Will shared decision making between patients with chronic musculoskeletal pain and physiotherapists, osteopaths and chiropractors improve patient care?

Patient involvement in medical decisions: a survey of shared decision making during physical therapy consultations

INTRODUCTION

Shared decision making (SDM) is widely affirmed as an ethical principle in healthcare; underpinned by both evidence of its positive outcomes among patients and strong inducements for its adoption by health professionals. This study investigated patients' involvement in SDM, determined its association with their personal characteristics and identified factors influencing their participation.

METHOD

A cross-sectional survey was executed among 148 consenting patients, who were recruited using convenience sampling technique and invited to complete self-report questionnaires on SDM. Data were analyzed via descriptive and inferential statistics.

RESULTS

Only 14 patients (9.5%) were involved in SDM whilst most patients (88.5%) had passive roles during consultation. SDM involvement had significant associations with age (p = .006) and educational status (p = .021). Most patients (67.6%) identified 'Doubt towards SDM,' as a factor that could hinder this collaborative process. Similarly, majority of the patients acknowledged the relevance of the influential factors: 'Physiotherapist's support' (83.7%) and 'Adequate health Information' (75%), toward promoting involvement in SDM.

CONCLUSION

Patient involvement in SDM was low in this study. Older and less/uneducated patients exhibited an increased tendency of noninvolvement. Key influential factors that either facilitate or hinder patients' involvement in SDM were revealed. There is a need to curtail drawbacks to SDM and promote its execution in physical therapy as well as general clinical practice.

Common reported barriers and facilitators for self-management in adults with chronic musculoskeletal pain: A systematic review of qualitative studies

BACKGROUND

Self-management strategies are considered a necessary component of chronic musculoskeletal pain management to address ongoing symptoms and challenges. However uptake of self-management can be impeded by a number of factors.

OBJECTIVES

The aim of this study was to explore common impeding and facilitating factors of self-management strategies from the patient perspective.

METHODS

An electronic search was performed between 2009 to May 2020 for the following databases: MEDLINE, AMED, PsychINFO, Cochrane Library, PubMed, CINAHL, PEDro, and Google Scholar. The search terms included peer-reviewed qualitative or mixed-method studies investigating the perspective of chronic musculoskeletal pain patients in regards to the use of self-management strategies. Study rigor and bias was assessed using the CASP (Critical Appraisal Skills Programme) questionnaire specific to qualitative studies. Qualitative data was coded using a three-stage thematic synthesis process. Confidence in findings was assessed using CERQual (The Confidence in the Evidence from Review of Qualitative Research).

RESULTS

Twenty-seven studies were included with 487 participants. Six major themes were identified and divided into external and internal influencing factors. The external influencing factors were made up of the following three themes: health care practitioner role, supportive environment, accessibility. While the three internal influencing themes were: physical factors, knowledge and understanding, and psychological factors.

CONCLUSION

Learning to self-manage for patients in chronic pain required ongoing support either from healthcare practitioners or from social circles. To further assist the self-management process practitioners can improve self-efficacy through increasing patient knowledge of chronic pain, utilising goal setting and finding ways an individual can access ongoing support, either from the practitioner or through group programs.

Lifestyle Medicine for Chronic Lower Back Pain: An Evidence-Based Approach

Lower back pain is a leading cause of work absence and activity limitations globally, with a 60% to 85% lifetime chance of occurrence. This article highlights the role that lifestyle medicine plays in managing lower back pain as a cost-effective intervention strategy. It is suggested that lifestyle medicine strategies, such as incorporating whole foods and a plant-based diet, sustainable physical activity and mind-body exercises, restorative sleep, stress resiliency, awareness and mitigation of substance abuse and addiction, and establishing meaningful social networks and self-care strategies, be a part of managing chronic lower back pain.

Do patients with low back pain remember physiotherapists' advice? A mixed-methods study on patient-therapist communication

OBJECTIVES

The primary aim of this study was to determine if the advice physiotherapists think they provide to patients with low back pain (LBP) is what the patients remember and take away from the clinical encounter. The secondary aim was to determine which factors may influence the retention of this advice.

METHODS

The first component of the study used questionnaires completed by patients and therapists after the initial visit. Related questionnaires of patients and therapists were screened for inconsistencies. The second component of the study involved semi-structured interviews.

RESULTS

Ninety pairs of questionnaires were completed. Therapists provided patients with one (N = 90), two (N = 85) or three (N = 51) items of advice regarding the management of their LBP. All patients remembered the first item of advice, 92% remembered a second, and 67% remembered the third piece of advice. All items of advice were deemed either 'relevant' or 'very relevant' by 97% of the patients. After the analysis of 14 interviews, data saturation was reached. Four themes emerged from the data analysis of the interviews: (a) Evaluation type, (b) Exercise factors, (c) Patient concerns about their diagnosis, and (d) Patient expectations.

