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Ahlsen B, Mengshoel AM, Engebretsen E. Legitimacy in clinical practice: How patients with chronic muscle pain position themselves in the physiotherapy encounter. J Eval Clin Pract 2023; 29:312-319. [PMID: 36121196 DOI: 10.1111/jep.13768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/26/2022]
Abstract
RATIONALE, AIMS & OBJECTIVE Patients who seek healthcare for long-lasting pain and symptoms without a detectable disease must put in extra work to be taken seriously and gain recognition as a patient. However, little is known about how patients' help-seeking is performed in clinical practice. The aim of the current study was to gain knowledge about the ways in which patients with chronic muscle pain position themselves as help-seekers during their first physiotherapy encounter. METHOD The material consisted of observation of 10 therapist-patient clinical interviews in primary care clinics and was analyzed using perspectives from discourse theory and the concept of positioning. RESULTS The study highlights how the patients positioned themselves in continually shift between two discourses: that of disease (considering the patient as an object under study) and that of illness (positioning the patient as an active and participating but also troubled individual). This shifting of position was negotiated in interaction with the therapist: patients' opportunities to position themselves within the discourse of illness were limited by therapists' focus on facts and causal relationships within the discourse of disease. CONCLUSION Patients with chronic muscle pain seek to establish their legitimacy through the positivistic discourse of medicine and also through their compliance with the moral discourse of the patient as someone active, willing to take responsibility for their own health-and therefore worthy of treatment.
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Affiliation(s)
- Birgitte Ahlsen
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,Department for Interdisciplinary Health Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Marit Mengshoel
- Department for Interdisciplinary Health Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eivind Engebretsen
- Centre for Sustainable Healthcare Education, Faculty of Medicine, University of Oslo, Oslo, Norway
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Widerström B, Elvén M, Rasmussen-Barr E, Boström C. "How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?". Musculoskelet Sci Pract 2021; 53:102374. [PMID: 33798815 DOI: 10.1016/j.msksp.2021.102374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/10/2021] [Accepted: 03/20/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. OBJECTIVE The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. DESIGN This was an exploratory interview study using inductive content analysis. METHOD Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). CONCLUSION This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.
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Affiliation(s)
| | - Maria Elvén
- Mälardalen University, School of Health, Care and Social Welfare, Division of Physiotherapy, Västerås, Sweden
| | | | - Carina Boström
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Huddinge, Sweden
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Christe G, Nzamba J, Desarzens L, Leuba A, Darlow B, Pichonnaz C. Physiotherapists' attitudes and beliefs about low back pain influence their clinical decisions and advice. Musculoskelet Sci Pract 2021; 53:102382. [PMID: 33915318 DOI: 10.1016/j.msksp.2021.102382] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Physiotherapists' biomedical orientation influences the implementation of evidenced-based care for low back pain (LBP) management. However, information on physiotherapists' own beliefs about their back and LBP and the influence of these on clinical decisions and advice is lacking. OBJECTIVES To identify attitudes and beliefs about LBP among physiotherapists and to analyse the association of these beliefs with physiotherapists' individual characteristics and clinical decisions and advice. DESIGN Cross-sectional survey. METHOD Attitudes and beliefs about LBP were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ) among French-speaking Swiss physiotherapists. Physiotherapists' clinical decisions and advice were assessed with a clinical vignette to determine their association with the Back-PAQ score. RESULTS The study included 288 physiotherapists. The mean Back-PAQ score (82.7; SD 17.2) indicated the presence of helpful beliefs in general, but unhelpful beliefs in relation to back protection and the special nature of LBP (nature of pain, impact, complexity) were frequently identified. Individual characteristics explained 17% of the Back-PAQ score. Unhelpful beliefs were associated with clinical decisions toward back protection and movement avoidance (r = - 0.47, p < 0.001). CONCLUSIONS While helpful beliefs and guidelines consistent decisions were generally identified, unhelpful beliefs about back protection and the special nature of LBP were frequently present among physiotherapists. These unhelpful beliefs were associated with less optimal clinical decisions. Educational approaches should challenge unhelpful beliefs and empower physiotherapists to provide explanations and management that increases patients' confidence in the back. Future research should investigate the effect of educational strategies on implementation of best practice for LBP management.
