Article

Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain: A Qualitative Study

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Abstract

Background: Cognitive Functional Therapy has been shown to reduce pain and disability in people with chronic low back pain. Objectives: To investigate participants' experience of Cognitive Functional Therapy by comparing those who reported larger or smaller improvements with treatment, potentially yielding insight into the implementation of this approach. Design: Non-interventional, cross-sectional study with an Interpretive Description framework. Methods: Individuals who had participated in Cognitive Functional Therapy in two physiotherapy settings (in Ireland and Australia) were recruited through purposive sampling based on disability outcomes post intervention (n=9), and theoretical sampling (n=5). This sampling strategy was used to capture a range of participant experiences, but was not used to define the final qualitative groupings. Semi-structured interviews were conducted 3-6 months post intervention. Results: Three groups emerged from the qualitative analysis; Large Improvers, Small Improvers and Unchanged. Two themes encapsulated the pivotal steps: (i) Changing Pain Beliefs and (ii) Achieving Independence. Changing pain beliefs to a more biopsychosocial perspective required a strong therapeutic alliance, development of body awareness and the experience of control over pain. Those who were Unchanged retained their biomedical beliefs. Independence was achieved by Large Improvers through newly cultivated problem solving skills, self-efficacy, decreased fear of pain and improved stress coping. Residual fear and poor stress coping meant Small Improvers were easily distressed and lacked independence. Those who were Unchanged continued to feel defined by their pain and retained a biomedical perspective. Conclusion: A successful outcome after Cognitive Functional Therapy is dependent on instilling biopsychosocial pain beliefs and developing independence among participants. Small Improvers may require ongoing support to maintain results. Further study is required to elucidate the optimal approach for those who were Unchanged.

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... In Western society, people of all ages, both with pain and without pain in geographically diverse settings, commonly hold unhelpful beliefs about the body and pain. [30][31][32][33] The body is often perceived as fragile and vulnerable to harm, and the experience of pain is interpreted as threatening and often understood as a sign of structural damage. As such, there is a perception that the painful body part always needs to be protected and "fixed." ...
... As such, there is a perception that the painful body part always needs to be protected and "fixed." [30][31][32][33] There are examples of this in people suffering from pain in the back, 30,34 knee, 35 and hip. 36 Our own clinical studies have demonstrated that people with and without back pain, as well as physical therapists who manage people with back pain, show an implicit (nonconscious) bias about the vulnerability of the back even when they explicitly report otherwise. ...
... A body of qualitative work 31,34,41,42 exploring the lives of people living with chronic pain and high fear provides compelling evidence that pain-related fear can be understood as a common-sense response to a threatening pain experience described as severe, uncontrollable, and unpredictable. For example, when a person believes that performing a painful activity will hurt and/or cause harm to their body, avoiding or modifying that activity is common sense. ...
Article
Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening, and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain, as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing cognitive functional therapy to promote safety learning. A process is described in which experiential learning combined with “sense making” disrupts a person’s unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.
... A summary of the included studies is presented in Table 1. In total, 512 participants of both sexes, with a variety of chronic pain conditions (eg, primary pain, [25][26][27]29,[31][32][33][34][35][36][37][40][41][42][43][44][45][46][47][48]5--57 musculoskeletal pain, 28,39 orofacial pain, 38 provoked vestibulodynia, 30 migraine 49 ) were interviewed. Studies were predominantly conducted in highincome countries such as the United Kingdom (n = 12), 35,36,38,39,[41][42][43][44][45]49,55 Europe (n = 9), 25,31,32,37,40,50,52,53,57 United States of America (n = 4), 27,34,46,47 Australia (n = 4), 26,32,48,56 and Canada (n = 3). ...
... In total, 512 participants of both sexes, with a variety of chronic pain conditions (eg, primary pain, [25][26][27]29,[31][32][33][34][35][36][37][40][41][42][43][44][45][46][47][48]5--57 musculoskeletal pain, 28,39 orofacial pain, 38 provoked vestibulodynia, 30 migraine 49 ) were interviewed. Studies were predominantly conducted in highincome countries such as the United Kingdom (n = 12), 35,36,38,39,[41][42][43][44][45]49,55 Europe (n = 9), 25,31,32,37,40,50,52,53,57 United States of America (n = 4), 27,34,46,47 Australia (n = 4), 26,32,48,56 and Canada (n = 3). 29,30,51 Four studies used mixed-method design, 28,36,39,44 the remaining used a qualitative design only. ...
... In total, 512 participants of both sexes, with a variety of chronic pain conditions (eg, primary pain, [25][26][27]29,[31][32][33][34][35][36][37][40][41][42][43][44][45][46][47][48]5--57 musculoskeletal pain, 28,39 orofacial pain, 38 provoked vestibulodynia, 30 migraine 49 ) were interviewed. Studies were predominantly conducted in highincome countries such as the United Kingdom (n = 12), 35,36,38,39,[41][42][43][44][45]49,55 Europe (n = 9), 25,31,32,37,40,50,52,53,57 United States of America (n = 4), 27,34,46,47 Australia (n = 4), 26,32,48,56 and Canada (n = 3). 29,30,51 Four studies used mixed-method design, 28,36,39,44 the remaining used a qualitative design only. ...
Article
Background: Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain. Purpose: The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention. Data sources: Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016. Study selection: Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention. Data extraction: A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence. Data synthesis: Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends. Limitations: This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located. Conclusions: The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.
... "Well, it's more of a physical thing with me than a mental thing, really." (Bunzli et al., 2016 I'm waiting for a knee replacement, cos I find it very difficult to get around, you know … I'm hoping the operation will correct it.". ( Hurley et al., 2010, p5) Negative/impeding psychological influences "Because if you're feeling really depressed then you just can't be bothered, you don't eat, you don't sleep, you don't do this, and you don't do that. ...
... "I think you build up confidence in your body when the worst happens and then you get through it." (Bunzli et al., 2016 A. Spink et al. ...
