What Do Patients with Chronic Spinal Pain Expect from Their Physiotherapist?

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study

PURPOSE

Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study.

MATERIAL AND METHODS

This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study.

RESULTS

Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists.

CONCLUSION

The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

Patients' expectations of physiotherapists before and after an intensive chronic low back pain rehabilitation programme: a qualitative study based on semi-structured interviews and observations

PURPOSE

To investigate the expectations regarding physiotherapists of patients attending an interdisciplinary CLBP rehabilitation programme and the response to these expectations.

MATERIALS AND METHODS

A thematic analysis was conducted, based on interviews of working-age patients with CLBP and without significant comorbidities.

RESULTS

Twenty patients participated (9 male, 11 female, aged 21-58 years; symptoms duration 4.3 ± 3.0 years; pain VAS 53 ± 21 mm). Patients expected to learn pain and activity management. Expected outcomes were a reduction of pain, increased well-being and a return to normality. A collaborative approach involving therapeutic and relational adaptation was expected. Despite divergences concerning emotional aspects, patients expected a large range of applied psychosocial skills.The programme met the expectations of most patients, especially when its goals matched those reported by the individuals. For most participants, the pain relief was below expectations. Active therapies were valued. After the programme, patients felt more ready to take responsibility for their back.

CONCLUSION

The expectation of developing self-management skills was prevalent. Expected treatments were mostly compatible with recommendations. Expectations to resume activities and decrease pain were in line with the rehabilitation goals, although the expected reduction in pain was overestimated. Relational expectations converged towards patient-centred care.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

OBJECTIVE

To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy.

METHODS

We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized.

RESULTS

Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.

CONCLUSION

Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain.

STUDY REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Barriers to the use of clinical practice guidelines: a qualitative study of Danish physiotherapists and chiropractors

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Providing evidence-based practice (EBP) for patients with LBP is more cost-effective compared with non-EBP. To help health care professionals provide EBP, several clinical practice guidelines have been published. However, a relatively poor uptake of the guidelines has been identified across various countries. To enhance future implementation of EBP, the aim of this study was to explore barriers to using LBP guidelines in clinical practice.

MATERIALS AND METHODS

A qualitative constructivist grounded theory design was employed in order to gain an in-depth understanding of the barriers. Semi-structured interviews (+/- observations) of nine physiotherapists and nine chiropractors from primary care in the Central Denmark Region were conducted.

RESULTS

Two key barriers were found to using guidelines in practice: (1) a scepticism due to doubts about validity and applicability of the guidelines, which emerged particularly among physiotherapists; and (2) a deep biomechanical professional identity, due to perceived role, interest, lack of skills, and patient preferences, which emerged particularly among chiropractors.

CONCLUSIONS

For guidelines to be better implemented in practice, these key barriers must be addressed in a tailored strategy. Furthermore, this study showed a difference in barriers between the two professions.

Implementing psychological interventions delivered by respiratory professionals for people with COPD. A stakeholder interview study

Implementing psychological interventions in healthcare services requires an understanding of the organisational context. We conducted an interview study with UK National Health Service stakeholders to understand the barriers and facilitators for implementing psychological interventions for people with chronic obstructive pulmonary disorder (COPD). We used TANDEM as an exemplar intervention; a psychological intervention recently evaluated in a randomised controlled trial. Twenty participants providing care and/or services to people with COPD were purposively sampled from NHS primary/secondary care, and commissioning organisations. Participants were recruited via professional networks and referrals. Verbatim transcripts of semi-structured interviews were analysed using thematic analysis. Four themes were identified: (1) Living with COPD and emotional distress affects engagement with physical and psychological services; (2) Resource limitations affects service provision in COPD; (3) Provision of integrated care is important for patient well-being; and (4) Healthcare communication can be an enabler or a barrier to patient engagement. People need support with physical and psychological symptoms inherent with COPD and healthcare should be provided holistically. Respiratory healthcare professionals are considered able to provide psychologically informed approaches, but resources must be available for training, staff supervision and service integration. Communication between professionals is vital for clear understanding of an intervention's aims and content, to facilitate referrals and uptake. There was widespread commitment to integrating psychological and physical care, and support of respiratory healthcare professionals' role in delivering psychological interventions but significant barriers to implementation due to concerns around resources and cost efficiency. The current study informs future intervention development and implementation.

