BACKGROUND
The effectiveness of physiotherapy to reduce low back pain depends on patient adherence to treatment. This requires effective strategies to facilitate but also tools to measure adherence to physiotherapy. Facilitators and barriers to patient adherence are multifactorial and include patient and therapist-related factors.
PURPOSE
This three-part research project aimed to identify strategies to facilitate adherence of patients with low back pain to physiotherapy.
A systematic review identified tools to measure and strategies to facilitate adherence.
The subsequent focus group study aimed to identify aspects of patients' experiences in their physiotherapy and physiotherapists' reflections that influenced adherence.
The final Delphi study aimed to reach an expert consensus on aspects influencing adherence.
METHODS
The three research studies were conducted sequentially and each built on the previous findings. The two-stage review study included a scooping procedure in stage one to identify tools for measuring adherence. Stage two included a systematic process that followed the PRISMA recommendations.
The focus group study included patients with low back pain (n = 10, 5 women) and physiotherapists (n = 11, 5 women). Data analysis was implemented using simple transcription with structured content analysis based on categorization (deductive/inductive) and coding.
In the final Delphi study, international experts were invited to participate in a three-round standard Delphi survey. The survey contained 49 items (32 original and 17 suggested by experts) which were rated on 5-point Likert scales. The items were assigned to six domains. The consensus level was defined as 60 %.
RESULTS
In the systematic review, 21 studies were included for stage one and 16 for stage two. Identified were six different tools to measure adherence. The most used tool was an exercise diary; the most common more multidimensional tool was the Sports Injury Rehabilitation Adherence Scale. The most promising strategies for facilitating adherence were based on cognitive behavioral principles.
The focus group study identified that patients with back pain requested more effective home programs, long-term rehabilitation management, and individualized therapy to achieve a higher level of adherence. Physiotherapists requested more time for patient education. Communication, quality of the therapist-patient relationship, and individualized therapy were identified as essential factors by both representatives.
The Delphi study experts agreed on the domains “Influence of biopsychosocial factors” (89%) and “Influence of cooperation between physiotherapists and patients” (79%) as major influencing aspects for patient adherence. Additional important domains were the “Influence of competencies of physiotherapists” (71%) and “Interdisciplinary congruence” (78%).
CONCLUSIONS
Biopsychosocial factors, therapeutic competencies, and patient-physiotherapist collaboration should be considered in physiotherapy practice to facilitate adherence in patients with back pain to physiotherapy. Future studies should prospectively evaluate the effectiveness of individual or combined identified aspects for their influence on patient adherence in longitudinal study designs.
IMPLICATIONS
The results of this three-part research provide recommendations for facilitating adherence of patients with back pain in physiotherapy. Future research is required to develop a multidimensional measurement tool for adherence and to evaluate the effectiveness of individual or combined strategies for long-term patient adherence.
Background
Evaluation of psychosocial aspects such as fear or catastrophizing have been increasingly included within physical therapy research and standards of practice. The implications have been an increased emphasis on screening for potential negative risk factors for outcomes and specifically addressing this within the treatment plan. The role of the patient or clinician's expectations has been increasingly found in the literature. Given this evolution in the understanding of the role of expectations, measurement, and treatment of patient expectations are less well defined. This is inconsistent with the large shift in practice patterns that focuses on the psychosocial factors in the overall management of the patient. Understanding expectations is the first step in approaching this topic. Knowledge translation into clinical practice is an area of need moving forward.
Purpose:
This project offers knowledge translation and clinical implementation strategies from our recent systematic reviews regarding patient expectations in musculoskeletal practice.
Methods:
Two systematic reviews were completed in accordance with PRISMA 2020 guidelines (pre-registration, PICO-guided searches in multiple databases, independent screening, appraisal and extraction, etc.) Both reviews linked musculoskeletal patient expectations (1- recovery expectations and 2- treatment expectations) to patient outcomes. Summarily asking, do patient outcomes differ between groups who 1- expect physical therapy to be of benefit compared to patients who do not expect physical therapy to help or 2- receive treatments they think will be of benefit versus receive treatments they do not think will be beneficial?
Results:
Recovery expectations were measured in 19 studies with 4,347 musculoskeletal patients while 1,855 patients’ treatment expectations were measured in 12 studies. The majority of studies were secondary analyses of randomized controlled trials or cohort studies with acceptable appraisal scores. Patient expectations were correlated with patient-reported outcomes in both reviews. The tools to measure expectations and outcomes were highly variable.