... This positive relationship offered external accountability for the patient to start and continue self-management (Matthias et al., 2012;Fu et al., 2016;Hållstam et al., 2015;Cooper et al., 2009;Finlay and Elander, 2016;Oosterhof et al., 2014). Clear communication while educating the patient about chronic pain improved active management (Dnes et al., 2020;Matthias et al., 2012Matthias et al., , 2016Fu et al., 2016Fu et al., , 2018Hållstam et al., 2015;Cooper et al., 2009;Bourgault et al., 2015;Buijs et al., 2009;Hurley et al., 2010;Bunzli et al., 2016;Pietilä Holmner et al., 2017;Stone and Baker, 2017;Oosterhof et al., 2014;Toye and Barker, 2012), and practitioner understanding of specific patient needs promoted more relevant self-management approaches (Dnes et al., 2020;Fu et al., 2016Fu et al., , 2018Hållstam et al., 2015;Cooper et al., 2009;Buijs et al., 2009;Stone and Baker, 2017). ...
Article
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.
... However, after a table discussion about the interpretation of inclusion and exclusion criteria, the agreement rate increased to 87% of studies. Three studies investigated the effect of TA on chronic musculoskeletal pain (Cheing et al. 2014;Ferreira et al. 2013;Fuentes et al. 2014) and four studies examined the factors that influence the strength of TA (Bunzli et al. 2016;Burns et al. 1999;Harman et al. 2014;Wilson et al. 2017). Table 1 summarizes each study's characteristics. ...
... Four non-randomized control studies biased the participant selection by: collecting data from only treatment "responders" (Wilson et al. 2017); using mixed methods of purposive sampling and terminating recruitment based on results already collected (Bunzli et al. 2016); or limiting subjects to a single subject design (Harman et al. 2014). The other non-randomized control study selectively reported only the correlations that were statistically significant (Burns et al. 1999). ...
... Factors relevant to the creation of the therapeutic alliance Four studies included in this review examined factors that influenced the strength of TA (Bunzli et al. 2016;Burns et al. 1999;Harman et al. 2014;Wilson et al. 2017). Three studies utilized semi-structured interviews (Bunzli et al. 2016;Harman et al. 2014;Wilson et al. 2017) to examine factors that positively influenced TA. ...
Article
Objective: To systematically determine the specific impact of therapeutic alliance (TA) on chronic musculoskeletal pain, identify factors influencing TA between physical therapists and patients with chronic musculoskeletal pain, and determine the working definition of TA across studies. Data sources: Databases, including PubMed, CINHAL, and Embase, were searched from inception to January 2017. Study selection: The initial search resulted in 451 papers. After screening, seven studies were identified that examined the role of TA on chronic pain (> 12 weeks) management in physical therapy settings. Data extraction: Authors extracted data into tables. Risk of bias was assessed using Cochrane Collaboration methodology. Data synthesis: Three studies examined the influence of a strong TA coupled with physical therapy on pain outcomes. Four studies identified factors that positively and negatively influenced TA. The working definition of TA was identified in each study. Conclusions: Emerging evidence suggests that for individuals participating in physical therapy for chronic musculoskeletal pain, a strong TA may improve pain outcomes. In order to facilitate a strong TA, physical therapists must understand factors that positively and negatively influence the relationship. Studies demonstrate that the definition of TA remains consistent as it transitions to the physical therapy setting.
... Exercises and training are common expectations (Bernhardsson, Larsson, Johansson, and Öberg, 2017;Calner, Isaksson, and Michaelson, 2017), which is in line with the recommendations of Semmons (2016). Earlier findings also elucidate how patients expect a trusting relationship and good communication with the physiotherapist (Bunzli et al., 2016;Slade, Patel, Underwood, and Keating, 2014;Stenberg, Fjellman-Wiklund, and Ahlgren, 2012); and to be actively engaged in the treatment (Bernhardsson, Larsson, Johansson, and Öberg, 2017;Stenberg, Fjellman-Wiklund, and Ahlgren, 2012). In addition to the treatment process, expectations of treatment outcomes are also described, encompassing several aspects. ...
... Additionally, Pietilä Holmner, Stålnacke, Enthoven, and Stenberg (2018) recognized that knowledge of chronic pain increased the individuals' ability to manage their pain in everyday life. Bunzli et al. (2016) also described results in line with ours, where the participants' improvements after intervention were related to their ability to self-manage their condition as result of gaining new information and improved body awareness. We find it interesting and encouraging that our findings of behaviour change in the primary care setting are aligned with the findings from studies focused on multidisciplinary and cognitive treatment programs (Pietilä Holmner, Stålnacke, Enthoven, and Stenberg, 2018;Wilson, Chaloner, Osborn, and Gauntlett-Gilbert, 2017). ...
... They also expected the physiotherapist to acknowledge and focus on their specific problems (Calner, Isaksson, and Michaelson, 2017). The importance of communication and a trusting relationship is in line with the studies of Bunzli et al. (2016) and Slade, Underwood, and Keating (Slade, Patel, Underwood, and Keating, 2014). The patient's need to be recognized and affirmed as an individual is another aspect of a therapeutic alliance (Stenberg, Fjellman-Wiklund, and Ahlgren, 2012). ...
Article
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The aim of this study was to explore and describe the physiotherapy treatment experiences of persons with persistent musculoskeletal pain. Eleven participants with persistent musculoskeletal pain in the back, neck, or shoulders were included in the study. Data was collected via semi-structured interviews and were analysed with qualitative content analysis. The analysis resulted in the theme “Towards acceptance and management of pain”, comprising four sub-themes: 1) Establishing and maintaining a therapeutic alliance; 2) Being active, taking initiative and facing challenges; 3) Appreciating guidance, incentive and having a sounding board; and 4) Acquired knowledge and new body awareness change behaviours. The theme and sub-themes describe how the participants used increased knowledge, awareness, movements and exercises learned from the physiotherapy treatment to develop strategies for managing pain and the process of acceptance. A trusting relationship and continual dialogue with the physiotherapist was considered to be important. The participants were actively involved in the process as exercises, activities and other treatment modalities were individualized. This was rewarding but also challenging and required effort on their part. The physiotherapist’s initiatives and actions were an important incentive and means of support.
