Pain science and practice as a 'threshold concept' within undergraduate and pre-registration physiotherapy education: a jewel of the curriculum?

BACKGROUND

Threshold concepts describe learning experiences that transform our understanding of a concept. Threshold concepts are variously: troublesome, transformative, irreversible, integrative and bounded.

PURPOSE

The aim of this narrative review is to consider the case for characterising pain science and practice as a threshold concept within undergraduate and pre-registration physiotherapy education. This article considers the underlying tenets of threshold concepts as they relate to teaching and learning and the relative merits and limitations of characterising pain science and practice as a threshold concept within undergraduate and pre-registration physiotherapy education from both pedagogical and epidemiological perspectives. By evaluating pain, as it relates to physiotherapy education and practice, according to the five defining characteristics of a threshold concept then presenting data related to the epidemiology and impact of pain, the worthiness of characterising pain science and practice as a threshold concept will be discussed and further debate invited.

Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study

INTRODUCTION

The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization.

OBJECTIVE

The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach.

METHODS

A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management.

RESULTS

The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management.

CONCLUSION

DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.

Do Physical Therapists Practice a Behavioral Medicine Approach? A Comparison of Perceived and Observed Practice Behaviors

OBJECTIVE

A behavioral medicine approach, incorporating a biopsychosocial view and behavior change techniques, is recommended in physical therapy for the management of musculoskeletal pain. However, little is known about physical therapists' actual practice behavior regarding the behavioral medicine approach. The aim of this study was to examine how physical therapists in primary health care judge their own practice behavior of a behavioral medicine approach in the assessment and treatment of patients with persistent musculoskeletal pain versus how they practice a behavioral medicine approach as observed by independent experts in video recordings of patient consultations.

METHODS

A prospective cohort study was conducted. Video recordings of 23 physical therapists' clinical behavior in 139 patient consultations were observed by independent experts and compared with the physical therapists' self-reported practice behavior, using a protocol including 24 clinical behaviors. The difference between observed and self-reported clinical behaviors was analyzed with a Chi-square test and a Fisher exact test.

RESULTS

The behavioral medicine approach was, in general, practiced to a small extent and half of the self-reported clinical behaviors were overestimated when compared with the observed behaviors. According to the observations, the physical perspective dominated in assessment and treatment, the functional behavioral analysis was never performed, and the mean number of behavior change techniques used was 0.7.

CONCLUSION

There was a discrepancy between how physical therapists perceived the extent to which they practiced a behavioral medicine approach in their clinical behavior compared with what the independent researchers observed in the video recordings.

IMPACT

This study demonstrates the importance of using observations instead of using self-reports when evaluating professionals' clinical behavior. The results also suggest that-to ensure that physical therapy integrates the biopsychosocial model of health-physical therapists need to increase their focus on psychosocial factors in clinical practice.

The ability of physiotherapists to identify psychosocial factors in patients with musculoskeletal pain: A scoping review

BACKGROUND

It is not known how well physiotherapists identify psychosocial factors in people with musculoskeletal pain, when using clinical judgement. The purpose of this scoping review was to examine the research related to physiotherapist ability in identifying psychosocial factors and to subsequently identify gaps in the literature to help direct future research.

DATA SOURCES

Searches using relevant key words, were conducted of Medline, Cinahl, the Cochrane Library, PEDro, PubMed, Scopus and Google Scholar. All primary quantitative and qualitative research from the year 2000 onwards, which met the search criteria, were included.

DATA EXTRACTION AND SYNTHESIS

A data extraction tool was used to tabulate data regarding demographics, study design and key findings of the included papers. The Mixed Methods Appraisals Tool (MMAT) was utilised to help examine the quality of included studies.

RESULTS

Overall, the quality of the included studies was moderate. The total number of studies which met the inclusion criteria was relatively small (n = 20). The most common method for determining ability was comparison of physiotherapist estimations with validated screening tools or questionnaires. Physiotherapist estimates of psychosocial factors were poor and in the qualitative research, the lack of clinician confidence in psychosocial assessment was evident.

