Perceptions of outpatients regarding the attire of physiotherapists

Contextual Factors-Enriched Standard Care on mechanical neck pain (ContextualizAR trial): Protocol for a randomised controlled trial

BACKGROUND

Understanding the influence of contextual factors (CFs) on interventions for mechanical neck pain (MNP) is essential for evidence-based practice in physical therapy. However, the specific effects and synergies of combining different CFs remain unclear.

OBJECTIVE

The primary purpose of this study will be to determine if a CFs-Enriched Standard Care (SC) approach is an effective treatment for MNP in terms of reducing pain and improving function.

METHODS

This will be an assessor-blinded, 2-group (1:1) randomised clinical trial (RCT) aiming to enrol 94 participants with neck pain persisting for more than 4 weeks. Both groups will undergo 4 weeks of SC twice weekly, following established clinical practice guidelines. In the intervention group, CFs will be enhanced, encompassing the physical, psychological, and social elements inherent in the clinical encounter, based on existing evidence. The primary outcomes will encompass changes in pain and disability after 4 weeks of treatment, with a follow-up reassessment at week 12 post-treatment. Secondary outcomes will include changes in Active Range of Motion, Global Rating of Change, and Satisfaction with treatment. The change between groups after treatment and at the 12-week follow-up will be reported for all outcomes, considering the difference from scores recorded at baseline.

RESULTS

We hypothesise that a 4-week CFs-Enriched SC approach will be superior to SC alone in terms of patient-reported disability and pain, with measurements conducted using the Northwick Park Neck Pain Questionnaire and the Numeric Pain Rating Scale, respectively.

CONCLUSION

This RCT rigorously assesses the effect of purposeful manipulation of CFs during MNP treatment. By elucidating the role of these factors, our findings have the potential to significantly refine clinical practice in managing MNP, thereby enhancing patient care, and advancing the fields of physical therapy and rehabilitation.

A modern way to teach and practice manual therapy

BACKGROUND

Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

PURPOSE

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

METHODS

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

CONCLUSIONS

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Systematic manipulation of experimenters' non-verbal behaviors for the investigation of pain reports and placebo effects

Objective

Non-verbal behaviors (NBs) of caregivers affect pain reports and placebo effects. However, little experimental research has systematically examined the caregivers' NBs. This study protocol and preparatory study report a systematic manipulation of experimenters' NBs to investigate pain report and placebo effects.

Methods

We propose an experiment in which videotaped experimenters (VEs) conduct a pain stimulation and a placebo treatment study. The VEs express one positively enhanced NB and keep the other NBs neutral. Participants will be randomized to either the positive facial expressions (+FE), tone of voice (+TV), body movement (+BM), or neutral NBs (i.e., neutral condition; NC) of the VEs. As a preparatory study for proof of concept, two groups of NB coders from Norway and the USA separately rated the degree of NBs (eye contact, body postures and movements, and tone of voice), and impressions of dominance and being in charge, positivity, and expressivity from each NB video. The NB videos had construct validity and reliability. The +BM and +FE were rated as more dominant and in charge than the +TV and the NC. The +FE and +BM were rated as the most positive and expressive NBs, respectively.

Expected results

+FE will have the largest placebo effects on pain and stress levels. However, transmitting the NBs to patients by VEs is challenging. Moreover, controlling for the effects of research assistants present in the testing room is challenging.

Discussion

We propose that caregivers' NBs affect pain reports and placebo effects. Moreover, different NBs elicit different impressions, and a better understanding of the role of caregiver NBs requires more rigorous investigations. Lastly, aiming to investigate the caregiver NBs, the varying degrees of micro-NBs and their effects on the formation of impressions should be considered.

Understanding patient preferences for student clinician attire: a cross-sectional study of a student chiropractic clinic in Australia

Objectives

Previous studies have investigated the role of clinical attire in establishing patient-held perceptions of professionalism and knowledgeability across various healthcare settings. This study aimed to understand patients' preferences for chiropractic student attire.

Methods

Three hundred and twenty patients were recruited from a university chiropractic clinic and asked to complete an online questionnaire. The patients' preferences for five different attires were rated and calculated as the composite score of five domains (knowledgeable, trustworthy, caring, professional, and comfortable).

Results

While 71.9% of participants indicated that how students dress was important to them, most (63.4%) disagreed that wearing a white coat was essential for chiropractic student clinicians. The most preferred form of attire was the current clinic shirt.

Conclusion

The attire worn by chiropractic student clinicians at a single institution was found to be an influential attribute. Student chiropractic clinicians should dress professionally to make a good first impression. This study provided some guidance with the ongoing debate around students' dress code.

