Measuring verbal communication in initial physical therapy encounters

Qualitative exploration of physical therapists' experiences providing telehealth physical therapy during COVID-19

BACKGROUND

Physical therapists are trained to provide treatment to patients through a mixture of strategies. The coronavirus (COVID-19) pandemic resulted in social distancing restrictions, and physical therapists, some without previous experience, adopted telehealth physical therapy modalities to treat their patients.

OBJECTIVES

The objective of this study was to explore physical therapists' experiences of providing telehealth physical therapy during the COVID-19 pandemic.

DESIGN AND METHODS

A multisite qualitative semi-structured interview study was conducted. Seventeen physical therapists were interviewed by videoconference or by phone, and the interviews were transcribed and analyzed thematically.

RESULTS

Three main themes emerged from the study. Firstly, physical therapists experienced professional challenges with diagnosing and treating patients hands-off and becoming more verbal. Secondly, telehealth physical therapy was perceived as not feasible or effective for certain patients, attesting to the digital care divide. Lastly, participants' perceptions of patient-therapist communication varied, expressing both communicative advantages and challenges.

CONCLUSIONS

Physical therapists who practiced telehealth physical therapy during the COVID-19 period experienced information and communication technology as professionally challenging. Physical therapists adapted positively to the use of telehealth physical therapy but perceived that not every patient could benefit from it. The study emphasized the need for a better understanding of physical therapists' hands-off skills for practicing telehealth physical therapy and considers the need to establish a patient classification for telehealth physical therapy.

Limited health literacy in primary care physiotherapy: Does a physiotherapist use techniques to improve communication?

OBJECTIVES

Research shows that health professionals should adapt their communication when addressing patients with limited health literacy (HL). However, the extent to which physiotherapists apply recommended communication techniques is unclear.

METHODS

We conducted a two phase mixed-method study, first holding focus group interviews among patients and experts on communication to explore the need for adjusted communication in physiotherapist-patient interaction. Second, we manually coded audio recordings of primary care physiotherapy consultations to investigate the extent to which physiotherapists applied these recommended communication techniques, and adjusted their communication towards patients with lower education.

RESULTS

Focus group interviews identified four categories of communication elements: the teach-back method, medical jargon explanation, summarizing patient's narratives, and checking patient's understanding. In 50 audio recordings we identified 2670 clauses. We report limited use of the recommended communication techniques; the teach-back method was used in 2% of consultations (95%CI: 0.4%-10.5%) while medical jargon explanation was used in 84% (95%CI: 71.5%-91.7%). Mixed effects logistic regression models showed no association between lower education and communication techniques.

CONCLUSION

Although physiotherapists need to adjust their communication to patients with lower education, they rarely apply the recommended communication techniques.

PRACTICE IMPLICATIONS

Knowledge about limited HL among physiotherapists needs to be increased.

Repetitions in online doctor-patient communication: Frequency, functions, and reasons

OBJECTIVES

To attain insights into language repetition during online doctor-patient communication (DPC), understand why doctors and patients use repetition, and improve the current deficiencies in online medical platforms.

METHODS

The study performed a content analysis of 72 sets of textual doctor-patient conversations on the Chinese online medical consultation platform Chunyu Doctor.

RESULTS

Repetitions occurred 1412 times in the 72 sets of online DPC. Patient self-repetitions were the most prevalent (30.7 %), while patient repetitions of doctors were the least common (17.1 %). Doctors used repetitions for explanations and affirmations. Patients used repetition for emphasis, verification, and turn-taking. The repetition frequencies of doctors and patients were primarily influenced by personal factors. However, doctor-dimension factors exerted a greater impact on the frequency of patient repetitions.

CONCLUSIONS

The reasons for repetitions in online DPC differ from those offline. Online DPC increases patient initiative and reduces doctor authority. Nevertheless, it could be affected by gender stereotypes generated during offline consultations. Doctors still dominated the conversations but attended sufficiently to the patient discourse. Online DPC is gradually attempting to fulfill the expectations of a new patient-centered healthcare pattern.

PRACTICAL IMPLICATIONS

The findings yield suggestions for healthcare providers and the designers of online healthcare platforms.

Complexity theory in the management of patients with musculoskeletal pain

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients’ health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of virtual consultations in an orthopaedic rehabilitation setting: how do changes in the work of being a patient influence patient preferences? A systematic review and qualitative synthesis

OBJECTIVES

To systematically review qualitative studies reporting the use of virtual consultations within an orthopaedic rehabilitation setting and to understand how its use changes the work required of patients.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, we conducted a systematic review of papers to answer the research question 'How do changes in the work of being a patient when using communication technology influence patient preferences?' Electronic databases were searched for studies meeting the inclusion criteria in April 2020.

