The Significance of Touch in Pediatric Physiotherapy

Exploring the role of therapeutic alliance and biobehavioural synchrony in musculoskeletal care: Insights from a qualitative study

BACKGROUND

Person-centred care underscores the therapeutic alliance (TA) as fundamental, fostering positive treatment outcomes through collaborative patient-clinician interactions. Biobehavioural synchrony within the TA, essential for effective care, reflects an adaptive process where organisms align responses during interactions. Enactivism and active inference provide profound insights into human perception, reshaping musculoskeletal care understanding. Touch and verbal communication, integral to the TA, foster synchrony and alignment of personal beliefs.

AIM

This study aimed to identify the tools used by manual therapists in musculoskeletal care to establish a TA with patients. Furthermore, it endeavours to evaluate the alignment of these strategies with current literature and their correlation with biobehavioural synchrony, enactivism, and the role of touch in active inference.

METHODS

The methodology followed rigorous qualitative research principles, particularly Grounded Theory and interpretative-constructivist principles, conducting eleven semi-structured interviews with open-ended questions.

RESULTS

The core category identified in the study is elucidated as follows: "Interwoven Connection: The Fabric of Therapeutic Synchrony." The interviews unveiled three main categories, each comprising sub-categories: (1) Creating a meaningful dialogue; (2) Promoting active patient participation; (3) Synchronisation.

CONCLUSION

Fostering meaningful dialogue, patient involvement, and therapeutic synchrony is crucial for a robust therapeutic alliance in musculoskeletal care. This underscores the importance of establishing a deep connection between clinicians and patients, central to effective person-centred care. Clinicians must prioritise two-way communication, empathy, and patient collaboration in defining personalised goals. Emphasizing touch and seeking patient feedback are also pivotal. Further research is needed to explore these elements and their impact.

Motor control and skill acquisition in pediatric physical therapy: an enactive proposal

Theories of motor control and skill acquisition strongly influence and guide various fields of clinical practice. In last decades, changes in theoretical frameworks related to the conceptualization of brain plasticity, functional structures within the child, and environment have led to a revision of therapy approaches progressing from therapist-driven to child-initiated approaches. Even though theoretical frameworks and clinical practice are closely linked to the child's body, the profession has paid less attention to theories concerning the body's role and status in interpersonal relationships when fostering motor control and skill acquisition in children. In this theoretical paper we discuss the theoretical frameworks of motor control and skill acquisition that currently guide clinical practice. Through highlighting valuable contributions of these theories, we explore theoretical and practical benefits pediatric physical therapy can acquire by taking an enactive approach as a means to bring the child as a subject into focus. We rely on enactive concepts of embodiment, autonomy, and participatory sense-making in our exploration to provide an extended understanding of motor control and skill acquisition shaping our beliefs about what counts in therapeutic encounters in pediatric physical therapy.

The osteopath-parent-child triad in osteopathic care in the first 2 years of life: a qualitative study

Background

Enactivism and active inference are two important concepts in the field of osteopathy. While enactivism emphasizes the role of the body and the environment in shaping our experiences and understanding of the world, active inference emphasizes the role of action and perception in shaping our experiences and understanding of the world. Together, these frameworks provide a unique perspective on the practice of osteopathy, and how it can be used to facilitate positive change in patients. Since the neonatal period is a crucial time for development, osteopaths should aim to create a therapeutic relationship. Arguably, through participatory sense-making, osteopaths can help the baby build a generative model (with positive priors) to deal with stress and needs throughout their life.

Aim

Since the literature considers that interactions with the environment, which enact the patients' experiences, depending on contextual factors and communication between patient and caregiver, this research explored whether there is a correspondence between the indications in the literature and clinical practice in the management of the mother/parent-child dyad during osteopathic care on children aged 0 to 2 years old.

Methods

Semi-structured interviews were conducted with a purposive sample of nine osteopaths with experience in the field of pediatrics. Interviews were transcribed verbatim, and constructivist grounded theory was used to conceptualize, collect and analyze data. Codes and categories were actively constructed through an interpretive/constructionist paradigm.

Results

The core category was the idea of the pediatric osteopath as a support for the family, not only for the child. Four additional categories were identified: (1) Preparing a safe environment for both children and parents, (2) Communication, (3) Attachment and synchrony, and (4) Synchronization.