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Affiliation(s)
- Guillaume Christe
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland; Swiss BioMotion Lab, Department of Musculoskeletal Medicine, University Hospital and University of Lausanne (CHUV-UNIL), Lausanne, Switzerland.
| | - Jessica Nzamba
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Ludovic Desarzens
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Arnaud Leuba
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Ben Darlow
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| | - Claude Pichonnaz
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland; Department of Musculoskeletal Medicine, University Hospital and University of Lausanne (CHUV-UNIL), Lausanne, Switzerland
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Benny E, Evans C. Ontario Musculoskeletal Physiotherapists' Attitudes toward and Beliefs about Managing Chronic Low Back Pain. Physiother Can 2020; 72:355-363. [PMID: 35110808 PMCID: PMC8781503 DOI: 10.3138/ptc-2019-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Purpose: The purpose of this study was to explore Ontario musculoskeletal physiotherapists' attitudes toward and beliefs about managing chronic low back pain (CLBP), and their biomedical (BM) and bio-psychosocial (BPS) treatment orientation. Method: Through a link in the Ontario Physiotherapy Association newsletter, we administered an electronic survey to registered physiotherapists via SurveyMonkey. We used a modified three-step Dillman approach to encourage participation. The questionnaire included the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) measure, and demographic-practice items. Results: A total of 99 physiotherapists met the eligibility criteria and completed the PABS-PT (72.7% women; mean 17 years of experience). Respondents scored a mean of 26.98 (SD 7.69) on the BM sub-scale and 34.43 (SD 4.84) on the BPS sub-scale. Physiotherapists in public practice had a stronger BPS orientation (mean 36.52) than those in private practice (33.80; p = 0.01). Less experienced physiotherapists (<10 y) had a higher BM sub-scale score (mean 29.33) than more experienced physiotherapists (25.24, p = 0.013), and 78.8% of physiotherapists reported an awareness of clinical practice guidelines. Conclusions: Our preliminary findings suggest that Ontario physiotherapists' attitudes and beliefs align with a BPS orientation. Future studies should explore the impact of education that promotes a BPS approach to the management of CLBP.
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Affiliation(s)
| | - Cathy Evans
- Department of Physical Therapy, University of Toronto, Toronto
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Horler C, Hebron C, Martyn K. Personalizing education: The clinical reasoning processes of physiotherapists using education for the treatment of people with chronic low back pain. Physiother Theory Pract 2020; 38:412-421. [DOI: 10.1080/09593985.2020.1765437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Christopher Horler
- School of Health Sciences, University of Brighton, Eastbourne, UK
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Clair Hebron
- School of Health Sciences, University of Brighton, Eastbourne, UK
| | - Kathy Martyn
- School of Health Sciences, University of Brighton, Eastbourne, UK
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Řasová K, Freeman J, Cattaneo D, Jonsdottir J, Baert I, Smedal T, Romberg A, Feys P, Alves-Guerreiro J, Habek M, Henze T, Santoyo-Medina C, Beiske A, Van Asch P, Bakalidou D, Salcı Y, Dimitrova E, Pavlíková M, Štětkářová I, Vorlíčková J, Martinková P. Content and Delivery of Physical Therapy in Multiple Sclerosis across Europe: A Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E886. [PMID: 32023868 PMCID: PMC7038126 DOI: 10.3390/ijerph17030886] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/25/2022]
Abstract
Background: Guidelines and general recommendations are available for multiple sclerosis rehabilitation, but no specific guidance exists for physical therapists. Describing aspects of physical therapy content and delivery in multiple sclerosis and its determinants and analysing whether general recommendations connected with physical therapy are implemented in practice is important for interpreting clinical and research evidence. Methods: An online cross-sectional survey of physical therapists specialized in multiple sclerosis (212 specialists from 26 European countries) was used. Results: There was distinct diversity in service delivery and content across Europe. Perceived accessibility of physical therapy varied from most accessible in the Western region, and least in the Southern region. Sixty-four physical therapists adjusted their approach according to different disability levels, less so in the Eastern region. Duration, frequency and dose of sessions differed between regions, being highest in Southern and Western regions. "Hands on treatment" was the most commonly used therapeutic approach in all apart from the Northern regions, where "word instruction" (providing advice and information) prevailed. Conclusions: The content and delivery of physical therapy differs across Europe. Recommendations concerning access to treatment and adjustment according to disability do not appear to be widely implemented in clinical practice.