Optimizing appreciation and persuasion of embodied conversational agents for health behavior change: A design experiment and focus group study

Embodied Conversational Agents (ECAs) can increase user engagement and involvement and can strengthen the effect of an intervention on health outcomes that is provided via an ECA. However, evidence regarding the effectiveness of ECAs on health outcomes is still limited. In this article, we report on a study that has the goal to identify the effect of a match between a health topic and the ECAs' appearance on ratings of personality characteristics, persuasiveness and intention to use. We report on an online experiment with three different ECAs and three different health topics, conducted among 732 older adults. We triangulated the quantitative results with qualitative insights from a focus group. The results reveal that older adults prefer an ECA that has an appearance matching a certain health topic, resulting in higher ratings on persuasiveness and intention to use. Personality characteristics should be measured embedded within a health topic, but are not rated higher because of a match. We furthermore provide guidelines for designing the content of the ECA.

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.

Factors That Affect Saudi Population Preferences Toward Their Dentist

OBJECTIVE

To explore the preference of Saudi population when selecting their dentist.

DESIGN

Cross-sectional observational study.

METHODS

An online questionnaire was distributed in Arabic language. The inclusion criteria were Saudi participants, aged 18 years or above. The questionnaire was divided into four sections that included participants' demographic data, preferred criteria on dentists and dental office design, and table for the importance of each of the factors studied.

RESULTS

A sample size of 5317 participants completed the questionnaire with a mean age of 30.5 ± 11.6 years old, 57% were females. Most of the participants had no preference on their dentist's nationality (63%) or gender (44%). There was a preference for dentists who are consultants (38%), well known (83%), and has an explanatory-style consultation (78%). Participants preferred scrub and lab coat attires for their male (41%) and female (38%) dentists. Less than half of the participants (44.8%) preferred the dentist to have a social media account. Of all social media platforms, Twitter was the most preferred one (37%). White clinic color was more preferable than other colors (56%). Of all the factors studied, dentist's reputation, clinical rank and cost of treatment were considered very important for most of the participants when selecting their dentist.

CONCLUSION

Overall, Saudi participants have specific preferences on their dentists and dental office design. Dentists might consider these factors to improve their dental practice and their patients' experience.

What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National Survey

Objective

The aim of this study was to investigate the knowledge of orthopedic manual therapists (OMTs) regarding context factors (CFs) capable of triggering nocebo effects during the treatment and how this knowledge is related to their socio-demographic features.

Design

A cross-sectional online survey.

Setting

National.

Main Outcome Measures

A 20 items questionnaire composed by open-ended and closed single-choice questions was administered to explore: (a) socio-demographic variables (10 questions); (b) the relation between different CFs and nocebo-related effects (2 questions); and (c) the knowledge of participants about nocebo-related effects and how they managed them in the clinical practice (8 questions).

Participants

1288 OMTs were recruited from the database of the Master in Rehabilitation of Musculoskeletal Disorders (MRDM) of the University of Genova from March to May 2019. Inclusion criteria were: (a) to possess a valid email account; (b) to understand and use as a native language the Italian; (c) to be graduated as OMTs; and (d) to be employed as physiotherapists specialized-OMTs during the survey.

Results

791 responses were received (61.4%); 473 of them were male (59.8%), with an average age of 31.0 ± 7.1 years. OMTs defined nocebo-related effects as the psychosocial context effects around therapy and patient with specific biological bases (72.2%). OMTs know that their clinical practice is pervaded by nocebo-related effects (42.5%), triggered by CFs. Participants communicated nocebo-related effects balancing the positive features of the therapy with the negative ones (50.9%), during the decision of the therapeutic plan (42.7%). They reported associative learning as the main mechanism involved in nocebo-related effects (28.8%). OMTs taught and trained patient’s strategies to manage nocebo-related effects (39.6%) through an evaluation and correction of patient’s anxieties, doubts and expectations (37.7%). OMTs most frequently considered themselves to have a “medium” education about nocebo-related effects (48.2%) and that their management should be taught during bachelor (78.6%).

Conclusion

OMTs believed that nocebo-related effects were present in their clinical practice and that they can be triggered by CFs.