RESULTS

The search strategy identified 2057 research articles from the database search. A review of titles and abstracts using the inclusion criteria yielded 21 articles for full-text review. Nine studies were included in the final analysis. Six studies explored real-time video conferencing and three explored telephone consultations. The use of communication technology changes the work required of patients. Such changes will impact on expectations for care, resources required of patients, the environment of receiving care and patient-clinician interactions. This adjustment of the work required of patients who access orthopaedic rehabilitation using communication technology will impact on their experience of receiving care. It is proposed that changes in the work of being a patient will influence preferences for or against the use of communication technology consultations for orthopaedic rehabilitation.

CONCLUSION

We found that the use of communication technology changes the work of being a patient. The change in work required of patients can be both burdensome (it makes it harder for patients to access their care) and beneficial (it makes it easier for patients to access their care). This change will likely to influence preferences. Keeping the concept of patient work at the heart of pathway redesign is likely to be a key consideration to ensure successful implementation.

PROSPERO REGISTRATION NUMBER

CRD42018100896.

Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy

Background

Placebo and nocebo effects embody psychoneurobiological phenomena where behavioural, neurophysiological, perceptive and cognitive changes occur during the therapeutic encounter in the healthcare context. Placebo effects are produced by a positive healthcare context; while nocebo effects are consequences of negative healthcare context. Historically, placebo, nocebo and context-related effects were considered as confounding elements for clinicians and researchers. In the last two decades this attitude started to change, and the understanding of the value of these effects has increased. Despite the growing interest, the knowledge and the awareness of using the healthcare context to trigger placebo and nocebo effects is currently limited and heterogeneous among physiotherapists, reducing their translational value in the physiotherapy field.

Objectives

To introduce the placebo, nocebo and context-related effects by: (1) presenting their psychological models; (2) describing their neurophysiological mechanisms; (3) underlining their impact for the physiotherapy profession; and (4) tracing lines for future researches.

Conclusion

Several psychological mechanisms are involved in placebo, nocebo and context-related effects; including expectation, learning processes (classical conditioning and observational learning), reinforced expectations, mindset and personality traits. The neurophysiological mechanisms mainly include the endogenous opioid, the endocannabinoid and the dopaminergic systems. Neuroimaging studies have identified different brain regions involved such as the dorsolateral prefrontal cortex, the rostral anterior cingulate cortex, the periaqueductal gray and the dorsal horn of spine. From a clinical perspective, the manipulation of the healthcare context with the best evidence-based therapy represents an opportunity to trigger placebo effects and to avoid nocebo effects respecting the ethical code of conduct. From a managerial perspective, stakeholders, organizations and governments should encourage the assessment of the healthcare context aimed to improve the quality of physiotherapy services. From an educational perspective, placebo and nocebo effects are professional topics that should be integrated in the university program of health and medical professions. From a research perspective, the control of placebo, nocebo and context-related effects offers to the scientific community the chance to better measure the impact of physiotherapy on different outcomes and in different conditions through primary studies.

Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review

Objective

Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research.

Methods

A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development.

Results

The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids.

Conclusions

Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.

How do physiotherapists solicit and explore patients' concerns in back pain consultations: a conversation analytic approach

Background: Guidelines advocate that non-specific chronic low back pain (NSCLBP) be considered within a multi-dimensional bio-psychosocial (BPS) framework. This BPS approach advocates incorporating the patient's perspective as part of the treatment process. 'Agenda setting' has been introduced as the key to understanding patients' concerns in medical encounters; however, this has received little attention in physiotherapy. This study explored how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to initial encounters. Method: The research setting was primary care. Twenty initial physiotherapy consultations were video-recorded, transcribed and analyzed using conversation analysis, a qualitative observational method. Both verbal and non-verbal features of the interaction were considered. Results: This data highlights a spectrum of communication styles ranging from more physiotherapist-focused, where the physiotherapists did not attend to patients' concerns, to a more patient-focused style, which provided greater opportunities for patients to voice their concerns. On occasions, patients were willing to pursue their own agenda when their concern was initially overlooked. Conclusion: This study provides empirical evidence on communication patterns in physiotherapy practice. A more collaborative style of communication with a shared conversational agenda provided patients with the conversational space to describe their concerns more fully.

The Patient-Professional Interaction Questionnaire (PPIQ) to assess patient centered care from the patient's perspective

OBJECTIVE

To investigate how patients evaluate the provision of patient-centered care (PCC) by healthcare professionals and psychometrically test a questionnaire to assess it. A tool previously developed for self-assessment of professionals' provision of PCC was adapted into a patient-rated form, named Patient-Professional Interaction Questionnaire (PPIQ).

METHODS

A sample of 1139 patients from six hospitals completed the 16-item PPIQ and the questionnaire structure, reliability, susceptibility to social desirability, and associations with other variables were tested.