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Affiliation(s)
- Kamila Řasová
- Department of Rehabilitation, Third Faculty of Medicine, Charles University, Ruská 87, 108 00 Prague, Czech Republic;
| | - Jenny Freeman
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Devon PL6 8BH, UK;
| | - Davide Cattaneo
- IRCCS Fondazione Don Carlo Gnocchi, Larice Lab, P20148 Milan, Italy; (D.C.); (J.J.)
| | - Johanna Jonsdottir
- IRCCS Fondazione Don Carlo Gnocchi, Larice Lab, P20148 Milan, Italy; (D.C.); (J.J.)
| | - Ilse Baert
- Faculty of Rehabilitation Sciences REVAL Rehabilitation Research Center REVAL, BIOMED, Hasselt University, 3500 Hasselt, Belgium;
| | - Tori Smedal
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, and Department of Physiotherapy, Haukeland University Hospital, 5021 Bergen, Norway;
| | - Anders Romberg
- Physiotherapy, Masku Neurological Rehabilitation Centre, 21250 Masku, Finland;
| | - Peter Feys
- Campus Diepenbeek, Faculty of Rehabilitation Sciences, REVAL Rehabilitation Research center REVAL, BIOMED, Hasselt University, 3500 Hasselt, Belgium;
| | - Jose Alves-Guerreiro
- School of Health Sciences, Health Research Unit, Polytechnic Institute of Leiria, Campus 2-Morro do Lena-Alto do Vieiro, 2411-901 Leiria, Portugal;
| | - Mario Habek
- Department of Neurology, Referral Center for Autonomic Nervous System, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Kispaticeva, 10000 Zagreb, Croatia;
| | - Thomas Henze
- Specialist Practice in Neurology, 93059 Regensburg, Germany;
| | - Carme Santoyo-Medina
- Neurology-Neuroimmunology Department & Neurorehabilitation Unit, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
| | | | - Paul Van Asch
- Fit Up, Fitness- and Physiotherapy Center, 2550 Kontich, Belgium;
| | - Daphne Bakalidou
- Department of physiotherapy, University of West Attica, Egaleo, 12243 Athens, Greece;
| | - Yeliz Salcı
- Department of Physical Therapy and Rehabilitation, Faculty of Health Science, Hacettepe University, 06100 Ankara, Turkey;
| | - Erieta Dimitrova
- Department for Rehabilitation of Musculoskeletal Disorders, Institute of Physical Medicine and Rehabilitation, Faculty of Medicine, “Ss. Cyril and Methodius” University, 1000 Skopje, Macedonia;
| | - Markéta Pavlíková
- Department of Rehabilitation, Third Faculty of Medicine, Charles University, Ruská 87, 108 00 Prague, Czech Republic;
| | - Ivana Štětkářová
- Department of Neurology, Third Faculty of Medicine, Charles University, 100 34 Prague, Czech Republic;
| | - Jana Vorlíčková
- Department of Statistical Modelling, Institute of Computer Science, Czech Academy of Sciences,18207 Prague, Czech Republic; (J.V.); (P.M.)
| | - Patricia Martinková
- Department of Statistical Modelling, Institute of Computer Science, Czech Academy of Sciences,18207 Prague, Czech Republic; (J.V.); (P.M.)