Translation and Validation of Low Back Pain Knowledge Questionnaire Among Hindi-Speaking Indian Women

Low back pain (LBP) is a common problem encountered among women worldwide. This research aimed at the cross-cultural translation, adaptation, and equivalence assessment of the Low Back Pain Knowledge Questionnaire (LBPKQ) in the Hindi language. The LBPKQ, originally in English (E-LBPKQ) was translated and validated in the Hindi language (H-LBPKQ). The forward-backward procedure was adapted from the recommended guidelines for cross-cultural adaptation of measures. Psychometric properties of the H-LBPKQ were evaluated among 250 Hindi-speaking Indian women with LBP. Test-retest reliability was evaluated in the first 161 participants of the study sample. The overall LBPKQ scores obtained a mean of 3.1 ± 1.1. The internal consistency was excellent for both E-LBPKQ and H-LBPKQ, with Cronbach's alpha of 0.983 (95% confidence interval [CI], 0.980-0.986) and 0.975 (95% CI, 0.970-0.979), respectively. Construct validity was good, with Kaiser-Meyer-Olkin value of 0.892 for E-LBPKQ and 0.852 for H-LBPKQ. Bartlett's test of sphericity (P < .0001) was significant for E-LBPKQ and H-LBPKQ. Two factors were extracted through principal component analysis. The H-LBPKQ is valid and reliable to assess LBP knowledge among Hindi speaking population. Low LBPKQ scores indicate poor LBP knowledge; hence, LBP sensitization is needed among Indian women.

An integrative review of the qualities of a 'good' physiotherapist

INTRODUCTION

Qualities of a physiotherapist may influence the therapeutic alliance and physiotherapy outcomes. Understanding what qualities constitute a 'good' physiotherapist has yet to be systematically reviewed notwithstanding potentially profound implications for the future practice of physiotherapy.

PURPOSE

The primary purpose of this review was to critically examine how physiotherapists and their patients describe the qualities of a 'good' musculoskeletal physiotherapist as depicted in peer-reviewed literature. The secondary aim was to synthesize qualities represented in the literature, and to compare patient and physiotherapist perspectives.

METHODS

An integrative review methodology was used to undertake a comprehensive literature search, quality appraisal of studies, and thematic analysis of findings. An electronic search of CINAHL, EMBASE, Nursing and Allied Health, PsycINFO, PubMed, and Scopus databases was conducted within a time range from database inception to June 14, 2019.

RESULTS

Twenty-seven studies met the inclusion criteria. Six qualities of a 'good' musculoskeletal physiotherapist were identified as: responsive, ethical, communicative, caring, competent, and collaborative.

CONCLUSIONS

The qualities of a 'good' physiotherapist identified in the review emphasize the human interaction between physiotherapists and patients and point to the centrality of balancing technical competence with a relational way of being.

Physiotherapists' opinions, barriers, and enablers to providing evidence-based care: a mixed-methods study

BACKGROUND

Physiotherapists deliver evidence-based guideline recommended treatments only half of the time to patients with musculoskeletal conditions. Physiotherapists' behaviour in clinical practice are influenced by many cognitive, social, and environmental factors including time and financial pressures. Many initiatives aimed at improving physiotherapists' uptake of evidence-based care have failed to appreciate the context involved in clinical decisions and clinical practice. Therefore, we aimed to describe: i) opinions toward evidence; ii) how evidence is accessed; iii) factors influencing evidence access; iv) factors influencing evidence application, for physiotherapists working in regional areas.

METHODS

We used a mixed-methods study with online survey and focus groups. We included registered physiotherapists in the survey and physiotherapists practising in regional New South Wales in the focus groups. Quantitative and qualitative data were used to inform all research objectives. We used eight domains of the Transtheoretical Domains Framework to design survey questions. We analysed quantitative and qualitative data in parallel, then integrated both sources through by developing a matrix while considering the Transtheoretical Domains Framework domains to generate themes.