... Although these factors increased their adherence to treatment, they also reported challenges within the process, such as discrepancy between expectations of the management and contents of PIP, strong and not always pleasant emotional experiences elicited by the exercises, and distress that developed from their growing awareness of the impact that pain has had on their lives [17]. Bunzli et al. [18] reported that for patients who underwent a CFT intervention, changing pain beliefs to a more biopsychosocial perspective and achieving independence were important for achieving a successful outcome. A strong therapeutic alliance, development of body awareness and the experience of control over pain were considered important precursors for changing beliefs. ...
... They found that depression and pain catastrophizing correlated with this difficulty [32]. Bunzli et al. also found that those with poor outcomes after a CFT intervention reported biomedical beliefs and continued feeling defined by their pain [18]. For many of our participants, the biopsychosocial approach to care came as a surprise and was different to what they had expected based on their previous physiotherapy experiences. ...
... However, there were also reports of the physiotherapist being timid and not listening to their wishes. Bunzli et al. reported strong therapeutic alliance, together with experience of control over pain and development of body awareness as the requirements for changing beliefs [18], consistent with previous research that has highlighted that a strong therapeutic relationship is a predictor of improved clinical outcomes [38], and that physiotherapists' interpersonal and communication skills are important factors of good therapeutic alliance [39]. ...
Article
Purpose: To explore the conceptions of patients with persistent low back pain (LBP) of undergoing physiotherapy delivered in Finnish primary healthcare by physiotherapists who had participated in brief training in Cognitive Functional Therapy (CFT). Methods: As part of a feasibility implementation study exploring CFT in management of LBP in the Finnish primary healthcare system, we interviewed nine patients from four geographical areas in Finland after receiving care. We used a phenomenographic approach to explore the variation in their conceptions. Results: The analysis revealed four descriptive categories: "hung out to dry," "stuck," "making sense and taking control," and "holistic approach to care and living," that varied based on six themes. Conclusions: Although the participants accepted this approach to care well, there was significant variation in patients' conceptions. Restricted access to care within the healthcare system and a lack of social support led some of them to feel they had been left alone to suffer with their pain. On the other hand, based on the results of this study, positive experiences of physiotherapy and good collaboration with the physiotherapist, wider social support outside of physiotherapy, a better understanding of the multidimen-sional nature of pain and the acquisition of self-management skills were reported as positive aspects of undergoing physiotherapy that may be related to positive treatment outcomes. IMPLICATIONS FOR REHABILITATION The participants of this study saw undergoing physiotherapy delivered within biopsychosocial framework as different from their previous physiotherapy experiences and for some the process ended with feeling empty-handed and for others it could be a turning point in their lives. This study encourages the health care providers to create flexible care pathways and ongoing support for more vulnerable individuals so that they don't feel abandoned by the system. Professionals could also pay attention to building strong therapeutic alliance, help patients understand pain in biopsychosocial framework, take into consideration social support networks of the patients, and support patients toward effective self-management strategies.
... Although the majority of articles also used psychological outcomes in combination with biological, the psychological outcomes received less attention. For example, disability, pain intensity and pain location were the most frequent primary outcomes used to assess and evaluate patients [39][40][41][42][43][44], and active range of motion, posture and spinal movement were also frequently used [43,[45][46][47][48][49][50]. In their perspective paper about a movement control schema, Alrwaily et al. [45] suggest that this type of approach exists within a BPS perspective. ...
... This approach was believed to result in changes in patient behaviour (such as movement patterns or levels of activity), and consequently a reduction in their pain. For example, nine studies [46][47][48][49][50][57][58][59][60] referred to an intervention known as cognitive functional therapy, which was discussed in the texts as being BPS-oriented. For example, in their overview of this treatment, Cowell et al. [57, p.80] state that "Cognitive functional therapy is a biopsychosocially oriented behavioural intervention for low back pain". ...
... For example, Berger mentioned that teams working with pain management should have skills in "[m]aintenance [which] focuses on self-management (e.g., exercise, cognitive behavioural) and ongoing symptomatic intervention" [64, p.17]. Self-management (individual behaviour change) was generally assumed to be the best approach [43,46,48,49]. ...
Article
Purpose: Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model. Material and methods: We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases. Results: Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care]. Conclusion: Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.
... Attention was paid to the participants' thoughts and beliefs related to performing the task, as these may otherwise limit the effect of the intervention. 27,28 Although most focus was on individualized exercises, manual therapy was provided if it was considered relevant and was delivered with a contemporary explanation of its effect. 29,30 The relevance and progression of the chosen intervention was re-evaluated and modified during each follow-up session as needed. ...
... 36,45,46 This is supported by qualitative findings that indicate, that a successful outcome in back pain rehabilitation, is related to changes in pain-related beliefs and achieving more independence in terms of self-managing the pain condition. 27 In the present study, the participants reported a significant reduction in fear-avoidance behavior and psychosocial factors, related to their pain condition, in parallel with improvements in pain and function. Nevertheless, no associations were found between any of the factors where significant improvements occurred, indicating that although these factors are present, an improvement in one is not contingent on an improvement in the other. ...