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França AA, Santos VD, Filho RL, Pires KF, Lagoa KF, Martins WR. 'It's very complicated': Perspectives and beliefs of newly graduated physiotherapists about the biopsychosocial model for treating people experiencing non-specific low back pain in Brazil. Musculoskelet Sci Pract 2019; 42:84-89. [PMID: 31054486 DOI: 10.1016/j.msksp.2019.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/10/2019] [Accepted: 04/16/2019] [Indexed: 01/06/2023]
Abstract
Non-specific low back pain is a common complaint frequently presented by patients and this complex clinical condition has challenged the biomedical model. The Biopsychosocial (BPS) model is recognized as an option for better guidance and patient management. However, physiotherapy training is based on the biomedical perspective, added to which, in clinical practice the applicability of the BPS model is a challenge for many professionals. In this article, we explore the feelings, beliefs, and attitudes of newly trained physiotherapists about using the BPS model to treat people with non-specific low back pain. It also aims to understand to what extent these physiotherapists are willing and prepared to use this model. Method: A qualitative phenomenological research was carried out in the Brazilian federal capital. A set of criteria was used to select 10 physiotherapists. The data were collected through semi-structured interviews and analyzed using five steps: familiarization, identification, indexation, mapping, and interpretation. Results: We identified one theme and three categories. The theme 'a practitioner physiotherapist can consider BPS aspects, but it is not necessary in his/her role to approach them' explains a shared belief about the use of BPS. The theme is better understood when looking at the three categories that explore and exemplify key elements of the theme: (i) understanding the BPS model and its relation to non-specific low back pain; (ii) the role of practitioner physiotherapists regarding the BPS model; and (iii) barriers: from undergraduate training to clinical settings.
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Affiliation(s)
- Andressa Alves França
- College of Physical Therapy, University of Brasilia (UnB), Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília, Distrito Federal, CEP: 72220-275, Brazil.
| | - Vagner Dos Santos
- College of Occupational Therapy, University of Brasilia (UnB), Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília, Distrito Federal, CEP: 72220-275, Brazil
| | - Reginaldo Lordelo Filho
- College of Physical Therapy, University of Brasilia (UnB), Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília, Distrito Federal, CEP: 72220-275, Brazil
| | - Kênia Fonseca Pires
- College of Physical Therapy, University of Brasilia (UnB), Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília, Distrito Federal, CEP: 72220-275, Brazil
| | | | - Wagner Rodrigues Martins
- College of Physical Therapy, University of Brasilia (UnB), Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília, Distrito Federal, CEP: 72220-275, Brazil
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Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare. Musculoskelet Sci Pract 2019; 41:6-14. [PMID: 30818071 DOI: 10.1016/j.msksp.2019.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed. OBJECTIVE The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare. DESIGN This was an explorative study using qualitative content analysis. METHOD Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities). CONCLUSION This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.
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Bernhardsson S, Samsson KS, Johansson K, Öberg B, Larsson MEH. A preference for dialogue: exploring the influence of patient preferences on clinical decision making and treatment in primary care physiotherapy. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2018. [DOI: 10.1080/21679169.2018.1496474] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Susanne Bernhardsson
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
- Department of Health and Rehabilitation, The Sahlgrenska Academy, Unit of Physiotherapy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Karin S. Samsson
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Department of Health and Rehabilitation, The Sahlgrenska Academy, Unit of Physiotherapy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Kajsa Johansson
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Maria E. H. Larsson
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Department of Health and Rehabilitation, The Sahlgrenska Academy, Unit of Physiotherapy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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Toye F, Seers K, Barker K. A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BackgroundPeople with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.Objectives(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.DesignWe used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.Data sourcesWe searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.ResultsWe screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (seeReport Supplementary Material 1; URL:www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.LimitationsThere are no agreed methods for determining confidence in QESs.ConclusionsWe highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.Future workFuture work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Fran Toye
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Kate Seers
- Royal College of Nursing Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Ahlsen B, Mengshoel AM, Bondevik H, Engebretsen E. Physiotherapists as detectives: investigating clues and plots in the clinical encounter. MEDICAL HUMANITIES 2018; 44:40-45. [PMID: 28912383 DOI: 10.1136/medhum-2017-011229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 06/07/2023]
Abstract
This article investigates the clinical reasoning process of physiotherapists working with patients with chronic muscle pain. The article demonstrates how physiotherapists work with clues and weigh up different plots as they seek to build consistent stories about their patient's illness. The material consists of interviews with 10 Norwegian physiotherapists performed after the first clinical encounter with a patient. Using a narrative approach and Lonergan's theory of interpretation, the study highlights how, like detectives, the therapists work with clues by asking a number of interpretive questions of their data. They interrogate what they have observed and heard during the first session, they also question how the patient's story was told, including the contextual and relation aspects of clue production, and they ask why the patient's story was told to them in this particular way at this particular time. The article shows how the therapists configure clues into various plots on the basis of their experience of working with similar cases and how their detective work is pushed forward by uncertainty and persistent questioning of the data.