CONCLUSION

The available research suggests that physiotherapists lack confidence and ability in identifying psychosocial factors. More rigorous, mixed-methods research is warranted to capture the complexity of the research question.

Psychosocial factors associated with disability in patients with non-specific chronic low back pain: A cross-sectional study

INTRODUCTION AND OBJECTIVES

Chronic low back pain is the main cause of disability worldwide, generating high costs for society. To evaluate the prevalence of disability in patients with non-specific chronic low back pain and associated factors, including the impacts of low back pain and psychosocial factors linked to kinesiophobia, catastrophism, anxiety, and depression.

PATIENTS

A cross-sectional study was carried out with 108 adult individuals who had non-specific chronic low back pain. The patients answered previously validated questionnaires, namely the Brief Pain Inventory, the Roland-Morris Disability Questionnaire, the Pain Catastrophizing Scale, the Tampa Kinesiophobia Scale, and the Hospital Anxiety and Depression Scale.

RESULTS

The prevalence of disability observed was 65.7%, with the mean disability score being 15.7±5.3 points in the Roland-Morris Disability Questionnaire. Although pain intensity and other domains of the Brief Pain Inventory, like anxiety, depression, and severe kinesiophobia were significant in the bivariate analyses, they were not associated with disability in the multivariate analysis. Only catastrophic thoughts (prevalence ratio [PR]=1.19; 95% confidence interval [CI]: 1.07-1.32), and the 'walking' domain (PR=1.08; 95% CI: 1.03-1.14) remained statistically associated with disability.

CONCLUSION

Pain catastrophization and impact on gait were associated with disability in individuals with non-specific chronic low back pain. Motor control thoughts and behaviors during functional activities were considered to be relevant aspects for the better assessment and treatment of these patients.

Implementation of a biopsychosocial approach into physiotherapists' practice: a review of systematic reviews to map barriers and facilitators and identify specific behavior change techniques

PURPOSE

Our first objective was to map the barriers and facilitators to the implementation of a biopsychosocial approach into physiotherapists' practice within the Theoretical Domains Framework (TDF). Our second objective was to identify the specific behavior change techniques (BCT) that could facilitate this implementation.

MATERIALS AND METHODS

We conducted a review of systematic reviews to identify barriers and facilitators to the use of a biopsychosocial approach by physiotherapists and we mapped them within the TDF domains. We then analyzed these domains using the Theory and Techniques tool (TaTT) to identify the most appropriate BCTs for the implementation of a biopsychosocial approach into physiotherapists' practice.

RESULTS

The barriers and facilitators to the use of a biopsychosocial approach by physiotherapists were mapped to 10 domains of the TDF (Knowledge; skills; professional role; beliefs about capabilities; beliefs about consequences; intentions; memory, attention and decision processes; environmental context; social influences; emotion). The inclusion of these domains within the TaTT resulted in the identification of 33 BCTs that could foster the use of this approach by physiotherapists.

CONCLUSIONS

Investigating the implementation of a biopsychosocial approach into physiotherapists' practice from a behavior change perspective provides new strategies that can contribute to successfully implement this approach.Implications for RehabilitationThe implementation of a biopsychosocial approach into physiotherapists' practice is a complex process which involves behavior changes influenced by several barriers and facilitators.Barriers and facilitators reported by physiotherapists when implementing a biopsychosocial approach can be mapped within 10 domains of the Theoretical Domain Framework.Thirty-three behavior change techniques (e.g., verbal persuasion about capability, problem solving, restructuring the physical environment, etc.) were identified to foster the implementation of a biopsychosocial approach and specifically target barriers and facilitators.By using a behavior change perspective, this study highlights new strategies and avenues that can support current efforts to successfully implement the use of a biopsychosocial approach into physiotherapists' practice.

