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

Efficacy of cognitive functional therapy in patients with low back pain: A systematic review and meta-analysis

BACKGROUND

Low back pain is a major public health problem worldwide, and there exists evidence that cognitive functional therapy may help improve patients' health condition. However, the utilization of cognitive functional therapy for low back pain is limited, and its clinical efficacy remains unclear.

OBJECTIVES

To determine the efficacy of cognitive functional therapy in the management of disability, pain intensity, and fear-avoidance beliefs in low back pain patients.

DESIGN

Systematic review and meta-analysis.

METHOD

A comprehensive study search of Pubmed, Web of Science, Medline, CINAHL, Embase, PsycINFO, and the Cochrane Library databases was conducted from their inception to August 14th, 2023. Two researchers independently conducted the literature search and data extraction. All statistical analysis was performed using Stata Version 17.0.

RESULTS

A total of eight randomized controlled trials were included. In the short-term, cognitive functional therapy significantly improved disability (7 studies, SMD = -1.05, 95 % CI = -1.74 to -0.35, I2 = 95.37 %, GRADE = very low), pain intensity (7 studies, SMD = -1.02, 95 % CI = -1.89 to -0.15, I2 = 97.21 %, GRADE = very low), and fear-avoidance beliefs (4 studies, SMD = -0.89, 95 % CI = -1.30 to -0.47, I2 = 82.49 %, GRADE = very low). In the medium-term, cognitive functional therapy also significantly improved disability (3 studies, SMD = -0.48, 95 % CI = -0.82 to -0.14, I2 = 77.97 %, GRADE = very low), pain intensity (3 studies, SMD = -0.34, 95 % CI = -0.58 to -0.10, I2 = 55.55 %, GRADE = very low), and fear-avoidance beliefs (2 studies, SMD = -0.62, 95 % CI = -1.19 to -0.04, I2 = 88.24 %, GRADE = very low). In the long-term, cognitive functional therapy significantly improved disability (4 studies, SMD = -0.54, 95 % CI = -0.95 to -0.13, I2 = 85.87 %, GRADE = very low) and fear-avoidance beliefs (3 studies, SMD = -0.76, 95 % CI = -1.17 to -0.34, I2 = 80.34 %, GRADE = very low).

CONCLUSION

Cognitive functional therapy might be effective in reducing disability and fear-avoidance beliefs at any of short-, medium- and long-term follow-ups, and reducing pain at short- and medium-term follow-ups. No definitive conclusions can be drawn about the impact of cognitive functional therapy on low back pain patients due to the very low certainty evidence base. Additional rigorous randomized controlled trials are needed to further confirm these findings.

REGISTRATION NUMBER

CRD42022287123 (PROSPERO).

Personalized assessment and management of non-specific low back pain

BACKGROUND AND OBJECTIVE

Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients.

DATABASES AND DATA TREATMENT

Narrative review.

RESULTS

NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively.

CONCLUSIONS

The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient.

SIGNIFICANCE STATEMENT

Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.

Building bespoke exercise: The clinical reasoning processes of physiotherapists when prescribing exercise for persons with musculoskeletal disorders

AIMS

This qualitative study aimed to explore physiotherapists' clinical reasoning when prescribing exercise for persons with musculoskeletal disorders.

METHODS

A constructivist grounded theory inspired methodological approach was used. Six physiotherapists working in the United Kingdom were recruited via purposive sampling. Data collection and analysis included semi-structured interviews, memo writing, coding, and a constant comparative method.

FINDINGS

A concept of 'building bespoke exercise' has been generated to conceptualise the participants' clinical reasoning when prescribing exercise.

CONCLUSION

The findings of this study highlight processes of co-designing and co-constructing exercise programmes in collaboration with persons receiving care. Physiotherapists can use this study to reflect on their own clinical reasoning to inform their own practice.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain

BACKGROUND

Movement and posture are commonly believed to relate to low back pain (LBP). Yet, we know little about how people make sense of the relationship between their LBP, movement and posture, particularly after recovery. We aimed to qualitatively explore this understanding, how it changes and how it relates to quantitative changes.

METHODS

A mixed method study in the context of an existing single-case design involving 12 people with disabling non-specific LBP. Interviews were conducted before and after a 12-week physiotherapy-led Cognitive Functional Therapy intervention, and qualitative findings from these were integrated with individualized, quantitative measures of movement, posture, psychological factors, pain and activity limitation.