A Qualitative Systematic Review of Effects of Provider Characteristics and Nonverbal Behavior on Pain, and Placebo and Nocebo Effects

Background: Previous research has indicated that the sex, status, and nonverbal behaviors of experimenters or clinicians can contribute to reported pain, and placebo and nocebo effects in patients or research participants. However, no systematic review has been published. Objective: The aim of this study was to investigate the effects of experimenter/clinician characteristics and nonverbal behavior on pain, placebo, and nocebo effects. Methods: Using EmBase, Web of Knowledge, and PubMed databases, several literature searches were conducted to find studies that investigated the effects of the experimenter's/clinician's sex, status, and nonverbal behaviors on pain, placebo, and nocebo effects. Results: Thirty-four studies were included, 20 on the effects of characteristics of the experimenter/clinician, 11 on the role of nonverbal behaviors, and 3 on the effects of both nonverbal behaviors and characteristics of experimenters/clinicians on pain and placebo/nocebo effects. There was a tendency for experimenters/clinicians to induce lower pain report in participants of the opposite sex. Furthermore, higher confidence, competence, and professionalism of experimenters/clinicians resulted in lower pain report and higher placebo effects, whereas lower status of experimenters/clinicians such as lower confidence, competence, and professionalism generated higher reported pain and lower placebo effects. Positive nonverbal behaviors (e.g., smiling, strong tone of voice, more eye contact, more leaning toward the patient/participant, and more body gestures) contributed to lower reported pain and higher placebo effects, whereas negative nonverbal behaviors (i.e., no smile, monotonous tone of voice, no eye contact, leaning backward from the participant/patient, and no body gestures) contributed to higher reported pain and nocebo effects. Conclusion: Characteristics and nonverbal behaviors of experimenters/clinicians contribute to the elicitation and modulation of pain, placebo, and nocebo effects.

Dental professionalism and influencing factors: patients' perception

BACKGROUND

Professionalism was recognized as a fundamental competency of medical/dental practice at the beginning of the twenty-first century. Organizations and experts published several definitions of professionalism, but research on patients' perception of professionalism has been limited. To address this gap in literature, this study explored dental patients' perception of dental professionalism, and then compared their perception with that of dental professionals.

METHODS

Of the 800 questionnaires that were distributed to dental patients in public and private clinics and hospitals, 504 were returned and were used in the analysis. A factor analysis was used to generate themes and sub-themes. Independent sample t-tests were performed to compare two independent groups and the ANOVA tests to compare means in more than two independent groups.

RESULTS

A factor analysis revealed four factors: excellence and communication skills; humanism, commitment, and service mindedness; competence in practice; and dentists' duties and management skills. Adherence to sterilization and infection control rules and procedures; personal hygiene and clean professional attire; good communication skills; diagnostic and clinical judgment and provision of the most efficient dental treatment; and ethical decisions and ethical care were ranked as the first five most important elements of dental professionalism from patients' perspective. Several demographic factors showed significant differences in perception.

CONCLUSION

Patients' and dentists' perception of dental professionalism and professional behavior vary in certain aspects. These differences must be addressed to ensure excellence of dental service. Dental professionals must also be aware of the personal factors that affect a patient's perception of professionalism.

What you wear does not affect the credibility of your treatment: A blinded randomized controlled study

OBJECTIVE

Professional appearance is easily modifiable, and might alter the effects of a clinical encounter. We aimed to determine whether professional attire influences a patient's perception of treatment credibility.

METHODS

We performed a single-blind randomized controlled study on 128 patients with acute non-specific low back pain who were about to receive treatment in primary care. The treating clinician was randomly allocated to wear formal attire (experimental condition) or casual attire (control condition) to the consultation. Clinicians provided a standardized briefing on the rationale behind the patient's forthcoming treatment. Treatment credibility (Credibility and Expectancy Questionnaire) was assessed immediately after this briefing.

RESULTS

All patients received the experimental or control condition as allocated and provided complete primary outcome data. Formal attire had no effect on perceived treatment credibility (Mean difference between groups 1.2 [95%CI-1.1 to 3.5]). Age was the only significant predictor of treatment credibility; older patients rated treatment credibility higher (Beta=0.16 [95%CI 0.08 to 0.24]).

CONCLUSION

In a trial setting, whether or not a clinician is formally dressed has no effect on perceptions of treatment credibility in patients with acute low back pain.

PRACTICE IMPLICATION

Clinicians should dress comfortably without fear of losing credibility.

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.

Uniforms, status and professional boundaries in hospital

Despite their comparative neglect analytically, uniforms play a key role in the delineation of occupational boundaries and the formation of professional identity in healthcare. This paper analyses a change to the system of uniforms in one UK hospital, where management have required all professions (with the exception of doctors) to wear the same 'corporate' uniform. Focus groups were conducted with the professionals and patients. We analyse this initiative as a kind of McDonaldisation, seeking to create a new 'corporate' worker whose allegiance is principally to the organisation, rather than a profession. Our findings show how important uniforms are to their wearers, both in terms of the defence of professional boundaries and status, as well as the construction of professional identity.