Use of Mental Health Interventions by Physiotherapists to Treat Individuals with Chronic Conditions: A Systematic Scoping Review

Purpose: Physiotherapists work with people with chronic conditions and can act as catalysts for behavioural change. Physiotherapy has also seen a shift to a bio-psychosocial model of health management and interdisciplinary care, which is important in the context of chronic conditions. This scoping review addressed the research question "How do physiotherapists use mental health-based interventions in their treatment of individuals with chronic conditions?" Method: The Embase, MEDLINE, PsycINFO, and CINAHL databases were searched, and a variety of study designs were included. Data were categorized and descriptively analyzed. Results: Data were extracted from 103 articles. Low back pain (43; 41.7%) and non-specified pain (16; 15.5%) were the most commonly researched chronic conditions, but other chronic conditions were also represented. Outpatient facilities were the most common setting for intervention (68; 73.1%). A total of 73 (70.9%) of the articles involved cognitive-behavioural therapy, and 41 (40.0%) included graded exercise or graded activity as a mental health intervention. Conclusions: Physiotherapists can use a variety of mental health interventions in the treatment of chronic conditions. More detailed descriptions of treatment and training protocols would be helpful for incorporating these techniques into clinical practice.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

Understanding the Process and Challenges for Return-to-Work Post-Hematopoietic Cell Transplantation from a Musculoskeletal Perspective: A Narrative Review

The current paper seeks to inform healthcare professionals on how adapting various components of return to work (RTW) programs that are already in use by other musculoskeletal rehabilitation settings can help optimize return to work process for patients with or without musculoskeletal manifestations, posthematopoietic cell transplantation. Since there is no universally agreed RTW structure for hematopoietic cell transplant patients, a narrative approach has been taken utilizing evidence from the existing musculoskeletal return to work assessment publications to help draw parallel for the hematopoietic cell transplant patients. Databases were searched including PUBMED, CINHAL, AMED, SCOPUS, and Cochrane using keywords RTW, functional restoration program, hematopoietic cell transplant, bone marrow transplant, stem cell transplant, and musculoskeletal functional assessment. The authors have managed to outline and propose a structured RTW assessment and monitoring program which can aid in getting patients back to employment by utilizing the functional capacity and job evaluation to help hematopoietic cell transplantation patients reintegrate socially. Patients undergoing hematopoietic cell transplant require additional support and a robust assessment system to allow safe RTW. The proposed model of RTW assessment can prove to be beneficial in helping patients return to work safely. Clinical Significance. To acknowledge the individuality in functional limitation is important in determining not only the rehab needs but also the RTW capabilities. The proposed RTW plan not only promotes an individualized approach to patients but also provides a structure for return to work assessments for hematopoietic cell transplantation patients, thus, eliminating the need for guess work by healthcare professionals. In line with the International Classification of Functioning, Disability, and Health (ICF) recommendations, a RTW assessment combined with a job evaluation helps healthcare professionals and stakeholders to understand the unique challenges and strengths of a patient and thereby design an individualized therapy approach.

Communication skills in the context of psychological flexibility: training is associated with changes in responses to chronic pain in physiotherapy students in Spain

Introduction

The aim of this study is to explore the effectiveness of a training programme aimed at managing patients' chronic pain in physiotherapy students in Spain. The programme addressed providing them with efficient skills to manage patients' chronic pain from psychological flexibility (PF) perspective.

Methods

The programme integrates communication skills training into PF-based training. It sought to contribute to better recognise the role of psychosocial factors in chronic pain and to better promote adherence to treatment. This is an observational study with a pre- and post-training programme design and a 2-month follow-up. A total of 35 physiotherapy students, divided into three groups, participated in a 10-hour training course. Training focused on three areas: (1) communication skills, (2) therapeutic adherence and (3) managing distress and pain. The three areas were addressed from the PF point of view. Impact of training was measured through standardised questionnaires that assessed attitudes towards chronic pain, an ad hoc questionnaire that assessed responses to difficult communicative situations and a training satisfaction scale.

