Beyond pain and disability: an explanatory mixed methods study exploring outcomes after physiotherapy intervention in patients with chronic low back pain

Patient acceptance of care of a novel care pathway for those at risk of poor outcomes from musculoskeletal pain: A mixed methods study

OBJECTIVE

Investigate people's acceptance of specialist musculoskeletal care within a new care pathway for common musculoskeletal conditions (low back pain, neck pain/whiplash, knee osteoarthritis).

DESIGN

Convergent parallel mixed methods design referencing the Theoretical Framework of Acceptability. The study included a subset of participants (n = 29) at-risk of poor outcomes from the intervention arm of the PAthway of CarE for common musculoskeletal conditions (PACE-MSK) trial. In the PACE-MSK arm, participants received specialist physiotherapist care as an adjunct to the care provided by their primary healthcare professional(s). One-to-one semi-structured interviews were conducted around 3-months after commencing in the trial. Quantitative data were collected at baseline and 3-month follow-up (health-related quality of life, pain self-efficacy, global perceived change, satisfaction).

RESULTS

Five themes were identified (Expectations and beliefs shaped patient experience; Clinical expertise and competence influence acceptance; Person-centred care; Mechanisms facilitating beneficial responses to care; Gaps in care pathway implementation). There were positive individual changes in physical quality of life for 17/29 (59%) participants, mental health quality of life for 12/29 (41%), pain self-efficacy for 8/29 (28%) and global perceived change for 19/29 (66%). Management met expectations with the majority reporting high levels of satisfaction. Integrating the qualitative and quantitative data with the Theoretical Framework of Acceptability, there were complementary meta-inferences in the constructs of 'ethicality', 'intervention coherence', 'self-efficacy' and 'affective attitude'. Divergence was identified in 'perceived effectiveness'.

DISCUSSION

In general, there was positive acceptance of the care pathway by participants. Specialist physiotherapists' care was perceived as a positive addition to usual care.

The concept of integration in mixed methods research: a step-by-step guide using an example study in physiotherapy

BACKGROUND

Integration is a unique attribute of Mixed Methods Research (MMR). However, some MMR studies, published in the field of physiotherapy and other allied health professions, have illustrated a lack of understanding of the concept of integration.

AIMS

The purpose of this paper is to provide guidance for integrating elements of mixed methods research in order to effectively support evidence-based practice in health.

METHODS

The concept of integration of findings is explained with reference to the author's recent PhD study, which used a mixed methods exploratory sequential design. This article describes how the author used a narrative joint display to integrate findings from both the qualitative and survey phases of the study. Then, a step-by-step approach is introduced to guide the interpretation and integration of the findings.

RESULTS

This four-step approach demonstrates integration of the two different datasets: Creating a joint display, linking activity, establishing relationships, and interpreting and reporting. Tables and Figures are used to support detailed description and illustration of the integration process.

DISCUSSION

A joint display provides a visual representation of how the qualitative and quantitative findings in a MMR study can be integrated. In this way, interpretation of the data drawn from this process extend beyond the individual findings of each study component to facilitate a greater understanding of complex health care issues.

Psychological, Pain, and Disability Factors Influencing the Perception of Improvement/Recovery from Physiotherapy in Patients with Chronic Musculoskeletal Pain: A Cross-Sectional Study

OBJECTIVES

The aim of this study was to identify the possible relationships between psychological, pain, and disability variables with respect to the perception of change/recovery from physiotherapy in patients with chronic musculoskeletal pain (CMP).

METHODS

A cross-sectional observational study was performed with 150 patients. All patients completed a series of self-administered questionnaires and a series of self-reports to quantify the perception of change with respect to the physiotherapy they underwent, the level of disability and pain intensity, the level of fear of movement, the level of catastrophism, the degree of self-efficacy, the level of therapeutic alliance and their adherence to the physiotherapy.

RESULTS

The strongest correlations were between the subjective perception of change and the number of sessions, treatment beliefs, self-efficacy, pain intensity, collaboration, and bonding. The linear regression model showed that the number of sessions, treatment beliefs, self-efficacy, compliance, pain intensity, and bonding were predictors of subjective perception of improvement, with 50% of the variance.