Conclusion

Through participatory sense-making, osteopaths manage contextual factors to establish an effective therapeutic alliance through the osteopath-parent-child triad to facilitate the construction of the child's internal generative model to promote healthy development. The therapeutic encounter is considered an encounter between embodied subjects, occurring within a field of affordances (ecological niche) that allows the interlocutors to actively participate in creating new meanings through interpersonal synchronization. Participatory sense-making and the establishment of a therapeutic alliance through the osteopath-parent-child triad are crucial to promote healthy development in the child.

Exploring the potential of a standardized test in physiotherapy: making emotion, embodiment, and therapeutic alliance count for women with chronic pelvic pain

Introduction

There has been an increased use of standardized measurements in health care meant to provide objective information to enhance the quality and effectivity of care. Patient performance tests are based on standardized predefined criteria with a limited focus. When facing multifaceted health conditions, information expanding the predefined criteria in a standardized test may be required to understand the patient's complex symptoms. Relying on test information based on measurements according to functional biology, one risks missing information communicated by the sensitive and expressive body of the individual patient. The aim of this article is to investigate how body, self and illness perception is constituted as a co-construction between a physiotherapist and a patient with complex symptoms, expanding the use of a standard physiotherapy test.

Methods

This qualitative study is based on video-recordings and in-depth interviews of seven women with the complex health condition chronic pelvic pain. The video recordings consist of the patients performing the Standard Mensendieck test pre- and post-treatment with Norwegian psychomotor physiotherapy. The interviews are based on the patients` and the physiotherapists` conversations while watching and elaborating on these video recordings. Empirical data is analyzed within the theoretical perspectives of phenomenology and enactive theory, especially focusing on the concepts of embodiment and intersubjectivity.

Results

Taking an embodied approach, considering the body as expressive, communicative, and vulnerable to the environment and context, the results show that through bodily expressions the patients experienced the test situation as demanding, thus providing information beyond what the test was intended to measure. Additionally, when administering a standardized test, the interaction between the therapist and the patient had an impact on the results. Sensitive attention towards the patients bodily expressive emotions as a vital part of the interaction, reinforced therapeutic alliance by ensuring the integrity and autonomy of the patient.

Discussion

Mutual communication, gave new insights regarding the patients' complex symptoms and reinforced their belief in themselves and their recovery processes. Applying the patient's expertise on herself and her life together with the professional expertise may make health care an interdependent practice where sensemaking is a co-construction of meaning between the patient and the health personnel.

A systematic synthesis of qualitative studies on parents' experiences of participating in early intervention programs with their infant born preterm

Early intervention programs involving both the parent and the infant born preterm have demonstrated positive effects on developmental outcomes for the children. However, studies have also shown that parental engagement and adherence when implementing intervention programs can be challenging. The aim of this review was to provide a comprehensive description and new insights into key messages gleaned from the parent reports on participating in early intervention with their infant born preterm; knowledge vital to facilitate implementation of early interventions into clinical practice when using a model of direct parent involvement. Early intervention is broadly defined as a multi-interdisciplinary field provided to children from birth to five years of age to foster child health, wellbeing, development, adapting parenting and family function. For this systematic synthesis we define early intervention as programs with specific activities completed with the infant during the first year after birth. We assembled qualitative interview studies on parents' experiences with participation in early intervention and applied Malterud's qualitative systematic meta-synthesis to synthesize and translate the original findings across studies. In the analysis we applied enactive concepts of embodiment, autonomy, participatory sensemaking, and agency. 10 qualitative studies were identified and included. The systematic synthesis reveals how parents' successful and meaningful participation in early intervention programs were facilitated by their "active embodied doing." The "embodied doing" appeared as the basis for the parents' sense-making processes, development of confidence, and the ability for parents to see new possibilities for actions within themselves, with and in the child. In that respect, a perception of mutuality in the interaction between parent, infant and interventionist was central. Consequently, an important consideration when implementing early intervention into clinical practice is to promote embodied parent-infant interactions as well as trust between the parent and the interventionist.

Developing fluency in a language of tactile communication

Touch has been an integral part of physiotherapeutic approaches since the inception of the profession. More recently, advances in the evidence-base for exercise prescription and "active" management have brought "touch" into question. This, in part, assumes that the patient or recipient simply passively receives the input rather than being an active partner in the interaction. In this article, we propose that touch can be used as a two-way conversation between therapist and client where each is engaged in tactile communication that has the potential to raise patient awareness and improve movement-based behaviour.