Article
Abstract Objective: Altered balance in nociception in response to noxious stimuli is commonly reported in chronic low back pain (LBP). However, it is unclear whether an improvement in the clinical presentation is contingent on a reduction in pain sensitivity. This study investigated whether the quantitative sensory testing (QST) profile changes in people undergoing rehabilitation for LBP. Design: A prospective, observational case-control study. Methods: Forty males and females, 18 to 40 years’ old (20 with LBP) participated in 2 sessions. QST was performed at baseline and after discharge from rehabilitation (LBP) or after 3 to 8 weeks (controls). The QST battery consisted of determining pressure-pain thresholds at the low back and shoulder, temporal summation of pain, and conditioned pain modulation. Questionnaire data was used to determine pain (Numeric Rating Scale [NRS]), disability (Roland-Morris Questionnaire [RMQ]), Fear Avoidance Beliefs (FABQ), and The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) at baseline and discharge. The treatment effect was determined by calculating the Cohen d. Results: No significant group×time interactions or main factor effect was found for any of the QST measures. The LBP group reported a significant reduction in NRS (P<0.0002, d=1.23), RMQ (P<0.0001, d=1.58), FABQ (P<0.001, d=0.87), and in the ÖMPSQ (P<0.00001, d=1.44). Conclusions: The results indicate that an improvement of clinical LBP is not contingent upon changes in the pain sensory profile. The value of screening pain sensitivity in LBP patients in primary care, needs to be investigated further, due to the patient population heterogeneity and the sensitivity of assessment methods.
... [12] It focuses on reconceptualizing the concept of pain by educating the patient about the underlying pain mechanisms, functionally retraining the altered movement patterns and modifying the lifestyle. [8,13] ...
... [27] It has been reported in qualitative case studies that patients perceive changed mindset towards pain, enhanced self-efficacy, and greater understanding of their pain. [13] A recently published case report evaluated the effect of cognitive functional therapy in a patient with chronic non-specific neck pain. It reported that CFT integrated with manual therapy and active exercises to reduce pain, disability and enhance confidence in the patient. ...
... The larger effects of CFT compared with usual care at six months may reflect differences between the CFT and usual care approaches to NS-PLBP. Individualized pain control strategies are a high priority in CFT, as the ability to control pain during valued activities is likely to reduce pain-related fear and distress, build self-efficacy, and increase the person's internal locus of control [36,37]. The reductions in fear of movement, anxiety, and catastrophizing observed in the CFT group suggest that a change in the patient's pain-related illness perceptions may have been associated with reductions in disability and pain intensity. ...
... The reductions in fear of movement, anxiety, and catastrophizing observed in the CFT group suggest that a change in the patient's pain-related illness perceptions may have been associated with reductions in disability and pain intensity. This is in line with previous research reporting that a lack of pain control is associated with high levels of pain-related fear [38] and that people benefiting from CFT report a changed mindset toward a broader multidimensional understanding of pain linked to the perception of enhanced pain control [37]. ...
Article
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Introduction: Multidisciplinary care is recommended for disabling persistent low back pain (pLBP) nonresponsive to primary care. Cognitive functional therapy (CFT) is a physiotherapy-led individualised intervention targeting psychological, physical, and lifestyle barriers to recovery, to self-manage pLBP. Objectives: This pilot study investigated clinical outcomes and pain thresholds after a 12-week CFT pathway in patients with severe pLBP referred to a University Pain Center. Exploratory analyses compared changes in clinical outcomes, opioid consumption, and costs after CFT with changes after a multidisciplinary pain management (MPM) pathway. Methods: In total, 47 consecutively referred pLBP patients consented to the CFT pathway. At baseline, 3 and 6 months, clinical outcomes and PPTs were assessed. Control patients (n = 99) who had completed an MPM pathway in the last 3 years were matched from the clinical pain registry used in the Pain Center in a 3:1 ratio based on propensity scores derived from relevant baseline variables of the CFT cases. Results: Most clinical outcomes and low back pressure pain threshold were improved at 3 and 6 months after the CFT pathway. Compared with MPM, CFT patients had significantly larger reductions in disability and improved quality of life after the interventions at a lower cost (-3688€ [confidence interval: -3063 to -4314€]). Reduction in pain intensity and proportion of patients withdrawing from opioids (18.2% vs 27.8%) were similar between CFT and MPM groups. Conclusion: Improvements in clinical and experimental pain were found after the CFT pathway. Fully powered randomized controlled trials comparing CFT with an MPM program in patients with disabling pLBP are warranted to control for the current limitations.
... The larger effects of CFT compared with usual care at six months may reflect differences between the CFT and usual care approaches to NS-PLBP. Individualized pain control strategies are a high priority in CFT, as the ability to control pain during valued activities is likely to reduce pain-related fear and distress, build self-efficacy, and increase the person's internal locus of control [36,37]. The reductions in fear of movement, anxiety, and catastrophizing observed in the CFT group suggest that a change in the patient's pain-related illness perceptions may have been associated with reductions in disability and pain intensity. ...
... The reductions in fear of movement, anxiety, and catastrophizing observed in the CFT group suggest that a change in the patient's pain-related illness perceptions may have been associated with reductions in disability and pain intensity. This is in line with previous research reporting that a lack of pain control is associated with high levels of pain-related fear [38] and that people benefiting from CFT report a changed mindset toward a broader multidimensional understanding of pain linked to the perception of enhanced pain control [37]. ...
Article
Background: Effective, inexpensive, and low-risk interventions are needed for patients with nonspecific persistent low back pain (NS-PLBP) who are unresponsive to primary care interventions. Cognitive functional therapy (CFT) is a multidimensional behavioral self-management approach that has demonstrated promising results in primary care and has not been tested in secondary care. Objective: To investigate the effect of CFT and compare it with usual care for patients with NS-PLBP. Design: Case-control study. Setting: A secondary care spine center. Subjects: Thirty-nine patients received a CFT intervention and were matched using propensity scoring to 185 control patients receiving usual care. Methods: The primary outcome was Roland Morris Disability Questionnaire (0-100 scale) score. Group-level differences at six- and 12-month follow-up were estimated using mixed-effects linear regression. Results: At six-month follow-up, a statistically significant and clinically relevant difference in disability favored the CFT group (-20.7, 95% confidence interval [CI] = -27.2 to -14.2, P < 0.001). Significant differences also occurred for LBP and leg pain, fear, anxiety, and catastrophizing in favor of CFT. At 12-month follow-up, the difference in disability was smaller and no longer statistically significant (-8.1, 95% CI = -17.4 to 1.2, P = 0.086). Differences in leg pain intensity and fear remained significantly in favor of CFT. Treatment satisfaction was significantly higher in the CFT group at six- (93% vs 66%) and 12-month (84% vs 52%) follow-up. Conclusions: These findings support that CFT is beneficial for patients with NS-PLBP who are unresponsive to primary care interventions. Subsequent randomized controlled trials could incorporate booster sessions, which may result in larger effects at 12-month follow-up.