RESULTS

Fifty-seven physiotherapists participated in the study (survey only n = 41; focus group only n = 8; both survey and focus group n = 8). Participants reported that evidence was important, but they also considered patient expectations, colleagues' treatment choices, and business demands in clinical decision making. Physiotherapists reported they access evidence on average 30 minutes or less per week. Competing demands like business administration tasks are barriers to accessing evidence. Participants reported that patient expectations were a major barrier to applying evidence in practice. Environmental and systemic factors, like funding structures or incentives for evidence-based care, and social factors, like lacking or having a culture of accountability and mentorship, were reported as both barriers and enablers to evidence application.

CONCLUSIONS

This study provides context to physiotherapists' opinion, access, and application of evidence in clinical practice. Physiotherapists' provision of evidence-based care may be improved by enhancing structural support from workplaces to access and apply evidence and exploring discrepancies between physiotherapists' perceptions of patient expectations and actual patient expectations.

Patients' Perceptions and Outcome Measures after Undergoing the Enhanced Transtheoretical Model Intervention (ETMI) for Chronic Low Back Pain: A Mixed-Method Study

This study aimed to evaluate the outcome measures and perceptions of patients with chronic low back pain (CLBP) after being treated with the Enhanced Transtheoretical Model Intervention (ETMI). In this process evaluation mixed-methods study, 30 patients with CLBP electronically completed self-reported measures (function, pain, and fear-avoidance beliefs) before and after ETMI treatment. Subsequently, each patient participated in one-on-one, semi-structured interviews, which were audio-recorded, transcribed, coded, and analyzed thematically. Quantitative analysis showed significant improvements in function (p < 0.001), pain (p < 0.001), and fear-avoidance beliefs (p < 0.001) after receiving ETMI treatment, with a large effect size (Cohen’s d = 1.234). Moreover, the average number of physiotherapy sessions was 2.6 ± 0.6 for the ETMI intervention, while the annual average number in Maccabi is estimated at 4.1 ± 1.5. Three main themes emerged from the thematic analysis: (1) communication between the patient and the practitioner; (2) psychosocial treatment elements, and (3) ETMI as a long-term solution for CLBP. The findings of the current study highlight patients’ perceived need for an open and sincere dialogue and for receiving reassurance and encouragement about their LBP. Notably, they had no problem with the fact that they did not receive passive treatment. Accordingly, together with the significant improvement in post-treatment outcome measures, patients perceived the ETMI method as a practical tool for self-managing their back problems in the long term.

Patients' prior perceptions and expectations of the Enhanced Transtheoretical Model Intervention for chronic low back pain: A qualitative study

BACKGROUND

The Enhanced Transtheoretical Model Intervention (ETMI) is an approach for treating chronic low back pain (CLBP), which demonstrated clinical and cost-effectiveness outcomes. ETMI highlights reassurance, return to normal activities and encouragement of recreational physical activity. In order to optimally implement ETMI, it is important to gain an understanding of the expectations and perceptions of patients before they engage with the intervention.

OBJECTIVES

To explore CLBP patients' perceptions and expectations of the ETMI method prior to their first consultation with physiotherapist.

METHODS

Qualitative semi-structured interviews were conducted with 30 CLBP patients. The interviews were audio-recorded, transcribed, coded, and analysed thematically. Patients were first asked about their expectations of treatment, then they were asked to comment on the ETMI method.

RESULTS

Three main themes emerged from the interviews: (1) Patient's perceptions of LBP; (2) patient's expectations from current physiotherapy and (3) Patient's expectations from ETMI method. The patients' perceptions of back pain centred on biomechanical causal factors, a desire for diagnostic tests and beliefs that rest cures the pain. Their expectations from current physiotherapy included pain reduction, passive treatment, a structured exercise program and clear information about LBP. In reference to the ETMI method, patients expected pain reduction, practical tools to self-manage, and a combination of ETMI with passive treatment.

CONCLUSION

addressing issues around patient's perceptions and expectations of current physiotherapy and of the ETMI method, prior to their first consultation with physiotherapist, could be beneficial for understanding how to improve the ETMI implementation in the health care system.