Results

Final analyses showed that attitudes changed significantly after training, biomedical attitude scores decreased and biopsychosocial attitude increased, while pain was considered less disabling, and informed empathic responses in communication situations increased. These changes were maintained at 2-month follow-up. Satisfaction with the training was high.

Conclusion

We conclude that a brief training programme based on the PF model may help students develop a more comprehensive approach and improve their skills for managing chronic pain.

Musculoskeletal ultrasound imaging - Integration with the biopsychosocial model

BACKGROUND AND METHOD

Musculoskeletal ultrasound imaging, (MSKUSI) has become a popular imaging modality in recent years and is being utilised by a variety of professions in clinical environments beyond radiology departments. A previously published study exploring physiotherapists' interests and use of MSKUSI in practice included in-depth interviews of participants, (n = 11). The data from this qualitative study were analysed thematically and five themes were identified; one was 'Application of the biopsychosocial model', the basis of this paper.

RESULT

The theme, 'Application of the biopsychosocial model' drew together three categories of analysed data: clinical reasoning, professional variance and communication opportunity. 'Clinical reasoning' reflected the participants' value on subjective assessment information and the integration of ultrasound imaging with physical examination findings. 'Professional variance' observed the scanning processes undertaken by physiotherapists tended to vary from other professionals, the physiotherapists perceived their use of dynamic imaging was greater, in particular scanning in symptom provoking positions. Another variance observed was the style of communication that physiotherapists used when scanning, this was categorised as a 'communication opportunity' as it represented an event that could be utilised to promote patient understanding of their presentation, link imaging findings to proposed management and enhance compliance with rehabilitation strategies. Participants emphasised their responsibility when communicating with patients to avoid language that could promote unhelpful behaviour, e.g. catastrophisation.

CONCLUSION

Participants placed value on integrating musculoskeletal ultrasound imaging into the biopsychosocial model, further research to explore the impact of this approach on patients' clinical outcomes and reported experiences is required.

Implementation of a behavioral medicine approach in physiotherapy: a process evaluation of facilitation methods

Background

In a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences.

Methods

An explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used.

Results

The physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking.

Conclusions

The findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time.

Translation, cultural adaptation, and psychometric testing of the Yoruba version of Fear-Avoidance Beliefs Questionnaire in patients with low-back pain

PURPOSE

To translate, culturally adapt, and validate the Fear-Avoidance Beliefs Questionnaire into Yoruba language.

MATERIALS AND METHODS

Translation and cultural adaptation of the Yoruba version of the Fear-Avoidance Beliefs Questionnaire was carried out following the Guillemin criteria. One hundred and thirty-one individuals with chronic low-back pain participated in the psychometric evaluation of the Yoruba language translation. Cronbach's alpha (α), principal component analysis, intra-class correlation, Bland-Altman analysis, Spearman rank correlation coefficient, and minimal detectable difference were used for the analysis. Alpha level was set at p < 0.05.

RESULTS AND CONCLUSION

The mean age of the respondents was 53.6 ± 11.6 years. The internal consistency of the Yoruba language version of the Fear Avoidance Beliefs Questionnaire yielded a Cronbach's alpha of 0.9. Principal component analysis yielded a three-factor structure including the "work", "beliefs related to work", and "physical activity" which accounted for 61.6% of variance in the Yoruba translation. Test-retest reliability of the Yoruba translation yielded an Intra class correlation coefficient 0.97 (0.95-0.98). The Yoruba Fear Avoidance Beliefs Questionnaire was poorly correlated with the Visual Analog Scale (r = 0.01) and Roland-Morris Disability Questionnaire (r = 0.3). The minimal detectable difference of the Yoruba translation was 7.0. The Yoruba Fear Avoidance Beliefs Questionnaire demonstrated excellent psychometric properties similar to existing versions and is appropriate for clinical use among Yoruba-speaking patients.IMPLICATIONS FOR REHABILITATIONThe Fear-Avoidance Beliefs Questionnaire is a culturally sensitive psychosocial outcome measure, necessitating its existence, and adaptation into different languages.The instrument was translated and culturally adapted into the Yoruba language following the Guillemin criteria.The Yoruba translation demonstrated excellent internal consistency, test-retest reliability and weak correlations with the Visual analog scale and Roland-Morris Disability Scale.The Yoruba version of the Fear-Avoidance Beliefs Questionnaire can be used to assess fear-avoidance beliefs among Yoruba speaking patients with low-back pain.