RESULTS

The PPIQ confirmed the original four-factor structure (effective communication, interest in the patient's agenda, empathy, and patient involvement in care) and showed acceptable reliability and measurement invariance across both in-/out-patients and first/non-first encounter with the evaluated professional. Associations with patients' social desirability were negligible and effective communication was rated the highest among the PPIQ dimensions. PPIQ scores varied according to patients' educational level and type of professional evaluated, while associations between first/non-first encounter and PPIQ scores varied according to in-/out-patient.

CONCLUSION

The PPIQ is a psychometrically sound patient-rated measure of the provision of PCC by healthcare professionals.

PRACTICE IMPLICATIONS

The PPIQ has potential value in promoting quality patient-professional interactions in the hospital setting, as patients' reported experience is an important dimension of the clinician's performance.

Physical therapists' perceptions and experiences about barriers and facilitators of therapeutic patient-centred relationships during outpatient rehabilitation: a qualitative study

BACKGROUND

Over recent years there has been a paradigm shift towards a patient-centred biopsychosocial care model in physical therapy. This new paradigm features a growing interest in understanding the contextual factors that influence the patient's experience of disease, pain and recovery. This includes generalized consensus regarding the importance of establishing a therapeutic relationship that is centred on the patient.

OBJECTIVE

To explore physical therapists' perceptions and experiences regarding barriers and facilitators of therapeutic patient-centred relationships in outpatient rehabilitation settings.

METHODS

This is a qualitative study with four focus groups including twenty-one physical therapists. Two researchers conducted the focus groups, using a topic guide with predetermined questions. The focus group discussions were audiotaped and videotaped, transcribed verbatim and analysed thematically using a modified grounded theory approach.

RESULTS

Physical therapists perceived that the therapeutic patient-centred relationship not only depends on the personal qualities of the professional, but also on the patient's attitudes and the characteristics of the context, including the organization and team coordination.

CONCLUSIONS

Although being more linked towards the patients' contextual factors and needs than towards the practice of the profession, a therapeutic relationship is worth considering by physical therapists. Furthermore this study highlights the need for physical therapists and administrators to rethink the situation and propose strategies for improvement.

Automated generation of ‘good enough’ transcripts as a first step to transcription of audio-recorded data

In the last decade, automated captioning services have appeared in mainstream technology use. Until now, the focus of these services have been on the technical aspects, supporting pupils with special educational needs and supporting teaching and learning of second language students. Only limited explorations have been attempted regarding its use for research purposes: transcription of audio recordings. This article presents a proof-of-concept exploration utilising three examples of automated transcription of audio recordings from different contexts; an interview, a public hearing and a classroom setting, and compares them against ‘manual’ transcription techniques in each case. It begins with an overview of literature on automated captioning and the use of voice recognition tools for the purposes of transcription. An account is provided of the specific processes and tools used for the generation of the automated captions followed by some basic processing of the captions to produce automated transcripts. Originality checking software was used to determine a percentage match between the automated transcript and a manual version as a basic measure of the potential usability of each of the automated transcripts. Some analysis of the more common and persistent mismatches observed between automated and manual transcripts is provided, revealing that the majority of mismatches would be easily identified and rectified in a review and edit of the automated transcript. Finally, some of the challenges and limitations of the approach are considered. These limitations notwithstanding, we conclude that this form of automated transcription provides ‘good enough’ transcription for first versions of transcripts. The time and cost advantages of this could be considerable, even for the production of summary or gisted transcripts.

Patterns of Clinical Reasoning in Physical Therapist Students

BACKGROUND AND PURPOSE

Clinical reasoning is a complex, nonlinear problem-solving process that is influenced by models of practice. The development of physical therapists' clinical reasoning abilities is a crucial yet underresearched aspect of entry-level (professional) physical therapist education.

OBJECTIVES

The purpose of this qualitative study was to examine the types of clinical reasoning strategies physical therapist students engage in during a patient encounter.

METHODS

A qualitative descriptive case study design involving within and across case analysis was used. Eight second-year, professional physical therapist students from 2 different programs completed an evaluation and initial intervention for a standardized patient followed by a retrospective think-aloud interview to explicate their reasoning processes. Participants' clinical reasoning strategies were examined using a 2-stage qualitative method of thematic analysis.

RESULTS

Participants demonstrated consistent signs of development of physical therapy-specific reasoning processes, yet varied in their approach to the case and use of reflection. Participants who gave greater attention to patient education and empowerment also demonstrated greater use of reflection-in-action during the patient encounter. One negative case illustrates the variability in the rate at which students may develop these abilities.

CONCLUSIONS

Participants demonstrated development toward physical therapist--specific clinical reasoning, yet demonstrated qualitatively different approaches to the patient encounter. Multiple factors, including the use of reflection-in-action, may enable students to develop greater flexibility in their reasoning processes.

