Patient- and Physical Therapist-Level Predictors of Patient-Reported Therapeutic Alliance: An Observational, Exploratory Study of Cohorts With Knee and Low Back Pain

Reasons for patient no-shows and drop-offs after initial evaluation in physical therapy outpatient care: a qualitative study

BACKGROUND

No-shows and drop-offs by patients after their initial physical therapy evaluation can significantly impact clinics and therapists. To our knowledge, no previous studies have examined the patient's perspective of why they terminated their recommended plan of care after only attending their initial evaluation.

OBJECTIVE

To gain insights regarding why patients do not follow through on a recommended physical therapy plan of care after the initial evaluation.

METHODS

This qualitative study used semi-structured phone interviews with patients who received a physical therapy evaluation for a musculoskeletal condition within a large regional healthcare system. Participants were purposefully sampled if they attended their initial evaluation, did not attend a follow-up visit within 30 days, and had no future appointments scheduled. After data collection and transcription, coding and thematic analysis took place to establish primary and secondary themes.

RESULTS

A total of 26 interviews were conducted, including 12 males and 14 females, with an average age of 51.04 (± 15.72) years. Five common themes emerged, including clinical improvement at an acceptable rate (23.1 %), access issues (26.9 %), did not see value or could do therapy on their own (23.1 %), other medical management was needed (15.4 %), and patient-provider relationship issues (11.5 %).

CONCLUSION

These findings highlight the patient's rationale for not following through on a physical therapist's recommended plan of care after an initial evaluation. They may help practice managers and clinicians to proactively address barriers, clinic access issues, and evaluation strategies to maximize the patient's follow-through on their plan of care.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Psychologically Informed Practice: The Importance of Communication in Clinical Implementation

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician-patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions.

Patients' Perceptions of Physical Therapists Addressing Opioid Misuse

INTRODUCTION

In the US, rising numbers of patients who misuse illicit or prescribed opioids provides opportunities for physical therapists (PTs) to be engaged in their care. Prior to this engagement, it is necessary to understand the perceptions of patients who access physical therapy services about their PTs playing such a role. This project examined patients' perceptions of PTs addressing opioid misuse.

METHODS

We surveyed patients, newly encountering outpatient physical therapy services in a large University-based healthcare setting, via anonymous, web-based survey. Within the survey, questions were rated on a Likert scale (1 = completely disagree to 7 = completely agree) and we evaluated responses of patients who were prescribed opioids versus those who were not.

RESULTS

Among 839 respondents, the highest mean score was 6.2 (SD = 1.5) for "It is OK for physical therapists to refer their patients with prescription opioid misuse to a specialist to address the opioid misuse." The lowest mean score was 5.6 (SD = 1.9) for "It is OK for physical therapists to ask their patient why they are misusing prescription opioids." Compared to those with no prescription opioid exposure while attending physical therapy, patients with prescription opioid exposure had lower agreement that it was OK for the physical therapist to refer their patients with opioid misuse to a specialist (β = -.33, 95% CI = -0.63 to -0.03).

CONCLUSIONS

Patients attending outpatient physical therapy seem to support PTs addressing opioid misuse and there are differences in support based on whether the patients had exposure to opioids.

Attitudinal responses to current concepts and opinions from pain neuroscience education on social media

BACKGROUND

Pain neuroscience education (PNE) programs have become popular among clinicians and are widely promoted through social and mainstream media.

PURPOSE

To test the hypothesis that people with persistent pain are likely to express negative attitudes to PNE statements and compare their responses to other social media user groups.

METHODS

A total of 1319 respondents completed an online survey and were directed into four groups: persistent pain, healthcare professionals with persistent pain, pain-free healthcare professionals, and pain-free controls. The survey included ten statements of popular PNE concepts. Feedback was invited by offering seven attitudinal response categories (three positives, three negatives, and one neutral). A two-step hierarchical regression model was used to assess the likelihood of reporting negatively.

RESULTS

Compared to controls, respondents from the persistent pain group were more likely to report negatively towards all statements (OR 1.6-2.16), except for two statements (#3 and #5). Healthcare professionals were less likely to report negative attitudes for 4 out of 10 statement (OR 0.35-0.58). Health care professionals living with persistent responded to most statements like the pain-free controls (besides statement #2, OR 0.59).

CONCLUSION

People living with persistent pain are more likely to express negative attitudes to PNE statements on social media, unlike healthcare professionals who were less likely to express negativity. Healthcare professionals living with persistent pain responded to most PNE statements like the pain-free control group. The study's main weaknesses include the lack of psychometric information of the questionnaire used, selection bias, small samples of the healthcare professionals and the overrepresentation of young social media users.