Implementation of a behavioral medicine approach in physiotherapy: impact and sustainability

Purpose: To explore the effects on and sustainability of physiotherapists' clinical behavior when using facilitation to support the implementation of a behavioral medicine approach in primary health care for patients with persistent musculoskeletal pain.Methods: A quasi-experimental pre-/post-test trial was conducted. Fifteen physiotherapists were included in the experimental group, and nine in the control group. Based on social cognitive theory and the Promoting Action on Research Implementation in Health Services framework, facilitation with multifaceted implementation methods was used during a six-month period. Clinical behaviors were investigated with a study-specific questionnaire, structured observations, self-reports and patient records. Descriptive and non-parametric statistical methods were used for analyzing differences over time and effect size.Results: A sustained increase in self-efficacy for applying the behavioral medicine approach was found. Clinical actions and verbal expressions changed significantly, and the effect size was large; however, changes were not sustained at follow-ups. The behavioral changes were mainly related to the goal setting, self-monitoring and functional behavioral analysis components. No changes in clinical behavior were found in the control group.Conclusion: Tailored multifaceted facilitation can support the implementation of a behavioral medicine approach in physiotherapy in primary health care, but more comprehensive actions targeting sustainability are needed.Implications for rehabilitationTailored multifaceted facilitation can support the implementation of an evidence based behavioral medicine approach in physiotherapy.Facilitation can be useful for increasing self-efficacy beliefs for using behavioral medicine approach in physiotherapist's clinical practice.Further research is required to establish strategies that are effective in sustaining behavioral changes.

Criterion scores, construct validity and reliability of a web-based instrument to assess physiotherapists' clinical reasoning focused on behaviour change: 'Reasoning 4 Change'

Background and aim: 'Reasoning 4 Change' (R4C) is a newly developed instrument, including four domains (D1-D4), to assess clinical practitioners' and students' clinical reasoning with a focus on clients' behaviour change in a physiotherapy context. To establish its use in education and research, its psychometric properties needed to be evaluated. The aim of the study was to generate criterion scores and evaluate the reliability and construct validity of a web-based version of the R4C instrument. Methods: Fourteen physiotherapy experts and 39 final-year physiotherapy students completed the R4C instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). Twelve experts and 17 students completed the R4C instrument on a second occasion. The R4C instrument was evaluated with regard to: internal consistency (five subscales of D1); test-retest reliability (D1-D4); inter-rater reliability (D2-D4); and construct validity in terms of convergent validity (D1.4, D2, D4). Criterion scores were generated based on the experts' responses to identify the scores of qualified practitioners' clinical reasoning abilities. Results: For the expert and student samples, the analyses demonstrated satisfactory internal consistency (α range: 0.67-0.91), satisfactory test-retest reliability (ICC range: 0.46-0.94) except for D3 for the experts and D4 for the students. The inter-rater reliability demonstrated excellent agreement within the expert group (ICC range: 0.94-1.0). The correlations between the R4C instrument and PABS-PT (r range: 0.06-0.76) supported acceptable construct validity. Conclusions: The web-based R4C instrument shows satisfactory psychometric properties and could be useful in education and research. The use of the instrument may contribute to a deeper understanding of physiotherapists' and students' clinical reasoning, valuable for curriculum development and improvements of competencies in clinical reasoning related to clients' behavioural change.