... There is emerging research evidence to support the idea that having a strong therapeutic alliance improves pain outcomes in patients with persistent pain. Factors such as trust, open communication, using a whole person approach, tailoring an individualised plan and the ability to work through challenges in the patient-clinician relationship have all been identified as enhancing this alliance (Kinney et al. 2018;Bunzli et al. 2016). ...
... This may be because of biomedicine's focus on a cure of a disease based upon the implicit belief of monocausality (single cause, single effect), linear causal relationships found amongst statistical frequencies and the lack of acknowledgement of context. In fact, the maintenance of biomedical causal beliefs in regards to pain has been found to be a barrier in the recovery of patients with low back pain (Bunzli et al. 2016). This may be because these patients are still looking for 'the' cure or the scan that will identify 'the' cause which will lead to the correct treatment and cure. ...
Chapter
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Physiotherapist Matthew Low is specialised in treating patients with musculoskeletal disabilities and uses dispositionalism as a framework in his clinical work. Low has developed and put into practice a clinical approach, following the dispositionalist theory, based on a ‘clinical alliance’ between patient and healthcare professional, who together try to make sense of the patient’s situation. This happens through the co-construction of a narrative, where the causal complexity of the patient’s experience is modelled using the dispositionalist vector model. In this chapter, Low translates into clinical reality several of the philosophical issues presented in Part I. First, he shows the necessity of considering the totality of causal evidence, including the qualitative and intrinsic propensities of the single patient at hand. Second, he demonstrates how patient narratives should be considered causal evidence and shows that evidence from population trials is just one piece of the puzzle for understanding causality in the single case. Low further reflects on the importance of moving past the biomedical and the bio-psychosocial models, that fail to honour the stories the patient tells or the full experience of persistent pain and how it affects (and is affected by) every aspect of one’s life. Taking the patients’ narrative seriously and working together with them on a long-term plan are essential tools when it comes to treating persistent pain.
... 39 Either approach can be used and 291 incorporated into daily tasks, progressing to overall activity and lifestyle training, and integrates 292 the cognitive and emotional aspects of pain with the physical. 40 The ICF classification will have 293 already identified activity limitations and participation restrictions, which provides information 294 to the AT on a starting point for progression. 38 Successful outcomes may also depend on whether 295 the client adopts a biopsychosocial belief system, and if the management of the condition is 296 progressed to self-management. ...
... 38 Successful outcomes may also depend on whether 295 the client adopts a biopsychosocial belief system, and if the management of the condition is 296 progressed to self-management. 40 297 ...
Article
Chronic musculoskeletal pain continues to be a rising cost and burden on individuals and society on a global level, thus driving the demand for improved management strategies. Despite the fact that the biopsychosocial model has long been a recommended approach to help manage chronic pain with its' consideration of the person and their experiences, psychosocial context and societal considerations, the biomedical model continues to be the basis of athletic therapy/training education programs and therefore clinical practice. For over 30 years, psychosocial factors have been identified in the literature to be predictors of outcomes relating to chronic pain, including (but not limited to) catastrophizing, fear-avoidance, and self-efficacy. Physical assessment strategies including use of validated outcome measures can be used by the Athletic Therapist and Athletic Trainer to determine the presence and/or severity of non-biogenic pain. Knowledge of these predictors and strategies will allow the Athletic Therapist and Athletic Trainer to frame use of exercise (e.g. graded exposure), manual therapy and/or therapeutic modalities in the appropriate way to improve clinic outcomes. Through change in educational curricula content, such as that recommended by the International Association for the Study of Pain (IASP), Athletic Therapists and Athletic Trainers can develop profession-specific knowledge and skills that will enhance clinical practice to better assist those living with chronic musculoskeletal pain conditions.
... Catastrophic thoughts about what LBP means are common and linked to a sense of hopelessness, despair, greater disability, and poor treatment response [48]. Unfortunately, it appears that many people with LBP have these beliefs about LBP instilled, or reinforced, by their encounters with healthcare professionals [49,50]. Such thoughts likely also reflect a person's behavioral conditioning based on how others respond to their pain, including family, friends, and society [7]. ...
Article
Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order relevant investigations is considered. An overview of contemporary pain mechanisms is provided, with specific reference to the wide range of risk factors for persistent low back pain. Education and exercise framed within a biopsychosocial framework are the cornerstones of treatment. There is a lack of data on more comprehensive personalized treatment approaches among adolescents. One such approach – Cognitive Functional Therapy – which has shown promise in adults and active adolescents with low back pain, is described and illustrated using a case study. The most promising avenues, in practice and research, may be those that view adolescent low back pain as less of a local structural spinal issue and more of an indication of the general health of the adolescent.
... Having pain affects life to a great extent and patients have described the impact of PP on their everyday living to make life not worth living and as pain is the master [6]. The importance of both physical and psychological approaches [7][8][9] and, of including the biopsychosocial perspective [10] has been stressed, considering the complex interaction of biological, psychological and social factors that need to be addressed in treatment of PP [11,12]. ...