DISCUSSION

In most cases, patients remembered what therapists told them and considered that the advice provided was relevant. Based on the qualitative data, patients were more likely to remember what therapists said when: (a) shared decision making was used during the initial encounter, (b) prescribed exercises were simple to perform and few in number, (c) patients' concerns about their diagnosis were addressed, and (d) patients' expectations were identified and addressed.

Patient Assessment and Chronic Pain Self-Management in Ethnomedicine: Seasonal and Ecosystemic Embodiment in Ayurvedic Patient-Centered Care

Background: Ayurveda’s preventive focus complements its strength with the interventionist approach of the biomedical in chronic pain self-management. Patient-centered care (PCC) using ethnomedicine promises greater patient self-management; however, few studies have examined environmental relationships and PCC in self-management of chronic pain through Ayurveda. Objective: To examine how Ayurveda’s philosophical focus on whole system frameworks describes the integration of the individual and the ecological in tailoring an integrative patient-centered diagnostic and prognostic approach to chronic pain management. Methods: This qualitative case study conducted in-depth semi-structured interviews of Ayurvedic physicians from India (N = 10) and a qualitative inductive content analytic approach. Findings: The diagnostic and interpretational framework of the doshas supports the integration of the individual and the ecological through (a) the circadian and seasonal cycles relating mind-body awareness with diet, lifestyle (e.g., yoga), and breath (e.g., pranayama), and (b) biogeographical and ecosystemic regions relating the biogeographical and the ecological (e.g., desh) with the regulatory principle of pain and its physiological and anatomical perception (vata) in an approach that goes beyond treating pain etiology to a whole person PCC approach. Conclusions: The study highlights how circadian and seasonal cycles and evolutionary spatial-temporal factors of biogeographical and ecological regions are employed in patient assessment and self-management to support patient involvement. Recommendations for PCC in integrative chronic pain management include supporting patient ownership of their care through the dosha framework that relates the individual and the ecological in the patient’s own life-context and supports co-creation of a collaborative plan of care using an ethnomedical framework.

The Impact of Pain Invisibility on Patient-Centered Care and Empathetic Attitude in Chronic Pain Management

Objectives

The use of interdisciplinary patient-centered care (PCC) and empathetic behaviour seems to be a promising avenue to address chronic pain management, but their use in this context seems to be suboptimal. Several patient factors can influence the use of PCC and empathy, but little is known about the impact of pain visibility on these behaviours. The objective of this study was to investigate the influence of visible physical signs on caregiver's patient-centered and empathetic behaviours in chronic pain context.

Methods

A convenience sample of 21 nurses and 21 physicians participated in a descriptive study. PCC and empathy were evaluated from self-assessment and observer's assessment using a video of real patients with chronic pain.

Results

The results show that caregivers have demonstrated an intraindividual variability: PCC and empathetic behaviours of the participants were significantly higher for patients who have visible signs of pain (rheumatoid arthritis and complex regional pain syndrome) than for those who have no visible signs (Ehler–Danlos syndrome and fibromyalgia) (p < 0.001). Participants who show a greater difference in their patient-centered behaviour according to pain visibility have less clinical experience.

Discussion

The pain visibility in chronic pain patients is an important factor contributing to an increased use of PCC and empathy by nurses and physicians, and clinical experience can influence their behaviours. Thus, pain invisibility can be a barrier to quality of care, and these findings reinforce the relevance to educating caregivers to these unconscious biases on their behaviour toward chronic pain patients.

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

Background

People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.

Objectives

(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.

Design

We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.

Data sources

We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.

Results

We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (seeReport Supplementary Material 1; URL:www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.

Limitations

There are no agreed methods for determining confidence in QESs.

Conclusions

We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.

Future work

Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Interdisciplinary Practice Models for Older Adults With Back Pain: A Qualitative Evaluation

Purpose

Older adults seek health care for low back pain from multiple providers who may not coordinate their treatments. This study evaluated the perceived feasibility of a patient-centered practice model for back pain, including facilitators for interprofessional collaboration between family medicine physicians and doctors of chiropractic.

Design and Methods

This qualitative evaluation was a component of a randomized controlled trial of 3 interdisciplinary models for back pain management: usual medical care; concurrent medical and chiropractic care; and collaborative medical and chiropractic care with interprofessional education, clinical record exchange, and team-based case management. Data collection included clinician interviews, chart abstractions, and fieldnotes analyzed with qualitative content analysis. An organizational-level framework for dissemination of health care interventions identified norms/attitudes, organizational structures and processes, resources, networks-linkages, and change agents that supported model implementation.