The use of an e-learning module on return to work advice for physiotherapists - A prospective cohort study

Background: Nonspecific low back pain (LBP) can progress to chronic disability and prolonged absence from work. Despite clinical and professional guidelines, physiotherapists often fail to address return to work outcomes. Aims: The aim of this exploratory study was to determine whether an e-learning resource tailored to physiotherapy practice could affect physiotherapists' attitudes and beliefs regarding return to work advice for their patients. Design: A prospective interventional cohort study (pilot). Methods: Participants were recruited via the Chartered Society of Physiotherapy website. Responses on a clinical vignette, the Health Care Providers' Pain and Impairment Scale (HC-Pairs), and the Behavioral Constructs Questionnaire (BCQ) were collected online at baseline (Q1) and 2-months post-intervention (Q2). Results: Fifty-four physiotherapists completed Q1 and the response rate for Q2 was 44/54 (81%). Changes in the degree of agreement with guidelines indicated that the intervention made an impact on respondents (kappa 0.345; p = 0.003). HC-Pairs and BCQ results showed a nonstatistically significant trend toward the target behavior. Conclusions: There is a need for interventions to improve adherence with advice for return to work following nonspecific LBP. An e-learning tool for physiotherapists on advising patients regarding return to work has potential to positively affect self-reported clinical behavior.

Strategies to translate knowledge related to common musculoskeletal conditions into physiotherapy practice: a systematic review

BACKGROUND

Many physiotherapists underuse evidence-based practice guidelines or recommendations when treating patients with musculoskeletal disorders, yet synthesis of knowledge translation interventions used within the field of physiotherapy fails to offer clear conclusions to guide the implementation of clinical practice guidelines.

OBJECTIVES

To evaluate the effectiveness of various knowledge translation interventions used to implement changes in the practice of current physiotherapists treating common musculoskeletal issues.

DATA SOURCES

A computerized literature search of MEDLINE, CINHAL and ProQuest of systematic reviews (from inception until May 2016) and primary research studies (from January 2010 until June 2016).

STUDY SELECTION AND ELIGIBILITY CRITERIA

Eligibility criteria specified articles evaluating interventions for translating knowledge into physiotherapy practice.

DATA EXTRACTION AND DATA SYNTHESIS

Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed data extraction, and performed quality assessment. Of a total of 13014 articles located and titles and abstracts screened, 34 studies met the inclusion criteria, including three overlapping publications, resulting in 31 individual studies.

RESULTS

Knowledge translation interventions appear to have resulted in a positive change in physiotherapist beliefs, attitudes, skills and guideline awareness. However, no consistent improvement in clinical practice, patient and economic outcomes were observed.

LIMITATIONS

The studies included had small sample sizes and low methodological quality. The heterogeneity of the studies was not conducive to pooling the data.

CONCLUSIONS AND IMPLICATION OF KEY FINDINGS

The intensity and type of knowledge translation intervention seem to have an effect on practice change. More research targeting financial, organizational and regulatory knowledge translation interventions is needed.

A therapist-focused knowledge translation intervention for improving patient adherence in musculoskeletal physiotherapy practice

Background

Nonadherence to treatment remains high among patients with musculoskeletal conditions with negative impact on the treatment outcomes, use of personal and cost of care. An active knowledge translation (KT) strategy may be an effective strategy to support practice change. The purpose of this study was to deliver a brief, interactive, multifaceted and targeted KT program to improve physiotherapist knowledge and confidence in performing adherence enhancing activities related to risk, barriers, assessment and interventions.

Methods

We utilised a 2-phase approach in this KT project. Phase 1 involved the development of an adherence tool kit following a synthesis of the literature and an iterative process involving 47 end-users. Clinicians treating patients with musculoskeletal conditions were recruited from two Physiotherapy and Occupational therapy national conferences in Canada. The intervention, based on the acronym SIMPLE TIPS was tested on 51 physiotherapists in phase 2. A pre- and post-repeated measures design was used in Phase 2. Graham’s knowledge-to-action cycle was used as the conceptual framework. Participants completed a pre—intervention assessment, took part in a 1-h educational session and completed a post—intervention assessment. A questionnaire was used to measure knowledge of evidence—based treatment adherence barriers, interventions and measures and confidence to perform evidence—based adherence practice activities. Data was analysed using descriptive statistics (frequency and percentage), Fisher’s exact test and Wilcoxon Sign-Ranked tests.