CONCLUSIONS

Treatment beliefs, therapeutic alliance, degree of self-efficacy, and pain intensity have been shown to be predictors of a subjective perception of improvement in patients with CMP. In turn, multimodal treatments had the greatest positive impact on the subjective perception of improvement.

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.

Use of the PROMIS-10 global health in patients with chronic low back pain in outpatient physical therapy: a retrospective cohort study

Background

Although evidence-based guidelines for physical therapy for patients with chronic low back pain (cLBP) are available, selecting patient-reported outcome measures to capture complexity of health status and quality of life remains a challenge. PROMIS-10 Global Health (GH) may be used to screen for impactful health risks and enable patient-centered care. The purpose of this study was to investigate the interrelationships between PROMIS-10 GH scores and patient demographics, health status, and healthcare utilization in patients with cLBP who received physical therapy.

Methods

A retrospective review of de-identified electronic health records of patients with cLBP was performed. Data were collected for 328 patients seen from 2017 to 2020 in three physical therapy clinics. Patients were grouped into HIGH and LOW initial assessment scores on the PROMIS-10 Global Physical Health (PH) and Global Mental Health (MH) measures. Outcomes of interest were patient demographics, health status, and healthcare utilization. Mann–Whitney U and chi-square tests were used to determine differences between groups, and binary logistic regression was used to calculate odds ratios (OR) to determine predictors of PH-LOW and MH-LOW group assignments.

Results

The PH-LOW and MH-LOW groups contained larger proportions of patients who were African American, non-Hispanic, and non-commercially insured compared to PH-HIGH and MH-HIGH groups (p < .05). The PH-LOW and MH-LOW groups also had a higher Charlson comorbidity index (CCI), higher rates of diabetes and depression, and more appointment cancellations or no-shows (p < .05). African American race (OR 2.54), other race (2.01), having Medi-Cal insurance (OR 3.37), and higher CCI scores (OR 1.55) increased the likelihood of being in the PH-LOW group. African American race (OR 3.54), having Medi-Cal insurance (OR 2.19), depression (OR 3.15), kidney disease (OR 2.66), and chronic obstructive pulmonary disease (OR 1.92) all increased the likeihood of being in the MH-LOW group.

Conclusions

Our study identified groups of patients with cLBP who are more likely to have lower PH and MH scores. PROMIS-10 GH provides an opportunity to capture and identify quality of life and global health risks in patients with cLBP. Using PROMIS-10 in physical therapy practice could help identify psychosocial factors and quality of life in the population with cLBP.

Pain reduction induced by tapentadol in patients with musculoskeletal chronic pain fosters better sleep quality

Background

Poor sleep may predict the increase and intensification of pain over time with increased insomnia symptoms being both a predictor and an indicator of worse pain outcomes and physical functioning status over time. However, the impact of different analgesic therapies on quality of life, functional recovery and sleep has been poorly assessed to date, whereas these evaluations may greatly help clinicians in the selection of treatment when dealing with patients with chronic pain (CP).

Methods

To explore whether tapentadol-induced pain relief may drive improved sleep quality, we carried out a pooled analysis of real-world data collected from 487 patients with CP (mean age, 68.3 years; 57.7% women) suffering from a wide range of chronic musculoskeletal pain conditions and treated with tapentadol.

Results

Following tapentadol treatment, patients experienced an 80% reduction in the frequency of very disturbed sleep as well as a 50% reduction in the predominant sleep complaint reported by patients with CP - that is, nocturnal awakenings. A significantly greater proportion of patients reported good/restful sleep at the end of the study period compared to baseline (72.4% versus 25.3%; p<0.01). This benefit was observed regardless of the clinical setting, treatment duration, posology or patient age and was associated with a higher proportion of patients reporting an improved global health status and good tolerability.

Conclusion

The reduction in pain intensity provided by tapentadol fosters sleep quality and favours a better quality of life. Therefore, our findings provide the rationale for addressing sleep quality as a relevant outcome, complementary to pain relief in CP management.