Results

Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups.

Implications

Family medicine residents and doctors of chiropractic viewed collaborative care as a useful practice model for older adults with back pain. Health care organizations adopting medical and chiropractic collaboration can tailor this general model to their specific setting to support implementation.

Shared decision-making in physical therapy: A cross-sectional study on physiotherapists' knowledge, attitudes and self-reported use

OBJECTIVE

This study aimed a) to investigate knowledge, attitudes, and self-reported use of shared decision-making (SDM) among physiotherapists in Germany, b) to explore their association with demographic characteristics, and c) to assess barriers to the implementation of SDM.

METHODS

We assessed above mentioned domains using an online survey. Two-level logistic regression models were used to examine factors associated with knowledge, attitudes and self-reported use of SDM.

RESULTS

60.5% of a total sample of 357 participants reported to have had no knowledge on SDM before participating in the survey. Attitudes towards SDM were mostly positive, half of all participants expressed a preference for SDM. About two thirds of all participants reported to use a rather paternalistic approach in routine care. Knowledge, attitudes, and self-reported use of SDM were associated with several demographic characteristics.

CONCLUSION

SDM was perceived as an appropriate concept in physiotherapy. However, missing knowledge and limited self-reported use of SDM in routine care on the one hand and positive attitudes towards SDM on the other hand indicate a need for action.

PRACTICE IMPLICATIONS

In order to emphasize the use of SDM in physiotherapy efforts need to be undertaken in research, clinical practice and health policy.

Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain

OBJECTIVES

We aimed to explore healthcare professionals' experience of treating chronic non-malignant pain by conducting a qualitative evidence synthesis. Understanding this experience from the perspective of healthcare professionals will contribute to improvements in the provision of care.

DESIGN

Qualitative evidence synthesis using meta-ethnography. We searched five electronic bibliographic databases from inception to November 2016. We included studies that explore healthcare professionals' experience of treating adults with chronic non-malignant pain. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We screened the 954 abstracts and 184 full texts and included 77 published studies reporting the experiences of over 1551 international healthcare professionals including doctors, nurses and other health professionals. We abstracted six themes: (1) a sceptical cultural lens, (2) navigating juxtaposed models of medicine, (3) navigating the geography between patient and clinician, (4) challenge of dual advocacy, (5) personal costs and (6) the craft of pain management. We rated confidence in review findings as moderate to high.

CONCLUSIONS

This is the first qualitative evidence synthesis of healthcare professionals' experiences of treating people with chronic non-malignant pain. We have presented a model that we developed to help healthcare professionals to understand, think about and modify their experiences of treating patients with chronic pain. Our findings highlight scepticism about chronic pain that might explain why patients feel they are not believed. Findings also indicate a dualism in the biopsychosocial model and the complexity of navigating therapeutic relationships. Our model may be transferable to other patient groups or situations.

Patients' Perception of Chronic-Pain-Related Patient-Provider Communication in Relation to Sociodemographic and Pain-Related Variables: A Cross-Sectional Nationwide Study

Pain is a personal experience and patient-provider communication therefore an essential part of diagnosis and treatment where the patient's perspective needs to be central. The aim of this descriptive cross-sectional study was to investigate chronic-pain-related patient-provider communication in the context of sociodemographic variables, pain variables, perceived outcome of care, and satisfaction with health care providers. A postal questionnaire measuring socio-demographic variables, pain characteristics, pain-related health care utilization and patient-provider communication was sent to a sample of 4,500 individuals randomly drawn from the national population of Iceland. A subsample reporting chronic pain and having visited a health care provider for pain the previous six months (n = 401) was analyzed. Relationships between patient-provider communication and other measured variables were tested using bivariate and multivariate statistics. The more chronic pain impaired health-related quality of life, the more provider control the patients perceived in the patient-provider communication. There was also a strong negative relationship between patients' perception of providers' support and openness to discussing symptoms, and satisfaction with health care provider. Patients' perception of their own control in patient-provider communication and involvement in decisions regarding care was related to sociodemographic variables (specifically, education and residence) but not to pain related variables. This study highlights the importance of assessing chronic pain in a broad spectrum, listening, and giving patients time and support to communicate chronic pain and how it affects their life situation. The more interfering the pain is, the more important this is.