Article
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Background: The purpose of this study was to describe how patients with persistent pain experience physiotherapist-guided Free Movement Dance (FMD) as a physiotherapy intervention. Methods: Individual interviews were conducted with 20 patients who had participated in FMD for 1–6 semesters with different guiding physiotherapists. The interviews were transcribed and analysed using qualitative content analysis with an inductive approach as described by Graneheim and Lundman. Results: The analysis resulted in one overarching theme—Physiotherapist-guided Free Movement Dance is empowering in everyday living—and five subthemes: Breaking unhealthy patterns generates physical confidence and strength, Developing greater understanding of the body signals, Accepting pain is important but challenging, Taking responsibility for myself and my well-being and Feeling calmer and happier in life. Conclusions: FMD was experienced as a physiotherapy intervention that enabled the patients to develop an awareness of their own movement, and also leading to the feeling of being empowered in everyday living. FMD can be seen to be in concordance with the core values of physiotherapy that individuals have the capacity to change as a result of their responses to physical, psychological, social and environmental factors.
... The evidence is now compelling that attitudes and beliefs play a key part in the recovery from back pain (Chen et al., 2018;Bunzli et al., 2016), and that people who relate their back pain to a structural or pathoanatomical cause have higher levels of disability (Briggs et al., 2010). These findings suggest thatat a minimumthe advice provided in manual handling guidelines and training needs to evolve to reflect contemporary evidence that there is no single 'safe' lifting posture. ...
Article
Background: The Back-Pain Attitudes (Back-PAQ) questionnaire measures back beliefs across 6 domains. Our previous study showed that manual handling advisors (MHAs) have more negative beliefs than physiotherapists (PTs), and those who think straight back lifting is safer than a rounder back have more negative beliefs. However, exactly which domains of the Back-PAQ are most negative is unknown. Objectives: Gain deeper understanding of how MHAs and PTs construct their back beliefs, and relate this safe lifting posture beliefs. Design: Data was collected via an electronic survey. Method: Participants’ back beliefs were collected via the Back-PAQ. They were also asked to select the safest lifting posture from four options: two with a straight back; two with a rounder back. Back beliefs were analysed in the 6 domains that construct the Back-PAQ. Relationships were investigated using multiple linear and regression models. Results: 400 PTs and MHAs completed the survey. MHAs scored higher (more negative beliefs) than PTs across all 6 domains, and those who perceive straight back lifting as safest scored higher across five of the 6 domains. The belief to keep active with back pain was common among all groups, but MHAs and those who prefer straight back lifting believe the back is vulnerable and more in need of protection. Conclusion: While all believe staying active is beneficial for back pain, residual negative beliefs regarding the vulnerability of the spine persist. Education campaigns may need to emphasise a ‘trust your back’ message rather than a ‘protect your back’ message while encouraging activity.
... Where Acceptance and Commitment Therapy and other mindfulness-based approaches recommend that pain controllability should not be a target of treatment, an intervention explicitly targeting pain control, Cognitive Functional Therapy, shows promising effects for fear reduction (Vibe Fersum et al. 2013). Findings from a qualitative investigation involving patients with CLBP undergoing Cognitive Functional Therapy suggest that improvements through Cognitive Functional Therapy may be mediated by alterations in pain representations and improvements in perceived control (Bunzli et al. 2016); however, this hypothesis remains to be tested through mediation analysis embedded in future studies of Cognitive Functional Therapy. ...
Chapter
Low back pain (LBP) is a leading cause of disability worldwide. One of the strongest predictors of LBP disability is pain-related fear. The fear avoidance model (FAM) describes how the belief that pain signals damage to the spine can lead individuals into a cycle of fear and avoidance, which in turn sustain pain and physical and psychosocial disability. A large body of research has supported the relationships proposed by the FAM; however, randomized controlled trials based on the model have reported modest effect sizes for reductions in fear and disability. Limitations of the model in its current form may be impeding its clinical utility and applicability to the wider population of people with LBP and high pain-related fear. In particular, while the FAM conceptualises pain-related fear as a “phobia” driven by the underlying belief that pain signals damage, it is possible that “non-phobic” processes also trigger pain-related fear and avoidance. In this chapter, we examine the lived experience of LBP and pain-related fear. We explore personal explanations and narratives related to the beliefs underlying pain-related fear, the factors associated with these beliefs and how fear may change over time. We consider how individual variance in qualitative data relates to scores on quantitative measures of fear. Finally, we offer an alternative framework to understand the lived experience of pain-related fear, based on “common sense” rather than only “phobic” processes. We will propose that incorporating a “common sense” perspective into future iterations of the FAM may extend its clinical utility and have implications for the next generation of fear avoidance research.
... Modifying pain-related functional behaviours, in the physical examination, was deemed to provide opportunities for facilitating patient reflection through behavioural modification and represented a powerful context for communication, beyond simply 'talking' to patients. Consistent with a recent qualitative study (Bunzli et al., 2016), it was felt that if patients could experience some control over their pain then this would help to strengthen their new belief system and provide impetus for engaging in more active strategies. ...
Article
Background: Physiotherapists have been urged to embrace a patient-oriented biopsychosocial (BPS) framework for the management of non-specific chronic low back pain (NSCLBP). However, recent evidence suggests that providing broader BPS interventions demonstrates small differences in pain or disability compared to usual care. Little is known about how to integrate a BPS model into physiotherapy practice and the challenges it presents. Objective: To explore the perceptions of physiotherapists' in primary care in England adopting a BPS approach to managing NSCLBP patients. Method: Qualitative semi-structured interviews were conducted with ten physiotherapists working in primary care. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes. Results: Three main themes emerged: (1) physiotherapists recognised the multi-dimensional nature of NSCLBP and the need to manage the condition from a BPS perspective, (2) addressing psychological factors was viewed as challenging due to a lack of training and guidance, (3) engaging patients to self-manage their NSCLBP was seen as a key objective. Conclusion: Although employing a BPS approach is recognised by physiotherapists in the management of NSCLBP, this study highlights the problems of implementing evidence based guidelines recommending that psychological factors be addressed but providing limited support for this. It also supports the need to allocate more time to explore these domains in distressed individuals. Engaging patients to self-manage was seen as a key objective, which was not a straightforward process, requiring careful negotiation.