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Affiliation(s)
- Birgitte Ahlsen
- Department of Physiotherapy, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
- Department of Health Science, University of Oslo, Institute of Health and Society, Oslo, Norway
| | - Anne Marit Mengshoel
- Department of Health Science, University of Oslo, Institute of Health and Society, Oslo, Norway
| | - Hilde Bondevik
- Department of Health Science, University of Oslo, Institute of Health and Society, Oslo, Norway
| | - Eivind Engebretsen
- Department of Health Science, University of Oslo, Institute of Health and Society, Oslo, Norway
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Toye F, Seers K, Barker KL. Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain. BMJ Open 2017; 7:e018411. [PMID: 29273663 PMCID: PMC5778293 DOI: 10.1136/bmjopen-2017-018411] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES We aimed to explore healthcare professionals' experience of treating chronic non-malignant pain by conducting a qualitative evidence synthesis. Understanding this experience from the perspective of healthcare professionals will contribute to improvements in the provision of care. DESIGN Qualitative evidence synthesis using meta-ethnography. We searched five electronic bibliographic databases from inception to November 2016. We included studies that explore healthcare professionals' experience of treating adults with chronic non-malignant pain. We used the GRADE-CERQual framework to rate confidence in review findings. RESULTS We screened the 954 abstracts and 184 full texts and included 77 published studies reporting the experiences of over 1551 international healthcare professionals including doctors, nurses and other health professionals. We abstracted six themes: (1) a sceptical cultural lens, (2) navigating juxtaposed models of medicine, (3) navigating the geography between patient and clinician, (4) challenge of dual advocacy, (5) personal costs and (6) the craft of pain management. We rated confidence in review findings as moderate to high. CONCLUSIONS This is the first qualitative evidence synthesis of healthcare professionals' experiences of treating people with chronic non-malignant pain. We have presented a model that we developed to help healthcare professionals to understand, think about and modify their experiences of treating patients with chronic pain. Our findings highlight scepticism about chronic pain that might explain why patients feel they are not believed. Findings also indicate a dualism in the biopsychosocial model and the complexity of navigating therapeutic relationships. Our model may be transferable to other patient groups or situations.
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Affiliation(s)
- Francine Toye
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kate Seers
- Royal College of Nursing Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S. Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. J Physiother 2017; 63:132-143. [PMID: 28655562 DOI: 10.1016/j.jphys.2017.05.017] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 04/03/2017] [Accepted: 05/22/2017] [Indexed: 11/30/2022] Open
Abstract
QUESTION What influence do physiotherapists' beliefs and attitudes about chronic low back pain have on their clinical management of people with chronic low back pain? DESIGN Systematic review with data from quantitative and qualitative studies. Quantitative and qualitative studies were included if they investigated an association between physiotherapists' attitudes and beliefs about chronic low back pain and their clinical management of people with chronic low back pain. RESULTS Five quantitative and five qualitative studies were included. Quantitative studies used measures of treatment orientation and fear avoidance to indicate physiotherapists' beliefs and attitudes about chronic low back pain. Quantitative studies showed that a higher biomedical orientation score (indicating a belief that pain and disability result from a specific structural impairment, and treatment is selected to address that impairment) was associated with: advice to delay return to work, advice to delay return to activity, and a belief that return to work or activity is a threat to the patient. Physiotherapists' fear avoidance scores were positively correlated with: increased certification of sick leave, advice to avoid return to work, and advice to avoid return to normal activity. Qualitative studies revealed two main themes attributed to beliefs and attitudes of physiotherapists who have a relationship to their management of chronic low back pain: treatment orientation and patient factors. CONCLUSION Both quantitative and qualitative studies showed a relationship between treatment orientation and clinical practice. The inclusion of qualitative studies captured the influence of patient factors in clinical practice in chronic low back pain. There is a need to recognise that both beliefs and attitudes regarding treatment orientation of physiotherapists, and therapist-patient factors need to be considered when introducing new clinical practice models, so that the adoption of new clinical practice is maximised. [Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S (2017) Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy 63: 132-143].