The advice given by physiotherapists to people with back pain in primary care

BACKGROUND

Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by clinicians to patients with back pain at their initial consultation.

METHODS

A secondary analysis was conducted with 25 audio-recordings and transcriptions of consultations between patients with back pain and physiotherapists in a primary care outpatients department. Using a Framework approach, the data were coded and analysed to identify the content of advice given and mode of delivery.

RESULTS

The mean duration of consultation was 38 min 59 s (range 26:21-53:16). Advice was given in 88% (n = 22/25) of consultations and 96% included additional exercise instruction. Cognitive reassurance was evident, focussing on getting people confident to 'move your back' despite pain and encouraging active lifestyle changes. Beyond reassurance and discussion to enhance confidence, the key topics of advice given were: activity promotion; postural changes; practical self-help advice regarding ways to sit; pain-management advice including medication and using heat. Gaps were identified in the advice given, most notably there was a lack of specificity relating to the frequency and duration of recommended tasks and activities.

CONCLUSIONS

Advice and reassurance are integral to enabling people to self-manage their back pain. It is important to avoid contradictory and unhelpful messages. Despite its importance, little is known about the advice offered by clinicians during initial back pain consultations highlighting the need for guidance to be patient-centred and tailored.

Exploring Integrated Care for Musculoskeletal and Chronic Health Conditions

Integrated care is a continuum of services delivered by a system organized around the health needs of people rather than diseases. People with chronic musculoskeletal pain often live with coexisting chronic health conditions. Current care for musculoskeletal pain remains narrowly focused on individual painful conditions, despite the complex health needs of patients. We explore the challenges of delivering integrated care to people with musculoskeletal pain and coexisting chronic health conditions. We discuss these challenges in relation to 3 areas: (1) the relationships between musculoskeletal conditions and other chronic health conditions, (2) the factors that impact the clinician's capacity to provide integrated care for musculoskeletal conditions, and (3) system-level constraints that impact both the clinician's delivery of care and the patient's health care experience. We suggest ways by which clinicians and researchers may move toward better integrated care for musculoskeletal pain and coexisting chronic health conditions. J Orthop Sports Phys Ther 2021;51(6):264-268. doi:10.2519/jospt.2021.10428.

What do the general public believe about the causes, prognosis and best management strategies for low back pain? A cross-sectional study

Background

Low back pain (LBP) is one of the most common reasons for seeking health care and is costly to the health care system. Recent evidence has shown that LBP care provided by many providers is divergent from guidelines and one reason may be patient’s beliefs and expectations about treatment. Thus, examining the nature of patient beliefs and expectations regarding low back pain treatment will help coordinate efforts to improve consistency and quality of care.

Methods

This study was a cross-sectional population-based survey of adults living in Newfoundland, Canada. The survey included demographic information (e.g. age, gender, back pain status and care seeking behaviors) and assessed outcomes related to beliefs about the inevitable consequences of back pain with the validated back beliefs questionnaire as well as six additional questions relating beliefs about imaging, physical activity and medication. Surveys were mailed to 3000 households in July–August 2018 and responses collected until September 30th, 2018.

Results

Fout hundred twenty-eight surveys were returned (mean age 55 years (SD 14.6), 66% female, 90% had experienced an episode of LBP). The mean Back Beliefs Questionnaire score was 27.3 (SD 7.2), suggesting that people perceive back pain to have inevitable negative consequences. Large proportions of respondents held the following beliefs that are contrary to best available evidence: (i) having back pain means you will always have weakness in your back (49.3%), (ii) it will get progressively worse (48.0%), (iii) resting is good (41.4%) and (iv) x-rays or scans are necessary to get the best medical care for LBP (54.2%).

Conclusions

A high proportion of the public believe LBP to have inevitable negative consequences and hold incorrect beliefs about diagnosis and management options, which is similar to findings from other countries. This presents challenges for clinicians and suggests that considering how to influence beliefs about LBP in the broader community could have value. Given the high prevalence of LBP and that many will consult a range of healthcare professionals, future efforts could consider using broad reaching public health campaigns that target patients, policy makers and all relevant health providers with specific content to change commonly held unhelpful beliefs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10664-5.

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.

