balance for function. Three themes were identified highlighting factors that mediated perceptions about measuring reactive balance: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Conclusions: The findings highlight that decision making for measuring reactive balance in rehabilitation settings is complex. There is a need for additional work to facilitate long-term implementation of clinical reactive balance measurement, such as refining patient criteria for administration, ensuring sufficient time to establish a trusting relationship, and developing and testing strategies to address physiotherapist fear.IMPLICATIONS FOR REHABILITATIONReactive balance is important for falls prevention and mobility, but is under-assessed among physiotherapists.This study identified three factors that influenced uptake of reactive balance measurement among physiotherapists in rehabilitation settings: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Knowledge of the identified factors may assist with design and use of reactive and other balance measurements.Strategies aimed at developing trusting relationships between physiotherapist and patient along with addressing physiotherapist fear could facilitate the uptake of clinical reactive balance measurement.

Patient-centeredness in Physiotherapy - A literature mapping review

Background and purpose: Research on patient-centeredness within physiotherapy points to a need for clarification about what the concept entails in science and practice and how research positions itself within health care. Thus, the aim is to systematically map the characteristics of research on patient-centeredness in physiotherapy and critically discuss the dominant understandings within. Methods: A systematic research mapping was carried out, based on searches in leading bibliographic databases. Four categories were selected in order to characterize the research field: focus, design, theoretical approach and inherent logic. Findings: Of 5,324 studies, 101 were included in the final mapping, pointing to a limited amount of research. The papers included were published in 47 different journals. Two major research foci emerges: one testing or developing technologies (tools) to promote patient-centeredness and one exploring patients' or professionals' experiences related to physiotherapy practice. Most papers reported on empirical research and there seems to be a dearth of conceptual papers. The theoretical approaches applied were mainly psychological, pedagogical and biomedical. The papers included were divided into equal amounts of studies carried out within inherent logics of causality and complexity. Conclusion: The mapping suggests an incipient awareness of patient-centeredness within the research field of physiotherapy. Empirical studies dominate the field, whereas conceptual and critical papers seem in need of wider acknowledgment. The research field is divided into two mutually disconnected trends: one concerned with understanding the complexity of clinical practice and patients' experiences of treatment and illness, and another trend concerned with solving "the problem" of patient involvement.

'He explains it in a way that I have confidence he knows what he is doing': A qualitative study of patients' experiences and perspectives of rotator-cuff-related shoulder pain education

BACKGROUND

Patient education is recommended in clinical practice guidelines for rotator-cuff-related shoulder pain (RCRSP), yet there are no guidelines for clinicians. A gap in the current literature relates to patients' perspectives.

AIMS

The aim of this study was to explore the experiences and perspectives of people with RCRSP about education for their condition.

MATERIALS AND METHODS

An inductive qualitative design was adopted. Eight participants with RCRSP participated in individual telephone interviews that were audio-recorded, transcribed and de-identified. Four researchers completed inductive thematic analysis. Institutional ethics approval was obtained.

RESULTS

Results are detailed as a thematic analysis from the interview responses. Three primary themes were identified: (1) a therapeutic alliance leads to trust of education; (2) education of RCRSP should be individualized and practical; and (3) delivery of educational interventions should be varied and multi-modal.

DISCUSSION

The results demonstrated that trust in the health professional providing the education facilitates adherence and increases belief that the condition is being effectively treated. Participants believed imaging were necessary for an individual diagnosis despite clinical practice guidelines not recommending imaging for the first 6-12 weeks of initial presentation. There was a general caution about generic online information which may adversely impact the value of exclusively online educational intervention in the future. Participants preferred clear and practical education about RCRSP, including activity modification, timeframes for recovery and potential detriments to their recovery. There was consensus that education is best delivered early in the rehabilitation process, however there were mixed preferences for delivery method between written, video and face-to-face which perhaps reflects different learning styles and indicates that a 'one size fits all' approach is not effective in adult education in this condition.