RESULTS

Strong beliefs about movement and posture were identified during the baseline interviews. Lived experiences of tension and stiffness characterized the embodiment of 'nonconscious protection', while healthcare and societal messages prompted pain-related fear and 'conscious protection'. Through varied journeys, most participants reported improvements over time with less protective movement and postural strategies. For some, being less protective required focused attention ('conscious non-protection'), but most returned to automatic, normal and fearless patterns ('nonconscious non-protection'), forgetting about their LBP. One participant reported no meaningful shift, remaining protective. Greater spinal range, faster movement, more relaxed postures and less back muscle EMG accompanied positive changes in self-report factors.

CONCLUSION

The findings offer a framework for understanding how people make sense of movement and posture during the process of recovery from persistent, disabling non-specific LBP. This involved a re-conceptualisation of movement and posture, from threatening, to therapeutic.

SIGNIFICANCE

Findings from qualitative interviews before and after a Cognitive Functional Therapy intervention in 12 people with disabling low back pain highlighted an individualized recovery journey from conscious and nonconscious protection to conscious non-protection for some, and nonconscious non-protection for many. Pre and post-quantitative measures of movement, posture, psychological factors, pain and activity limitation integrated well with the qualitative findings. The findings suggest movement and posture may form part of a multidimensional pain schema.

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care

ABSTRACT

What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

Kindness, Listening, and Connection: Patient and Clinician Key Requirements for Emotional Support in Chronic and Complex Care

Emotional support for patients is critical for achieving person-centered care. However, the literature evidences an ongoing challenge in embedding emotional support within current health services. This study aimed to investigate the strategies to embed emotional support from the perspectives of patients and clinicians. This is an exploratory qualitative study that collected data through focus group discussions (FGDs) and interviews from 11 patients, 2 carers, and 7 clinicians in the multi-disciplinary care teams in an outpatient complex and chronic care setting in New South Wales, Australia. The FGDs and interviews were recorded, transcribed, and thematically analyzed. Three main themes emerged from the experience of both the patients and clinicians: (1) warmth and kindness, (2) deep listening, and (3) social connection in the process of treatment. Clinicians’ and patients’ shared experience of these themes was key to embed emotional support in care. Practical strategies including promoting shared understanding of emotional support, enhancing provider's capability to deliver emotional support, and building patient's networking opportunities in treatment processes were discussed to facilitate emotional support in patient care and health services.

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain

Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety-learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing Cognitive Functional Therapy to promote safety learning. A process is described in which experiential learning combined with "sense making" disrupts a person's unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.

Physiotherapists' knowledge, attitude and practice behavior to prevent chronification in patients with non-specific, non-traumatic, acute- and subacute neck pain: A qualitative study

BACKGROUND

The purpose of this study was to explore physiotherapists' knowledge, attitude, and practice behavior in assessing and managing patients with non-specific, non-traumatic, acute- and subacute neck pain, with a focus on prognostic factors for chronification.

METHOD

A qualitative study using in-depth semi-structured interviews was conducted with 13 physiotherapists working in primary care. A purposive sampling method served to seek the broadest perspectives. The knowledge-attitude and practice framework was used as an analytic lens throughout the process. Textual data were analyzed using qualitative content analysis with an inductive approach and constant comparison.

RESULTS

Seven main themes emerged from the data; physiotherapists self-estimated knowledge and attitude, role clarity, therapeutic relationship, internal- and external barriers to practice behavior, physiotherapists' practice behaviors, and self-reflection. These findings are presented in an adjusted knowledge-attitude and practice behavior framework.

CONCLUSION

A complex relationship was found between a physiotherapist's knowledge about, attitude, and practice behavior concerning the diagnostic process and interventions for non-specific, non-traumatic, acute, and subacute neck pain. Overall, physiotherapists used a biopsychosocial view of patients with non-specific neck pain. Physiotherapists' practice behaviors was influenced by individual attitudes towards their professional role and therapeutic relationship with the patient, and individual knowledge and skills, personal routines and habits, the feeling of powerlessness to modify patients' external factors, and patients' lack of willingness to a biopsychosocial approach influenced physiotherapists' clinical decisions. In addition, we found self-reflection to have an essential role in developing self-estimated knowledge and change in attitude towards their therapeutic role and therapist-patient relationship.