A critical phenomenological investigation in the use of touch as "know how" in practical physiotherapy in primary care with children and adults

In this article, we examine the interactions between physiotherapists and patients in actual situations, focusing on how touch is expressed, what it may mean and how physiotherapists know (or do not know) when and how to touch. The empirical material is obtained from two Norwegian research projects. In both of them, the first author observed physiotherapeutic practice and conducted interviews with patients (children and adults) and physiotherapists. A phenomenological research approach was applied, and analysis of the empirical data was guided by the concept of bridling, implying adopting a questioning attitude and being open to that which presents itself and exploring its possibilities. Three processed excerpts from the empirical data are presented to illustrate how, in different ways, physiotherapists' expert knowledge about how to relate to and interact with individual patients is put into play and expressed in real physiotherapy encounters. Each excerpt is presented individually, followed by analysis. Our findings reveal aspects of the epistemology of physiotherapeutic practice to be intercorporal and illuminated by the concept and phenomenon of letting the other be.

Relationship-driven, family-centered care via TelePT: Reflections in the wake of COVID-19

In response to the throttling of children’s therapy programs precipitated by COVID-19 shutdowns, interest in the use of telehealth has increased among service providers at both the clinical and administrative levels. TelePT promises to be particularly appropriate in devising programs of on-going, therapeutic exercise interventions for children with neuromotor disorders. From the lay perspective, physical/physiotherapy (PT) which is seemingly characterized by the “hands-on,” and corrective approach to managing impairments, makes it a counter-intuitive candidate for delivery over telehealth. Over the past decades, however, PT as a discipline has increasingly adhered to a relationship-driven, family-centered model of intervention. This model is “hands-off,” figuratively if not always literally, and hence is not necessarily disconsonant with delivery mediated by telehealth technology. The current study explores in-depth the experiences and reflections of seven practicing therapists, on the impact of telehealth, telePT on the operationalization of relationship-based, family-centered methods into therapy. Interpretative phenomenological analysis was selected as the analytic method for understanding participants’ experience providing services using both distance and standard face-to-face practice modalities. Results identified eight principal themes emerging from participants’ descriptions of their experience of delivering therapy over telePT. Four of these themes correspond to the tenets of relationship-driven, family-centered care identified across four frameworks applied to pediatric rehabilitation. The remaining four themes focus on the particularities of the telePT modality and its viability in clinical practice. The ability telePT afforded to “see into the child’s environment” emerged arguably as the greatest value of the modality in patient care. It revealed to therapists so much that they did not know about their patients’ progress and, more strikingly, had not realized they did not know. TelePT provides a unique window into the child’s functioning in the hours he is not in therapy. Given its potential in parent–therapist relationship building, assuring the ecological validity of therapy programs, and the empowerment of families who seek it, telePT is likely to be part of the future of PT and one driver of its evolution as a profession. There is a compelling case to retain telePT modalities offering them alongside in-person formats for convenience, safety, and service quality enhancement.

Enactive explorations of children's sensory-motor play and therapeutic handling in physical therapy

Introduction

In pediatric physical therapy, there is an ongoing debate about the use of therapeutic handling and its potential effects on motor learning. In this study, we build on enactive theoretical perspectives to explore the role of therapeutic handling in connection to children's sensory-motor play, engagement, and performance during a single physical therapy session.

Material and methods

This is a qualitative study based on video observations of therapy sessions and interviews with 15 physical therapists (PTs) each treating two different children aged 0–3. The authors utilized a framework of co-reviewing, discussing, and reflecting on the sessions. Themes were identified and used to describe the ways by which PTs’ therapeutic handling unfolds, with connections to theories on sensory-motor play and learning, along with enactive perspectives on embodiment, experience, mutual incorporation, and sense-of-agency.

Results

The characteristics and purposes of therapeutic handling are presented in two main themes: (1) position and support, and (2) directing movement. We found that position and support promoted sensory-motor improvement when the PTs’ handling aligned with the child's play interests and engagements. As part of play, the children used new and additional support surfaces to self-initiate better posture and movement solutions and reach play goals. The PTs’ ways of directing movements varied. To awaken curiosity and induce a child's self-driven motor exploration the PT needs to be subtle, flexible, and precise in the directing of movement. This entails responsiveness to the child's signals and bodily know-how in the placing of hands and direction of pressure to enable the child to actively participate in and eventually self-drive movement.

Discussion

Therapeutic handling that is mutually incorporated between PT and child can enrich the child's playing-to-learn-to-move process by providing novelty and facilitating the child's sense-of-agency in the self-initiated exploration and refinement of movement possibilities. In the PTs’ effort to merge therapeutic handling with children's play, the momentum of interaction can open new therapeutic windows of movement experience and learning opportunities.