CONCLUSION

People with RCRSP believe education about their condition is important and is best delivered by a trusted source early in their rehabilitation. There is a belief that scans are necessary to provide an individualized diagnosis and assists in their understanding of the condition. There is an opportunity for online education; however, this may best be utilised as an adjunct method to face-to-face care.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain (PREVSAM): a randomised controlled trial protocol

BACKGROUND

Musculoskeletal pain is globally a leading cause of physical disability. Many musculoskeletal-related pain conditions, such as low back pain, often resolve spontaneously. In some individuals, pain may recur or persist, leading to ong-term physical disability, reduced work capacity, and sickness absence. Early identification of individuals in which this may occur, is essential for preventing or reducing the risk of developing persistent musculoskeletal pain and long-term sickness absence. The aim of the trial described in this protocol is to evaluate effects of an early intervention, the PREVSAM model, on the prevention of sickness absence and development of persistent pain in at-risk patients with musculoskeletal pain.

METHODS

Eligible participants are adults who seek health care for musculoskeletal pain and who are at risk of developing persistent pain, physical disability, and sickness absence. Participants may be recruited from primary care rehabilitation centres or primary care healthcare centres in Region Västra Götaland. Participants will be randomised to treatment according to the PREVSAM model (intervention group) or treatment as usual (control group). The PREVSAM model comprises an interdisciplinary, person-centred rehabilitation programme, including coordinated measures within primary health care, and may include collaboration with participants' employers. The primary outcome sickness absence is operationalised as the number and proportion of individuals who remain in full- or part-time work, the number of gross and net days of sickness absence during the intervention and follow-up period, and time to first sickness absence spell. Secondary outcomes are patient-reported short-term sickness absence, work ability, pain, self-efficacy, health-related quality of life, risk for sickness absence, anxiety and depression symptoms and physical disability at 1 and 3 months after inclusion (short-term follow-up), and at 6 and 12 months (long-term follow-up). A cost-effectiveness analysis is planned and drug consumption will be investigated.

DISCUSSION

The study is expected to provide new knowledge on the effectiveness of a comprehensive rehabilitation model that incorporates early identification of patients with musculoskeletal pain at risk for development of sickness absence and persistent pain. The study findings may contribute to more effective rehabilitation processes of this large patient population, and potentially reduce sickness absence and costs.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol ID: NCT03913325 , Registered April 12, 2019. Version 2, 10 July 2020. Version 2 changes: Clarifications regarding trial aim and inclusion process.

Reflections of older people about their experience of fall prevention exercise in the community- a qualitative study exploring evidence-based practice

BACKGROUND

Evidence-based practice (EBP) ensures that clinicians use effective interventions to achieve desired outcomes, thereby contributing to the best quality of care. The perspective of the participants is fundamental in EBP, as they have their own individual and meaningful rationale for participating in fall prevention. This study aims to explore community-dwelling older people reflections about their reflections about EBP in physiotherapy based on their experiences of a fall prevention exercise program.

METHODS

We conducted semi-structured interviews with 16 community-dwelling older people (men = 7; women = 9). Data were analyzed using thematic analysis.

RESULTS

The analysis revealed three themes: 1) the tension between knowing and doing, 2) the power of the therapist-participant relationship and the process of putting knowledge into action, and 3) research is interwoven with successful therapy and is an integral component of it. EBP was considered as a collective negotiation and learning process of creating knowledge for clinical practice. The negotiation between different types of knowledge must be performed in a transparent dialogue and through interactive collaboration between the persons involved. The participants appreciated that the research findings indicate that practice gives results.

CONCLUSIONS

EBP was understood and utilized as a seal of approval and a "guarantee of high quality" treatment, and its effects varied based on older people's preferences, needs, and skills. The therapist's relational competence appeared to be crucial for the negotiation of various sources of knowledge relative to the older people's preferences.

Preferences of people with Type 2 diabetes for diabetes care: a discrete choice experiment

AIMS

Limited knowledge exists on the preferences of people with Type 2 diabetes towards diabetes care. Consequently, these care preferences cannot yet be considered in the development of tailored diabetes care approaches. Therefore, this study aimed to assess care preferences and their determinants in people with Type 2 diabetes.