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

Purpose: The primary aim of this study was to explore relevant outcome domains for patients with chronic low back pain (CLBP) undergoing physiotherapy. A secondary aim was to examine potential discrepancies between meaningful changes in pain and disability and the global perception of improvement.Methods: An explanatory mixed methods design was employed. Twenty-two patients with CLBP completed self-reported measures before and after a physiotherapy programme. After the intervention, three focus groups were conducted with patients who perceived an overall improvement. Discussions were recorded, transcribed and analysed using thematic analysis.Results: Quantitative analysis showed an inconsistent relationship between changes in pain and disability measures and global improvements as perceived by patients. Two main themes emerged from the thematic analysis: "pain relief" (subthemes: reducing pain intensity and other symptoms; reducing medication intake; improving sleep quality) and "gaining control over the LBP condition" (subthemes: ability to self-manage; return to function; and sense of well-being and normality).Conclusion: Patients with CLBP perceived multiple outcomes from physiotherapy treatment that cover the domains of global, physical, mental and social health. These study findings suggest that the targets of measurement for physiotherapy need to be expanded in order to reflect outcome domains valued by patients.Implications for rehabilitationMinimum important changes in pain intensity and disability were not valid indicators of global improvements as perceived by patients.Patients with chronic low back pain undergoing physiotherapy perceived gains in multiple health domains that ranged beyond pain and disability domains.Physiotherapy outcome assessment needs to integrate other patient-relevant outcomes such as medication intake, sleep quality, ability to self-manage and sense of well-being.

Transcultural adaption and preliminary evaluation of "understanding low back pain" patient education booklet

Background

Low back pain (LBP) is the number one cause of disability globally. LBP is a symptom associated with biological, psychological and social factors, and serious causes for pain are very rare. Unhelpful beliefs about LBP and inappropriate imaging are common. Practitioners report pressure from patients to provide inappropriate imaging. A recently developed patient education and management booklet, ‘Understanding low back pain’, was designed to target previously identified barriers for reducing inappropriate imaging. The booklet includes evidence-based information on LBP and supports communication between patients and practitioners. Our aim was to 1) describe the translation process into Finnish and 2) study patients’ and practitioners’ attitudes to the booklet and to evaluate if it improved patients’ understanding of LBP and practitioners’ ability to follow imaging guidelines.

Methods

We translated the booklet from English to Finnish. Preliminary evaluation of the booklet was obtained from LBP patients (n = 136) and practitioners (n = 32) using web-based questionnaires. Open-ended questions were analysed using thematic analysis.

Results

Approximately half of the patients reported that reading the booklet helped them to understand LBP, while a third thought it encouraged them to perform physical activity and decreased LBP-related fear. Eighty percent of practitioners reported that the booklet helped them to follow imaging guidelines. In addition, practitioners reported that they found the booklet helpful and that it decreased the need for imaging.

Conclusions

The booklet seemed to be helpful in LBP management and in decreasing the need for LBP imaging according to patients and practitioners. Further research on the clinical effectiveness of the booklet in controlled study settings is needed.

Trial registration

ISRCTN, ISRCTN14389368, Registered 4 April 2019 - Retrospectively registered; ISRCTN11875357, Registered 22 April 2019 - Retrospectively registered.

Healthy Lifestyle Program (HeLP) for low back pain: protocol for a randomised controlled trial

INTRODUCTION

Low back pain is one of the most common and burdensome chronic conditions worldwide. Lifestyle factors, such as excess weight, physical inactivity, poor diet and smoking, are linked to low back pain chronicity and disability. There are few high-quality randomised controlled trials that investigate the effects of targeting lifestyle risk factors in people with chronic low back pain.