Conclusion(s):
Expectations should be measured at evaluation as part of a holistic examination process given their relationship to patient outcomes. There is greater evidence to support measuring recovery expectations than treatment-specific expectations. Future research to further investigate these and other expectations will serve to enhance patient outcomes.
Implications: The role of psychosocial factors in managing musculoskeletal conditions has been well established. The distinct area that is needed is knowledge translation into the clinical sector. Exploring the factors clinicians should consider related to expectations and discussing real-world applications is the focus of this presentation. This presentation will provide clinicians with a robust understanding of expectations to consider, tools and or approaches to assist in the assessment of these factors, and evidence-informed strategies to assist in the management of different expectations in the clinic. As a clinician, it is critical to both understand and apply this knowledge in the clinical setting to provide the best possible care for patients with musculoskeletal conditions.
Background: Belief is a powerful driving force in one’s behaviour. Health locus of control (HLOC) refers to a person’s belief of where responsibilities for his/her health condition lies. Evidence suggests that HLOC is associated with health attitudes, health behaviours and the key clinical elements of non-specific chronic low back pain (NSCLBP) such as pain and disability. These are the key areas musculoskeletal physiotherapists seek to address in their practice. However, it is not known whether a physiotherapy-led cognitive-behavioural chronic low back pain (CBCLBP) programme effects patient HLOC.
Purpose: To determine: (1) the effects of a six-week CBCLBP programme on patient HLOC, pain intensity, disability, fear-avoidance belief (FAB) and self-care attitude; (2) the association between changes in pain intensity, disability, FAB and changes in HLOC; and (3) the costs of producing any effect and healthcare utilization.
Methods: In an A-B-A same-subject design, patients with NSCLBP and high FAB were recruited. Patients completed a four-week course of 1:1 physiotherapy followed by a six-week CBCLBP programme. Outcomes were measured before and after the 1:1 physiotherapy, immediately after the CBCLBP programme, and 3- and 6-months later. Friedman’s ANOVA and Wilcoxon signed-rank tests determined changes between phases. Multiple regression determined the relationship between HLOC and outcome of interest. Significance was set at 0.05.
Results: N=70 patients were recruited. N=55 patients entered the programme and completed the 6-month follow-up (79%). No significant improvement was seen after the 1:1 physiotherapy. Significant improvement in HLOC (p < 0.001), pain intensity (p < 0.001), disability (p < 0.001), FAB (p < 0.001) and self-care attitude (p < 0.001) was found immediately after the CBCLBP programme, with improvements sustained for 6 months. Changes in HLOC explained 6%, 0.5% and 31.9% variances in changes in pain, disability and FAB respectively, after controlling other variables. Increased internal locus of control (ILOC) was a significant predictor of reduction in FAB (p=0.002). HLOC had no predictive importance in the reduction of pain intensity or disability. The mean provider’s cost of the programme was £285.82 per patient. At 6-month, 25% of the participants re-visited their GP, and 16% consulted other therapy.
Conclusion: The CBCLBP programme significantly improved patients’ HLOC, pain intensity, disability, FAB and self-care attitude for 6 months. Increase in ILOC was a unique significant predictor of reduction in FAB, highlighting the potential importance of improving ILOC in attaining better FAB outcome, which in turn is related to reduction in pain intensity and disability. As a guide to stakeholders, £285.82 per patient is less costly compared to 1:1 physiotherapy.
Implications: HLOC should be targeted in CBCLBP programme to optimize treatment outcomes in NSCLBP. For this subgroup of NSCLBP patients, the CBCLBP programme was more effective in addressing the multi-dimensional nature of NSCLBP than 1:1 physiotherapy. It is recommended that policy makers and clinicians should routinely consider the CBCLBP programme as a first-line intervention rather than a last resort for this subgroup.
Background:
Many patients with musculoskeletal problems do not adhere to home exercises or self-management advice provided by physiotherapists. This is due to numerous factors, many of which can be targeted by Behaviour Change Techniques (BCTs).