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Affiliation(s)
| | | | | | | | | | - Stephen Goodall
- Centre for Health Economics Research & Evaluation, University of Technology Sydney, Sydney, Australia
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Bernhardsson S, Larsson MEH, Johansson K, Öberg B. “In the physio we trust”: A qualitative study on patients’ preferences for physiotherapy. Physiother Theory Pract 2017; 33:535-549. [DOI: 10.1080/09593985.2017.1328720] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Susanne Bernhardsson
- Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Maria E. H. Larsson
- Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
- Department of Health and Rehabilitation, Sahlgrenska Academy at University of Gothenburg, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Kajsa Johansson
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
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Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K. Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study. J Physiother 2016; 62:215-21. [PMID: 27634160 DOI: 10.1016/j.jphys.2016.08.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/26/2016] [Accepted: 08/04/2016] [Indexed: 11/28/2022] Open
Abstract
QUESTION What are physiotherapists' perspectives on managing the cognitive, psychological and social dimensions of chronic low back pain after intensive biopsychosocial training? DESIGN Qualitative study design using semi-structured interviews to explore physiotherapists' perceptions of their identification and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive Functional Therapy (CFT) training. PARTICIPANTS Thirteen qualified physiotherapists from four countries who had received specific CFT training. The training involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive descriptive analysis was performed using a qualitative software package. RESULTS Four main themes emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in professional practice; altered scope of practice; and increased confidence and satisfaction. Participants described increased understanding of the nature of pain, the role of patient beliefs, and a new appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in communication, and adoption of a functional approach. Since undertaking CFT training, participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors. CONCLUSION Physiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training, so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K (2016) Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study.Journal of Physiotherapy62: 215-221].
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Affiliation(s)
- Aoife Synnott
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Mary O'Keeffe
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Samantha Bunzli
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - Peter O'Sullivan
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Katie Robinson
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Kieran O'Sullivan
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
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Deane JA, McGregor AH. Current and future perspectives on lumbar degenerative disc disease: a UK survey exploring specialist multidisciplinary clinical opinion. BMJ Open 2016; 6:e011075. [PMID: 27633633 PMCID: PMC5030539 DOI: 10.1136/bmjopen-2016-011075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Despite lumbar degenerative disc disease (LDDD) being significantly associated with non-specific low back pain and effective treatment remaining elusive, specialist multidisciplinary clinical stakeholder opinion remains unexplored. The present study examines the views of such experts. DESIGN A reliable and valid electronic survey was designed to establish trends using theoretical constructs relating to current assessment and management practices. Clinicians from the Society of Back Pain Research (SBPR) UK were invited to take part. Quantitative data were collated and coded using Bristol Online Surveys (BOS) software, and content analysis was used to systematically code and categorise qualitative data. SETTING Specialist multidisciplinary spinal interest group in the UK. PARTICIPANTS 38/141 clinically active, multidisciplinary SBPR members with specialist spinal interest participated. Among them, 84% had >9 years postgraduate clinical experience. INTERVENTIONS None. OUTCOME MEASURES Frequency distributions were used to establish general trends in quantitative data. Qualitative responses were coded and categorised in relation to each theme and percentage responses were calculated. RESULTS LDDD symptom recurrence, in the absence of psychosocial influence, was associated with physical signs of joint stiffness (26%), weakness (17%) and joint hypermobility (6%), while physical factors (21%) and the ability to adapt (11%) were postulated as reasons why some experience pain and others do not. No one management strategy was supported exclusively or with consensus. Regarding effective modalities, there was no significant difference between allied health professional and medic responses (p=0.1-0.8). The future of LDDD care was expressed in terms of improvements in patient communication (35%), patient education (38%) and treatment stratification (24%). CONCLUSIONS Results suggest that multidisciplinary expert spinal clinicians appear to follow UK-based assessment guidelines with regard to recurrent LDDD; there are, however, inconsistencies in the management approaches supported. This reflects the current literature and the lack of specific, formalised guidance. LDDD treatment stratification and further research are explicitly supported.