METHODS

A discrete choice experiment was conducted to elicit people's preferences. People with Type 2 diabetes, treated in 30 Dutch primary care practices, were asked to choose repeatedly between two hypothetical diabetes care packages, which differed in six attributes: role division in daily diabetes care planning, lifestyle education method, type of medication management support, consultation frequency, emotional support and time spend on self-management. A mixed-logit model was used to estimate the relative importance of the included attributes. Preference heterogeneity among people with different person- and disease-related characteristics was investigated.

RESULTS

In total, 288 participants completed the experiment. They preferred to plan their daily diabetes care together with a healthcare provider, to receive individual lifestyle education, medication and emotional support from a healthcare provider, one consultation visit every 3 months and to spend less time on self-management. Participants did not prefer to receive emotional support from a psychologist. Heterogeneity in preferences could partly be explained by differences in sex, education level and glucose-lowering drug use.

CONCLUSION

People with Type 2 diabetes show a preference for traditional care models. Emotional support was identified by participants as the most important attribute. It is therefore important to adequately guide them when changes in diabetes care organization are implemented.

Patient values in physiotherapy practice, a qualitative study

OBJECTIVES

Physiotherapy is, like all healthcare professions, relational and value-laden. Patient-centred care, evidence-based practice and value-based practices are concepts in which patient values lie at the heart of high-quality healthcare practices. Nevertheless, physiotherapists have limited awareness of what patient values are in the physiotherapy encounter. The purpose of this study is to explore these patient values.

METHODS

A qualitative study design using content analysis was used involving 17 adult participants with chronic or recurrent musculoskeletal pain. Data were collected during July 2015-July 2016 in three primary care physiotherapy facilities in Rotterdam, The Netherlands. Two researchers analysed the interviews and derived relevant codes from the data. After an iterative process of comparing, analysing, conceptualizing, and discussing the data, a pre-existing analytic framework was refined in which distinct values were delineated.

RESULTS

Emerging patient values were encompassed in three themes, each consisting of two to four elements: (1) values about oneself (uniqueness and autonomy), (2) values regarding actions of the professional (technically skilled professional, conscientious professional, compassionate professional, responsive professional) and (3) values regarding interactions between patients and the professionals (partnership and empowerment).

CONCLUSION

This study emphasizes the need for discussing patient values in the clinical encounter and helps physiotherapists to understand what deems to be important for patients with musculoskeletal pain in physiotherapy practice. The results of this study contribute to the existing body of knowledge of this important aspect of the quality of physiotherapy practice and may inspire clinicians and educators to actively implement patient values in clinical practice and the physiotherapy education.

Do patients with low back pain remember physiotherapists' advice? A mixed-methods study on patient-therapist communication

OBJECTIVES

The primary aim of this study was to determine if the advice physiotherapists think they provide to patients with low back pain (LBP) is what the patients remember and take away from the clinical encounter. The secondary aim was to determine which factors may influence the retention of this advice.

METHODS

The first component of the study used questionnaires completed by patients and therapists after the initial visit. Related questionnaires of patients and therapists were screened for inconsistencies. The second component of the study involved semi-structured interviews.

RESULTS

Ninety pairs of questionnaires were completed. Therapists provided patients with one (N = 90), two (N = 85) or three (N = 51) items of advice regarding the management of their LBP. All patients remembered the first item of advice, 92% remembered a second, and 67% remembered the third piece of advice. All items of advice were deemed either 'relevant' or 'very relevant' by 97% of the patients. After the analysis of 14 interviews, data saturation was reached. Four themes emerged from the data analysis of the interviews: (a) Evaluation type, (b) Exercise factors, (c) Patient concerns about their diagnosis, and (d) Patient expectations.

DISCUSSION

In most cases, patients remembered what therapists told them and considered that the advice provided was relevant. Based on the qualitative data, patients were more likely to remember what therapists said when: (a) shared decision making was used during the initial encounter, (b) prescribed exercises were simple to perform and few in number, (c) patients' concerns about their diagnosis were addressed, and (d) patients' expectations were identified and addressed.