Assessing patient-centred care for chronic pain: Validation of a new research paradigm

BACKGROUND

Chronic pain is a complex phenomenon resulting from biological, psychological and social factors, and the use of patient-centred care (PCC) appears to be a promising avenue for its treatment. Various methods have been used for measuring PCC in nurses and physicians (caregivers); however, methodological problems have been raised following the observation of real clinical encounters or standardized patient simulations. The development of new strategies is required.

OBJECTIVE

To develop and validate an observation scale for the assessment of PCC in caregivers, using standardized videos of real patients with chronic pain.

METHODS

An expert panel developed five videos and the Sherbrooke Observation Scale of Patient-Centered Care (SOS-PCC), which were tested in a sample of 21 nurses and 21 physicians working with chronic pain patients. The content validity, internal consistency and inter-rater reliability of the SOS-PCC were assessed.

RESULTS

The expert panel was satisfied with the content validity of the SOS-PCC. Results revealed good internal consistency (Cronbach's alpha = 0.88) and inter-rater reliability (intraclass coefficient = 0.93) for this scale.

CONCLUSIONS

To the authors' knowledge, the SOS-PCC is the first instrument available in French to assess PCC behaviour of caregivers using videos of real patients with chronic pain. The psychometric qualities of these instruments are good. Future studies will need to assess this instrument with other populations of caregivers.

Operationalizing a shared decision making model for work rehabilitation programs: a consensus process

PURPOSE

The objective of this study was to design and operationalize shared decision making (SDM) rehabilitation model for worker rehabilitation programs. SDM has previously been shown to improve decision outcomes in patient-health care professional relationships. To date, SDM has not yet been adapted to work rehabilitation, although it could be a valuable approach to better understand and agree on return-to-work decisions.

METHODS

We designed a preliminary model for return-to-work decisions for workers suffering from pain due to musculoskeletal injuries. We submitted the preliminary model and a questionnaire to expert health care professionals. Using the Technique for Research of Information by Animation of a Group of Experts method, a group consensus process was used to discuss and refine the experts' responses to operationalize a model adapted for rehabilitation.

RESULTS

Eleven occupational therapists (three were clinical coordinators) and four psychologists participated in three group consensus sessions. The final version of the model included one general longitudinal objective (the maintenance of a working alliance and assuring mutual comprehension among all stakeholders), and 11 specific objectives: establishing a working alliance, seven in the deliberation phase of the SDM process, and three in the implementation of the decision. Participants also reached consensus on between 1 and 8 indicators per objective.

CONCLUSION

We developed and operationalized an SDM rehabilitation model intended for a return-to-work implementation plan. The next step will be to document its feasibility among the main stakeholders (employer, union, insurer and worker) taking part in decisions about return to work.

A holistic approach to chronic pain management that involves all stakeholders: change is needed

Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses', pharmacists' and physiotherapists' skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels - for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain - it is vital they continue.

Shared decision-making in back pain consultations: an illusion or reality?

PURPOSE

Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain.

METHOD

Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians.

RESULTS

The mean OPTION score was 24.0% (range 10.4-43.8%).

CONCLUSION

Shared decision-making was under-developed in the observed back pain consultations. Clinicians' strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented.

Patients' expectations of private osteopathic care in the UK: a national survey of patients

Background

Patients’ expectations of osteopathic care have been little researched. The aim of this study was to quantify the most important expectations of patients in private UK osteopathic practices, and the extent to which those expectations were met or unmet.

Methods

The study involved development and application of a questionnaire about patients’ expectations of osteopathic care. The questionnaire drew on an extensive review of the literature and the findings of a prior qualitative study involving focus groups exploring the expectations of osteopathic patients. A questionnaire survey of osteopathic patients in the UK was then conducted. Patients were recruited from a random sample of 800 registered osteopaths in private practice across the UK. Patients were asked to complete the questionnaire which asked about 51 aspects of expectation, and post it to the researchers for analysis.

The main outcome measures were the patients-perceived level of expectation as assessed by the percentage of positive responses for each aspect of expectation, and unmet expectation as computed from the proportion responding that their expectation “did not happen”.

Results

1649 sets of patient data were included in the analysis. Thirty five (69%) of the 51 aspects of expectation were prevalent, with listening, respect and information-giving ranking highest. Only 11 expectations were unmet, the most often unmet were to be made aware that there was a complaints procedure, to find it difficult to pay for osteopathic treatment, and perceiving a lack of communication between the osteopath and their GP.

Conclusions

The findings reflected the complexity of providing osteopathic care and meeting patients’ expectations. The results provided a generally positive message about private osteopathic practice. The study identified certain gaps between expectations and delivery of care, which can be used to improve the quality of care. The questionnaire is a resource for future research.