... se vuelven más fibrosos, rígidos; cualidad que los protege aunque sea a costa de menguar su capacidad de movimiento.(Puentes, Puentes, Puentes, & Chávez, 2017) Figura 2: La zona lumbar2.2. Los Factores que Favorecen la Aparición de Molestias Lumbares1) Situación estresante y estado anímico en tensión, pueden producir molestias en nuestra espalda.(Bunzli, McEvoy, Dankaerts, O'sullivan, & O'sullivan, 2016;Bravo & González-Durán, 2001) 2) La práctica continúa de algunos deportes no simétrico (MonroyAntón, González Catalá, & Santillán Trujillo, 2017; Bauer, y otros, 2017). ...
Thesis
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Los ejercicios Pilates se aplican como un método de entrenamiento combinado y fluido de diversas disciplinas como el yoga y la gimnasia, cuyo propósito es mejorar la tonificación muscular que incluye la coordinación y la flexibilidad con alta precisión de la técnica de movimientos propia del método. Dentro de las ventajas y recomendaciones en la aplicación de ejercicios Pilates está el posible tratamiento de problemas de la espalda. Por ello, se ha planteado como objetivo de la investigación determinar el nivel de influencia ejercidas por el método Pilates en la disminución del dolor provocado por la lumbalgia de origen mecánico en exdeportistas del Club el Nacional. La investigación es de tipo descriptiva, analítica y correlacional, con sentido cuasiesperimental, y por ende de orientación eminentemente mixta. Se estudian a 40 exdeportistas que padecen lumbalgia subaguda y crónica de origen mecánico (rango promedio 30-46 años), dividiendo la muestra en dos grupos independientes, un Grupo Control (aplicación de ejercicios Williams) y un Grupo Experimental (aplicación de ejercicios Pilates). Se controló algunas variables de interés relacionadas con la cantidad de crisis registradas en dos meses y el índice de dolor percibido en dos momentos evaluativos, antes y después de implementada la propuesta de intervención con ejercicios Williams y Pilates a cada grupo independiente estudiado. Se demostró para el presente estudio una disminución significativa en las crisis registradas y el índice de dolor percibido con énfasis en el grupo experimental, evidenciando que el método Pilates tuvo mejor efectividad en la recuperación de los exdeportistas sometidos a estudio.
... Coaching patients at the end of physiotherapy training to find an appropriate and feasible long-term commitment to physical training helps to adhere to the prescribed exercises. Furthermore, a good coaching process initiates self-efficacy and independence from medical interventions; these personal attributes have been associated with positive treatment outcome (Bunzli et al., 2016). ...
Article
Background: Adherence to an exercise programme impacts the outcome of physiotherapy treatment in patients with non-specific low back pain. Objectives: The aim of this study was to explore the patients' perspectives on long term adherence to such exercise programmes. Design: This qualitative study was embedded in a randomised controlled trial (RCT) which compared the effectiveness of two types of exercise programme on patients with nonspecific low back pain. Methods: Answers from 44 participants to three open-ended questions were analysed using thematic analysis. Results/findings: Patients’ perceptions related to the following themes: 1) the role of knowledge in long-term exercise adherence; 2) strategies to support exercise adherence; 3) barriers to exercise adherence 4) the role of perceived effects of exercise. Conclusions: Adherence to long-term exercise is supported through knowledge of the exercises and correct performance. A self-initiated training strategy is the most successful in the perception of participants. Individually supervised physiotherapy treatment that includes coaching towards strategies for post-treatment long term exercise behaviour is recommended.
... 77 Qualitative data and case studies support that people benefiting from CFT report that they have a changed mind-set toward a more multidimensional understanding of their pain, experience increased pain controllability and enhanced self-efficacy about achieving functional and lifestyle goals. 78 Although the mediators of change are not yet known, they are likely to be multidimensional reflecting both central and peripheral processes. ...
Article
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Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual’s disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.
... In fact, evidence suggests that improvements in BP are unrelated to motor changes in trunk muscles (Mannion et al., 2012). Rather, improvements are related to development of helpful back beliefs, reducing pain-related catastrophic thoughts, about the need to protect the body (Mannion et al., 2012), and improved self-efficacy (Bunzli et al., 2016). ...
... participants at times utilised active coping strategies such as self-searching for knowledge and exercises, thus demonstrating self-efficacy. A recent qualitative CLBP study42 reported patients require an explanation and understanding of their CLBP, consistent with our study.Many searched relentlessly, primarily via reliance on HCPs for biomedical interventions, perhaps reflecting the importance participants attached to finding a diagnosis that would legitimise their pain.19 Meanwhile, Punjabi participants' initial reliance on HCPs to provide passive 'quick fix' interventions and a dependency on family members may highlight their biomedical beliefs, underpinned by a lack of understanding and control over pain resulting in low self-efficacy. ...
... 41 Most white British participants at times used active coping strategies such as self-searching for knowledge and exercises, thus demonstrating self-efficacy. A recent qualitative CLBP study 42 reported patients require an explanation and understanding of their CLBP, consistent with our study. Many participants searched relentlessly, primarily via reliance on HCPs for biomedical interventions. ...