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Gordon R, Bloxham S. A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare (Basel) 2016; 4:healthcare4020022. [PMID: 27417610 PMCID: PMC4934575 DOI: 10.3390/healthcare4020022] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/15/2016] [Accepted: 04/19/2016] [Indexed: 01/14/2023] Open
Abstract
Back pain is a major health issue in Western countries and 60%–80% of adults are likely to experience low back pain. This paper explores the impact of back pain on society and the role of physical activity for treatment of non-specific low back pain. A review of the literature was carried out using the databases SPORTDiscuss, Medline and Google Scholar. A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.
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Affiliation(s)
- Rebecca Gordon
- Department of Sport and Health Sciences, University of St Mark and St John, Plymouth PL6 8BH, UK.
| | - Saul Bloxham
- Department of Sport and Health Sciences, University of St Mark and St John, Plymouth PL6 8BH, UK.
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Bernhardsson S, Öberg B, Johansson K, Nilsen P, Larsson MEH. Clinical practice in line with evidence? A survey among primary care physiotherapists in western Sweden. J Eval Clin Pract 2015; 21:1169-77. [PMID: 25988993 DOI: 10.1111/jep.12380] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2015] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables. METHODS 419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire. RESULTS The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1-16). The most common treatment interventions across the three conditions were advice on posture (reported by 82-94%), advice to stay active (86-92%), and different types of exercise (65-92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29-96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience. CONCLUSIONS Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.
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Affiliation(s)
- Susanne Bernhardsson
- Närhälsan Rehabilitation, Region Västra Götaland, Hönö, Sweden.,Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Kajsa Johansson
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Social Medicine, Linköping University, Linköping, Sweden
| | - Maria E H Larsson
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Unit of Physiotherapy, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Evaluative language in physiotherapy practice: How does it contribute to the therapeutic relationship? Soc Sci Med 2015; 143:128-36. [DOI: 10.1016/j.socscimed.2015.08.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 08/17/2015] [Accepted: 08/20/2015] [Indexed: 11/23/2022]
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20
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Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J Physiother 2015; 61:68-76. [PMID: 25812929 DOI: 10.1016/j.jphys.2015.02.016] [Citation(s) in RCA: 234] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/13/2015] [Accepted: 02/19/2015] [Indexed: 12/13/2022] Open
Abstract
QUESTION What are physiotherapists' perceptions about identifying and managing the cognitive, psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)? DESIGN Systematic review and qualitative metasynthesis of qualitative studies in which physiotherapists were questioned, using focus groups or semi-structured interviews, about identifying and managing cognitive, psychological and social factors in people with LBP. PARTICIPANTS Qualified physiotherapists with experience in treating patients with LBP. OUTCOME MEASURES Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists' perceptions. RESULTS Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them. CONCLUSION Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP. REGISTRATION CRD 42014009964. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.Journal of Physiotherapy61: 68-76].
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Affiliation(s)
- Aoife Synnott
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Mary O'Keeffe
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Samantha Bunzli
- School of Physiotherapy, Curtin University, Perth, Australia
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | | | - Kieran O'Sullivan
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
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