Interviewers' Experiences with Two Multiple Mini-Interview Scoring Methods Used for Admission to a Master of Physical Therapy Programme

Purpose: To describe participants' attitudes, beliefs, and experiences with the use of two methods of scoring the Multiple Mini-Interview (MMI) for admission to a Master of Physical Therapy program: a rank-based scoring system (RBS; used from 2007 to 2013) and a criterion-based scoring system (CBS; tested in 2014). The MMI uses short independent assessments to obtain an aggregate score of candidates' professionalism and interpersonal skills, based on behavioural questions within scenarios that assess one attribute at a time. Method: This qualitative descriptive inquiry sought to capture the experiences of 18 MMI interviewers primarily through semi-structured interviews. Interviews were transcribed verbatim, and the data were analyzed using thematic analysis. The results were validated by theoretical and investigator triangulation and member checking. Results: One major theme, scoring systems, and two sub-themes, CBS and RBS, emerged across all data. Participants unanimously agreed that CBS is a more fair and objective way to score candidates' interviews. Conclusions: CBS was well accepted by participants, and the majority preferred it over RBS. Participants felt that CBS presented a more accurate depiction of candidates.

Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes

INTRODUCTION

Placebo and nocebo represent complex and distinct psychoneurobiological phenomena in which behavioural and neurophysiological modifications occur together with the application of a treatment. Despite a better understanding of this topic in the medical field, little is known about their role in physiotherapy.

PURPOSE

The aim of this review is: a) to elucidate the neurobiology behind placebo and nocebo effects, b) to describe the role of the contextual factors as modulators of the clinical outcomes in rehabilitation and c) to provide clinical and research guidelines on their uses.

IMPLICATIONS

The physiotherapist's features, the patient's features, the patient-physiotherapist relationship, the characteristics of the treatment and the overall healthcare setting are all contextual factors influencing clinical outcomes. Since every physiotherapy treatment determines a specific and a contextual effect, physiotherapists should manage the contextual factors as a boosting element of any manual therapy to improve placebo effects and avoid detrimental nocebo effects.

'Tell me about your troubles': description of patient-physiotherapist interaction during initial encounters

BACKGROUND AND PURPOSE

Communication skills are essential for physiotherapy practice. It has been shown that patients, especially those with chronic pain problems, are more satisfied with services when therapists communicate adequately. The objective of this study was to explore how French-speaking physiotherapists and patients with low back pain explore and assess the patient's pain experience during initial encounters.

METHODS

The initial consultation of six consenting patients with low back pain and two physiotherapists was videotaped. Conversation analysis was used to describe and analyse the communication practices related to pain assessment.

RESULTS

When physiotherapists explored patients' pain experience, they specifically focused on the impact of pain on function. The observed physiotherapists used the following communication strategies: 1) using yes/no questions and 'okay' as a resource to shift to a new topic; 2) following documentation quite stringently without allowing digression; 3) building the next question on the basis of the patient's discourse; 4) inviting the patient to talk using formulations such as 'tell me about your troubles?'; and 5) using gaze and nodding as continuers. The physiotherapists used two different approaches to close the encounter. While one therapist chose to summarize the consultation, including a prognostic assessment, the other one ended the consultation by organizing the follow-up consultation.

CONCLUSION

This exploratory study examines the interaction between patients and physiotherapists during initial encounters and identifies assumptions underlying pain assessment that shape the therapists' exploration of patients' pain experience. It also shows evidence of the physiotherapists' difficulties to inquire about the patient's perspective.

Opening clinical encounters in an adult musculoskeletal setting

Effective communication between healthcare professionals and their patients is crucial for successful consultations, and can profoundly affect patients' adherence to treatment. Despite this evidence, communication within the physiotherapy profession is still underexplored, in particular, how 'best' to open clinical encounters. This study explores the issue by seeking the preferences of physiotherapists for opening encounters in the adult musculoskeletal outpatient setting. Initially, 42 consultations and 17 first follow-up encounters were observed between qualified physiotherapists and patients with back pain. These encounters were audio-recorded, analysed and used to develop a questionnaire to determine clinicians' preferences for opening encounters. From these findings, a synopsis of the questionnaire was posted on the four most-relevant professional networks of the national, interactive Chartered Society of Physiotherapy (iCSP) website, to canvass opinion more widely. Among the 43 physiotherapists who responded, the preferred 'key clinical question' for an initial encounter was: "Do you want to just tell me a little bit about [your 'problem presentation'] first of all?"; and for follow-up encounters: 'How have you been since I last saw you?' These results provide an important and novel contribution to the profession, as debate on this issue has not previously been published. Although the sample size in this study is small, the aim of this paper is to generate reflection and debate among clinicians on their preferences for opening patient encounters and optimising the non-specific treatment effects.