METHODS AND ANALYSIS

The aim of this study is to determine the effectiveness of a Healthy Lifestyle Program (HeLP) for low back pain targeting weight, physical activity, diet and smoking to reduce disability in patients with chronic low back pain compared with usual care. This is a randomised controlled trial, with participants stratified by body mass index, allocated 1:1 to the HeLP intervention or usual physiotherapy care. HeLP involves three main components: (1) clinical consultations with a physiotherapist and dietitian; (2) educational resources; and (3) telephone-based health coaching support for lifestyle risk factors. The primary outcome is disability (Roland Morris Disability Questionnaire) at 26 weeks. Secondary outcomes include pain intensity, weight, quality of life and smoking status. Data will be collected at baseline, and at weeks 6, 12, 26 and 52. Patients with chronic low back pain who have at least one health risk factor (are overweight or obese, are smokers and have inadequate physical activity or fruit and vegetable consumption) will be recruited from primary or secondary care, or the community. Primary outcome data will be analysed by intention to treat using linear mixed-effects regression models. We will conduct three supplementary analyses: causal mediation analysis, complier average causal effects analysis and economic analysis.

ETHICS AND DISSEMINATION

This study was approved by the Hunter New England Research Ethics Committee (Approval No 17/02/15/4.05), and the University of Newcastle Human Research Ethics Committee (Ref No H-2017-0222). Outcomes of this trial and supplementary analyses will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12617001288314.

Physical Therapy Informed by Acceptance and Commitment Therapy (PACT) Versus Usual Care Physical Therapy for Adults With Chronic Low Back Pain: A Randomized Controlled Trial

Chronic low back pain (CLBP) is a major cause of global disability and improving management is essential. Acceptance and commitment therapy (ACT) is a promising treatment for chronic pain but has not been modified for physical therapy. This randomized controlled trial (RCT) compared physical therapy informed by ACT (PACT) against standard care physical therapy for patients with CLBP. Patients with CLBP (duration ≥12 weeks, mean 3 years) were recruited from physical therapy clinics in 4 UK public hospitals. The Roland-Morris Disability Questionnaire (RMDQ) at 3 months' post-randomization was the primary outcome. Two hundred forty-eight participants (59% female, mean age = 48) were recruited and 219 (88.3%) completed measures at 3 and/or 12 months' follow-up. At 3 months, PACT participants reported better outcomes for disability (RMDQ mean difference = 1.07, p = .037, 95% CI = -2.08 to -.07, d = .2), Patient Specific Functioning (p = .008), SF12 physical health (p = .032), and treatment credibility (p < .001). At 12 months' follow-up, there were no significant differences between groups. PACT was acceptable to patients and clinicians and feasible to deliver. Physical therapists incorporated psychological principles successfully and treatment was delivered with high (≥80%) fidelity. Our results may inform the management of CLBP, with potential benefits for patients, health care providers, and society. PERSPECTIVE: Psychologically informed physical therapy has great potential but there are challenges in implementation. The training and support included in the PACT trial enabled the intervention to be delivered as planned. This successfully reduced disability in the short but not long term. Findings could inform physical therapists' treatment of CLBP.

Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

BACKGROUND

Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP.

METHODS

We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach.

RESULTS

Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies).

CONCLUSIONS

Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption.

REGISTRATION

PROSPERO 2017, CRD42017070703.

Enhancing dysphonia clinic consultations through a focus on patients' expectations: streamlining and validation of a new tool ('ACaPELa-R' questionnaire)

OBJECTIVE

The Assessing and Caring for Patients' Expectations in Laryngology ('ACaPELa') questionnaire was developed to guide laryngology clinic consultations. This study aimed to audit its use, revise it depending on outcomes and validate it.

METHODS

The questionnaire was completed by all new patients attending a laryngology clinic over one year. The questionnaire was refined and validated in a new cohort of patients over a six-month period.

RESULTS

Thirty-seven of 242 patients (15.3 per cent) incorrectly gave the same ranking to more than one question. Questions with similar content were collapsed to cover broader themes, and an outcome question was added, resulting in the five-item Assessing and Caring for Patients' Expectations in Laryngology - Revised ('ACaPELa-R') questionnaire. Using this revised questionnaire, there was a significant reduction in the number of same-ranked questions (4.4 vs 15.3 per cent; p = 0.003) and high patient satisfaction post-consultation (95.7 per cent).

CONCLUSION

The Assessing and Caring for Patients' Expectations in Laryngology - Revised questionnaire makes patients' rank ordering of questions easier. It can be used to inform how different topics should be approached during the consultation and utilised for clinician self-audit.