Purpose:
For the physiotherapy management of people with musculoskeletal problems, the purpose of this systematic scoping review and mapping exercise was to 1) identify modifiable determinants (barriers and facilitators) of home exercise adherence and self-management, 2) for determinants with supporting evidence from ≥2 studies, map these to the Theoretical Domains Framework and BCTs and 3) provide examples of BCTs for clinical practice.
Methods:
The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Medline, Embase, CINAHL, and AMED were searched from inception to December 2022. Two independent reviewers carried out manuscript selection, data extraction, quality assessment, and mapping. Risk of bias (RoB) was assessed using the Quality in Prognosis Studies (QUIPS) tool. The Theory and Techniques Tool was used to map determinants to BCTs.
Results:
Thirty-two publications, describing 29 cohorts were included. Thirteen modifiable determinants were supported by ≥2 studies. Five of six studies reported a positive association between exercise self-efficacy and adherence, the only determinant supported by evidence from ≥2 cohort studies with low RoB. Patient understanding, being observed, receiving feedback, physiotherapists providing information, and a lower number of prescribed exercises were each investigated in 2-3 studies, all of which demonstrated a positive association with adherence and included one cohort study with low RoB. For physical activity, perceived treatment efficacy, social support, and task appreciation there was evidence from some studies of no association with adherence. These studies were of higher RoB and less or equal in number compared to those showing a positive association. Evidence of a positive association between coping and task self-efficacy with adherence was not consistent, with a greater number of studies reporting no association.
Determinants were mapped to 7 of 14 TDF categories. These mapped onto 42 of 93 BCTs, the most common being problem solving and instruction on how to perform the behaviour. The six most common categories of BCTs were goals and planning, feedback and monitoring, natural consequences, repetition and substitution, reward and threat, and antecedents.
Conclusions:
For people receiving physiotherapy for musculoskeletal problems, this review has identified modifiable determinants of exercise adherence and self-management and mapped these to evidence based BCTs. It has provided guidance and clinical examples to help physiotherapists select BCTs which specifically target the determinants of importance for individual patients. Research is needed to investigate the effectiveness of integrating BCTs into physiotherapy.
Implications:
The actions of both the patient and their physiotherapist are determinants of exercise adherence and engagement with self-management, indicating a joint responsibility. A wide range of BCTs mapped to the identified determinants, indicating that physiotherapist may need to upskill their knowledge in this field. Integrating behaviour change science into existing pre- and post-graduate physiotherapy curriculum will help cascade learning and promote a culture of behaviour change management into standard clinical practice.
Background: Chronic musculoskeletal pain (CMP) is a public health global epidemic that inequitably impacts minorities, immigrants, and females. CMP is often reported as an “invisible” disease by patients who encounter stigma and biases when seeking care. A socially-just neuroethics perspective encourages clinicians to contextually understand their patients’ pain experiences to minimize the risk of inadvertently providing stigmatized or implicitly biased care. Racial, ethnic, and cultural differences have been previously demonstrated for pain severity, pain beliefs and coping. However, few studies have looked at a linguistically diverse population’s perceptions about CMP. Purpose: The primary aims of this mixed method study were to: 1) describe the self-reported pain experiences in people living in the Piedmont Region of North Carolina (United States) who have CMP and speak Arabic, English, or Spanish and 2) interpret their experiences of living with CMP. Methods: A multi-modal, multi-language sequential explanatory mixed method study was implemented. This study design allowed for a broad survey sample and in-depth follow-up.The ethics of social justice support this design as it provided agency to community participants. The biopsychosocial model, the social ecological model, and Bronfenbrenner’s ecological model were the guiding theoretical frameworks. Descriptive statistics summarized the Phase 1 results and a one-way analysis of variance was used to explore differences in pain severity. Cross-tabulation analyses determined the relationship between languages concerns that day-to-day activities will increase pain, pain interference perceptions, and beliefs regarding the safety of physical activity when one is in pain. An interpretative phenomenological analysis lens was used in Phase 2. Results: The findings are from 909 survey respondents (Phase 1) and 10 Phase 2 participants. Significant differences were demonstrated between the languages for pain severity, pain interference perceptions, and concerns that day-to-day activities would increase their pain. While Arabic and Spanish speaking participants were evenly split as to whether physical activity was safe or not, English-speakers believed physical activity was safe at a two-to-one margin. The uniqueness of their individualized CMP experience, “only I live with my pains” resonated with all. Common strategies across all languages included staying active and using massage, creams, and heat. The preferred resources varied by language, and resource decisions were underpinned by polices related to access to health care and access to the internet. Conclusions: Similarities and differences were noted in the pain experiences of Arabic-, English-, and Spanish-speakers. Some of the differences may be attributed to cultural preferences. However, the results also indicate that disparate policies underpinned some of the findings. Implications: Increasing awareness of broad policies that impact a population’s health is an important first step to improving inequitable outcomes in CMP. Clinicians wishing to address health disparities in CMP can prioritize community engagement to learn from linguistically diverse populations about their priorities and needs.