Twenty-five years after the introduction of Evidence-based Medicine: knowledge, use, attitudes and barriers among physiotherapists in Italy - a cross-sectional study

OBJECTIVES

To explore the knowledge, use, attitudes towards Evidence-based Medicine, also known as Evidence-based Practice (EBP), and perceived barriers to its dissemination among physiotherapists.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Members of the Italian Association of Physiotherapists (n=2000) were invited to participate in an online survey about EBP knowledge and use.

PRIMARY OUTCOME MEASURES

The survey questionnaire comprised four sections: (1) respondent characteristics; (2) knowledge of EBP principles; (3) attitude, use and perceived effectiveness of EBP; (4) perceived barriers to implementing EBP in clinical practice.

RESULTS

Out of 2000 physiotherapists, 1289 participated in the survey (64.5% response rate). Overall, 90% perceived EBP as useful and necessary for their clinical practice. More than 85% stated that they were familiar with the principles of EBP, 75% reported that they were able to search online databases for relevant information and 60% reported that they were able to understand statistical analyses. However, 56% believed that patient preferences and 39% that clinical expertise are not part of the EBP model. Half stated that they understood and could explain the term 'meta-analysis' but only 17% knew what a forest plot is and just 20% correctly judged the finding of a given meta-analysis. Lack of time was reported as the main barrier to EBP.

CONCLUSION

The majority of Italian physiotherapists overrated their knowledge about EBP, demonstrating a gap between perceived and actual knowledge of EBP in this population.

Self-evaluated ethical competence of a practicing physiotherapist: a national study in Finland

Background

Patients have the right to equal, respectful treatment. Nowadays, one third of patient complaints concern health care staff’s behavior towards patients. Ethically safe care requires ethical competence, which has been addressed as a core competence in physiotherapy. It has been defined in terms of character strength, ethical awareness, moral judgment skills in decision-making, and willingness to do good. The purpose of this study was to analyze the ethical competence of practicing physiotherapists.

Method

A self-evaluation instrument (Physiotherapist’s Ethical Competence Evaluation Tool) based on an analysis of a concept “ethical competence” was constructed in 2016 and physiotherapists (n = 839), working in public health services or private practice responded to the questionnaire.

Results

Based on the results, most of the physiotherapists evaluated themselves highly ethically competent in all areas of ethical competence, subscales being Strength, Awareness, Skills and Will. Willingness to do good was evaluated as highest, while character strength, including the strength to support ethical processes and speak on behalf of the patient, was evaluated the lowest. Physiotherapists most commonly consult a colleague when encountering an ethical problem. Other methods for problem solving are not very familiar, neither are the international or national ethical codes of conduct.

Conclusions

This was the first attempt to assess all aspects of ethical competence empirically in a clinical environment in physiotherapy, using a novel self-evaluation instrument. Even if physiotherapists evaluate themselves as competent in ethics, further exploration is needed for ethical awareness. Also the patients’ viewpoints about ethically competent care should be considered, to better ensure ethical safety of the patient.

Challenges in promoting clinical empathy skills in medical students: A content analysis study

Background: Empathy is a key clinical skill in the medical profession, and many studies have reported a decline in it among medical students during their years of education; especially, in the clinical stage, and this affective decline persists in the physician-hood. This study aimed to explore the participants' perceptions about challenges for promoting clinical empathy in training stages. Methods: A qualitative design using content analysis was applied. Semi-structured interviews were applied to obtain data. Individual interviews were conducted with 14 interns and six clinical professors. The data were analyzed through conventional content analysis and the credibility, trustworthiness, and conformability of the data were confirmed. Results: Data analysis led to the extraction of two main categories, including overt and covert challenges, and also four categories and nine sub-categories. Conclusion: Resolving clinical empathy challenges in medical students requires financial and human resources, and training on the principles of effective doctor-patient interactions. Furthermore, professionalism should be strengthened in professors, and both official and hidden curricula should be revised accordingly.