Results

Barriers and facilitators of adherence were identified under three domains (therapist, patient, health system) in phase 1. Seventy percent of the participants completed the questionnaire. Results indicated that 46.8% of respondents explored barriers including the use of behaviour change strategies and 45.7% reported that they measured adherence but none reported the use of validated outcomes. A significant improvement in post-self-efficacy scores for the four adherence enhancing activities was observed immediately after the workshop.

Conclusion

The use of a multi-modal KT intervention is feasible in an educational setting. A brief interactive educational session was successfully implemented using a toolkit and caused a significant increase in physiotherapists’ knowledge and confidence at performing adherence enhancing activities in the very short-term. Further testing of SIMPLE TIPS on long-term adherence practices could help advance best practices specific to treatment adherence in MSK practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s40945-016-0029-x) contains supplementary material, which is available to authorized users.

Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study

QUESTION

What are physiotherapists' perspectives on managing the cognitive, psychological and social dimensions of chronic low back pain after intensive biopsychosocial training?

DESIGN

Qualitative study design using semi-structured interviews to explore physiotherapists' perceptions of their identification and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive Functional Therapy (CFT) training.

PARTICIPANTS

Thirteen qualified physiotherapists from four countries who had received specific CFT training. The training involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive descriptive analysis was performed using a qualitative software package.

RESULTS

Four main themes emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in professional practice; altered scope of practice; and increased confidence and satisfaction. Participants described increased understanding of the nature of pain, the role of patient beliefs, and a new appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in communication, and adoption of a functional approach. Since undertaking CFT training, participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors.

CONCLUSION

Physiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training, so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K (2016) Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study.Journal of Physiotherapy62: 215-221].

Physical therapists' assessments, analyses and use of behavior change techniques in initial consultations on musculoskeletal pain: direct observations in primary health care

Background

Behavioral medicine (BM) treatment is recommended to be implemented for pain management in physical therapy. Its implementation requires physical therapists (PTs), who are skilled at performing functional behavioral analyses based on physical, psychological and behavioral assessments. The purpose of the current study was to explore and describe PTs’ assessments, analyses and their use of behavioral change techniques (BCTs) in initial consultations with patients who seek primary health care due to musculoskeletal pain.

Methods

A descriptive and explorative research design was applied, using data from video recordings of 12 primary health care PTs. A deductive analysis was performed, based on a specific protocol with definitions of PTs’ assessment of physical and psychological prognostic factors (red and yellow flags, respectively), analysis of the clinical problem, and use of BCTs. An additional inductive analysis was performed to identify and describe the variation in the PTs’ clinical practice.

Results

Red and yellow flags were assessed in a majority of the cases. Analyses were mainly based on biomedical assessments and none of the PTs performed functional behavioral analyses. All of the PTs used BCTs, mainly instruction and information, to facilitate physical activity and improved posture. The four most clinically relevant cases were selected to illustrate the variation in the PTs’ clinical practice. The results are based on 12 experienced primary health care PTs in Sweden, limiting the generalizability to similar populations and settings.

Conclusion

Red and yellow flags were assessed by PTs in the current study, but their interpretation and integration of the findings in analyses and treatment were incomplete, indicating a need of further strategies to implement behavioral medicine in Swedish primary health care physical therapy.

Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review

QUESTION

What are physiotherapists' perceptions about identifying and managing the cognitive, psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)?

DESIGN

Systematic review and qualitative metasynthesis of qualitative studies in which physiotherapists were questioned, using focus groups or semi-structured interviews, about identifying and managing cognitive, psychological and social factors in people with LBP.

PARTICIPANTS

Qualified physiotherapists with experience in treating patients with LBP.

OUTCOME MEASURES

Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists' perceptions.

RESULTS

Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them.

CONCLUSION

Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP.

REGISTRATION

CRD 42014009964. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.Journal of Physiotherapy61: 68-76].