Background:
Patients with non-specific chronic low back pain (NSCLBP) face a long-lasting, painful and potentially disabling condition. In the absence of visible damage and physical explanations for the origin of the pain, they may experience poor social recognition and disbelief. It is important to understand what they specifically expect from physiotherapists in this context, as the influence of expectations on clinical decision making, relationships and outcomes has previously been highlighted.
Purpose:
The aim of this study is to identify NSCLBP patients' expectations of physiotherapists prior to a 3-week rehabilitation programme and their perceived fulfilment 1 month after the programme.
Methods:
A purposive sample of 20 patients (9♀ , 11♂ , 41.0±10.5 years, 4.3±3.5 symptom duration, 3 on sick leave, 2 professional retraining) participated in semi-structured interviews conducted by anthropologists before and after the programme. The first and last individual sessions of 10 patients were also observed. The qualitative data were crossed with the clinical data. Coding was done with Atlas.tiR, crossed content analysis was done by two anthropologists and two physiotherapists.
Results:
The goals of the majority of patients were consistent with those of the programme. Patients mainly expected an active programme. Although pain reduction was the most expected outcome, strengthening, return to valued activities and improved well-being were also expected. Patients expected physiotherapists to deal mainly with physical problems and to provide a functional diagnosis of their problem. They also expected advice, explanations and skills development to help them cope with NSCLBP. Technical, gestural and relational individualisation was strongly expected in individual sessions, while social support was expected in group sessions. Relational expectations mainly included listening, mutual trust, support and personalisation. However, patients' opinions differed on whether or not physiotherapists should address emotional issues. Most patients felt that their expectations were met during the programme. However, they were not met when rehabilitation goals and patient goals diverged. Physiotherapists were generally not held responsible for unmet outcome expectations as long as they showed personal involvement and attention to the patient. Observations showed that expectations and responses given were often formulated indirectly.
Conclusion(s):
Expectations are specific to a sample of experienced patients enrolled in an NSCLBP rehabilitation programme. Patients' adherence to programme goals was fundamental to the fulfilment of expectations. Patients' expectations converged towards notions of patient-centred care and the development of a personalised therapeutic alliance with the physiotherapist. Patients differentiated the fulfilment of expectations towards the programme outcome from those towards the physiotherapist. In the case of a mitigated rehabilitation outcome, they considered their expectations of the physiotherapist to be met if he/she showed commitment and adaptation to their person and situation. Further research is needed to understand the factors that shape and influence patients' expectations.
Implications:
Awareness and discussion of patients' expectations could help to optimise the mutual therapeutic and relational fit between patient and physiotherapist. Physiotherapists need to help clarify expectations as they are often expressed indirectly. Consideration of expectations could help to improve the patient's sense of recognition and rehabilitation achievement.
“The pain is not necessarily less, but I experience it differently”: A qualitative study about how people with persistent pain experience physiotherapy care blended with a biopsychosocial digital intervention.
Poolman EYa,b, Vorstermans Lc, Donker MHd, Coppieters MWa,e, Cuijpers Pb, Scholten-Peeters GGMa, de Wit LMb
a Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences - Program Musculoskeletal Health, The Netherlands.
b Amsterdam Public Health Research Institute, Department of Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, The Netherlands.
c Master Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, The Netherlands.
d Department of Health Sciences, Faculty of Beta Sciences, Vrije Universiteit Amsterdam, The Netherlands.
e Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Brisbane & Gold Coast, Australia.
ABSTRACT
Background: A blended intervention consisting of face-to-face therapy and psychologically informed digital care was developed to optimise the management of people with persistent spinal pain who also have psychosocial risk factors associated with the development or maintenance of persistent pain. This study aimed to gain insights in how participants experienced this blended intervention.
Methods: An interpretative qualitative study using semi-structured interviews was conducted. Eleven people with persistent non-specific spinal pain who received the blended intervention within a randomised clinical trial were included. All interviews were recorded, transcribed verbatim and analysed independently by two researchers. Data were analysed using a thematic inductive approach.
Results: The analysis identified four themes: (1) Experiencing a better understanding of the relationship between own physical and mental health, which also highlights the variations in preferences for receiving such psychologically informed care; (2) Importance of the physiotherapist’s active involvement in biopsychosocial blended care, which describes the crucial role of physiotherapists in supporting participants in this; (3) Appreciation of digital care, to better understand persistent pain and make meaningful lifestyle changes; and (4) Trials and triumphs, revealing gains such as reduced suffering, but also challenges with implementation of changes into long-term routines.
Conclusion: Participants of the blended intervention experienced positive changes in thoughts and behaviours, which highlights the feasibility and acceptability of the blended intervention as a more holistic treatment within pain management. The differences in personal preferences for receiving psychologically informed digital care poses challenges for implementation of blended biopsychosocial care in evidence-based practice.
Background: Non-specific neck pain (NSNP) contributes substantial socio-economic burden internationally. Up to 50% people experience NSNP annually. Patients with NSNP can experience physical (e.g., pain and disability) and psychological (e.g., fear avoidance, anxiety and depression) problems, leading to reducing quality of life. Furthermore, recurrent symptoms and chronicity are frequently reported. Thus, an effective intervention is still required to manage the multiple components of NSNP. An active behavioural physiotherapy intervention (ABPI), a complex intervention delivered within a flexible framework addressing both physical and psychological aspects, may be feasible to manage patients with acute NSNP to prevent chronicity based on the findings of a previous pilot and feasibility trial in acute whiplash-associated disorders.
Purpose: To evaluate feasibility and procedures of the ABPI to prevent the transition to chronicity in patients with acute NSNP in order to inform design of a future adequately powered definitive trial.
Methods: An external pilot and feasibility cluster-randomised double-blind (assessors and participants) parallel two-arm clinical trial (ABPI versus standard physiotherapy intervention [SPI]) was performed based on a pre-specified published protocol to minimise potential biases. Six physiotherapy departments in six public hospitals in Thailand were recruited and cluster-randomised to either ABPI (n=3) or SPI (n=3) using computer-generated randomisation with block sampling. Sixty participants (30 each arm, 10 per hospital) with acute NSNP (< 4 weeks) were recruited. Participants were assessed at baseline and 3-months follow-up post baseline (planned primary endpoint definitive trial). The planned primary outcome measure was the Neck Disability Index (NDI). The Numerical Pain Rating Scale (NPRS), Fear-Avoidance Beliefs Questionnaire (FABQ), Cervical Range of Motion (CROM) and EuroQol 5-dimension 5-level (EQ-5D-5L) were planned secondary outcome measures. Data were analysed descriptively consistent with the nature of a pilot and feasibility trial. Fully recovered status was evaluated using an NDI cut-off ≤ 4/50. Treatment session details and costs of management were collected to explore feasibility of cost-effectiveness analyses.
Results: All procedures worked well. All participants attended in person assessments at baseline and 3-month follow-up. The median age of participants was 36.5 years (range 21-59, interquartile range: 20.75). Considering the median of difference between intervention arms, the findings suggest that the ABPI could improve all physical (NDI [12/50:9/50], NPRS [5/10:4/10] and CROM all directions) and psychological (FABQ [17/66:6/66] and its sub-scores) outcomes including quality of life rather than the SPI. The exceptions were the EQ-5D-5L dimensions of mobility, self-care, pain/discomfort and anxiety/depression which were similar for both interventions. The number of fully recovered participants following ABPI (27/30, 90.00%) was higher than SPI (16/30, 53.33%) with fewer treatment sessions and lower costs of management. No adverse or serious adverse events were reported.
Conclusions: The findings suggest that the ABPI is feasible and valuable (e.g., high number of fully recovered participants, fewer treatment sessions and reduced management costs compared to the SPI). Conducting a future definitive trial to evaluate effectiveness of the ABPI is supported without modifications based on the a priori criteria.
Implications: A definitive trial is feasible to evaluate effectiveness of the ABPI to prevent chronicity for acute NSNP patients.