Article
Full-text available
Introduction: Disabling chronic low back pain (CLBP) is associated with negative beliefs and behaviours, which are influenced by culture, religion and interactions with healthcare practitioners (HCPs). In the UK, HCPs encounter people from different cultures and ethnic backgrounds, with South Asian Indians (including Punjabis) forming the largest ethnic minority group. Better understanding of the beliefs and experiences of ethnic minorities with CLBP might inform effective management. Objectives: To explore the CLBP beliefs and experiences of English-speaking Punjabi and white British people living with CLBP, explore how beliefs may influence the lived experience of CLBP and conduct cross-cultural comparisons between the two groups. Design: Qualitative study using semistructured interviews set within an interpretive description framework and thematic analysis. Setting: A National Health Service hospital physiotherapy department, Leicester, UK. Participants: 10 CLBP participants (5 English-speaking Punjabi and 5 white British) purposively recruited from physiotherapy waiting lists. Results: Participants from both groups held negative biomedical CLBP beliefs such as the 'spine is weak', experienced unfulfilling interactions with HCPs commonly due to a perceived lack of support and negative psychosocial dimensions of CLBP with most participants catastrophising about their CLBP. Specific findings to Punjabi participants included (1) disruption to cultural-religious well-being, as well as (2) a perceived lack of understanding and empathy regarding their CLBP from the Punjabi community. In contrast to their white British counterparts, Punjabi participants reported initially using passive coping strategies; however, all participants reported a transition towards active coping strategies. Conclusion: CLBP beliefs and experiences, irrespective of ethnicity, were primarily biomedically orientated. However, cross-cultural differences included cultural-religious well-being, the community response to CLBP experienced by Punjabi participants and coping styles. These findings might help inform management of people with CLBP.
... The codebook was discussed between them until agreement was reached. 30 The a-priori codebook was revised to add other themes that emerged in the first three interviews. The second author coded the remainder of interviews using Atlas.ti. ...
Article
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Background: Prior research has established that falls are commonplace in adults with hemophilia, and advises that physical therapy and exercise are successful in fall prevention. Recognizing obstacles and catalysts to physical therapy and exercise in people with hemophilia may augment the efficacy of efforts to prevent falls in this population. Objectives: To learn about the experiences and ideas of patients with hemophilia, especially associated with balance, falls, and exercise. Methods: Semi-structured interviews with 14 adult patients with hemophilia were performed. The interviews were coded for themes founded on the study aims. Results: Most subjects described difficulty with balance, often ascribed to joint problems. They believed that staying strong and fit could positively influence balance, but expressed concerns and fear related to falling. Those who exercised regularly did not view exercise as hazardous, while those who did not dependably exercise articulated worry that dangers of exercise may offset the benefits. The most common obstacle to exercise was pain and having someone to exercise with was often described as an enabler. Barriers to partaking in physical therapy included weak proof of its success and distrust in the therapist. Positive physical therapy experiences in the past and the connection with the therapist were reported as facilitators. Conclusions: People with hemophilia describe some attitudes and experiences that are unique to hemophilia while others are found in the general population. Attending to fear, pain, and support for interventions, while encouraging a robust therapeutic alliance and a plan for routine exercise may aid fall prevention behaviors.
... Although self-efficacy was not measured in this trial, and mediation analyses were not performed, reductions in depression and anxiety, and fear avoidance beliefs regarding work were observed in the CFT group. Previous qualitative research identified that people who positively respond to CFT report a change in their pain beliefs towards a biopsychosocial understanding of their pain, enhanced pain control strategies and self-efficacy to achieve independence in engaging in valued activities (Bunzli, McEvoy, Dankaerts, O'Sullivan, & O'Sullivan, 2016). ...
Article
Full-text available
Objectives This randomized controlled trial investigated the efficacy of cognitive functional therapy (CFT) compared with manual therapy and exercise (MT‐EX) for people with non‐specific chronic low back pain (NSCLBP) at 3‐year follow‐up. Methods 121 patients were randomized to CFT (n=62) or MT‐EX (n=59). 3‐year data were available for 30 (48.4%) participants in the CFT group, and 33 (55.9%) participants in the MT‐EX group. The primary outcomes were disability (Oswestry disability Index (ODI)) and pain intensity (numerical rating scale (NRS)) and secondary outcomes were anxiety/depression (Hopkins Symptoms Checklist) and pain related fear (Fear Avoidance Belief Questionnaire). A full intention to treat analysis was conducted using linear mixed models. Results Significantly greater reductions in disability were observed for the CFT group, with ODI scores at 3‐years 6.6 points lower in the CFT than the MT‐EX group (95%CI:‐10.1 to ‐3.1, p<.001, standardized effect size =0.70). There was no significant difference in pain intensity between the groups at 3 years (0.6 points 95%CI:‐1.4 to 0.3, p=.195). Significantly greater reductions were also observed for the CFT group for Hopkins Symptoms Checklist and Fear Avoidance Belief Questionnaire (Work). Conclusions CFT is more effective at reducing disability, depression/anxiety and pain related fear, but not pain, at 3‐year follow‐up than MT‐EX. This article is protected by copyright. All rights reserved.
... Patients' improved understanding of their condition also appeared as a prominent perceived patient benefit, with physiotherapists stating this led to patients appreciating the link between their psychological and physical health. Likewise, Bunzli, McEvoy, Dankaerts, O'Sullivan, and O'Sullivan (2016), found that when incorporating cognitive functional therapy into rehabilitation, patients who had the largest improvement in outcomes, were more accepting of a biopsychosocial model for their pain. Taken together, these results imply that a shift from a biomedical perspective to a biopsychosocial approach in physiotherapy is potentially being acknowledged and more accepted by patients. ...
Article
Background: This study aimed to determine what physiotherapists perceive are the benefits of using psychosocial strategies in their own practice, and whether perceived barriers extend beyond practitioner and contextual barriers. Methods: Content analysis of two open-ended questions was conducted. Australian physiotherapists (n = 206) provided written comments. Results: Three key categories of benefits emerged: patient benefits, shared patient and physiotherapist benefits, and physiotherapist benefits. Patient benefits included improved rehabilitation experience, improved patient wellbeing and improvement of psychosocial responses. Specifically, increased patient enjoyment, improved self-management and improved understanding of the links between their physical and psychological health. Therapeutic alliance appeared as a shared patient and physiotherapist benefit, with specific reference to enhanced partnerships and improved patient-centred practice. Physiotherapist benefits comprised of improved needs assessment and occupational benefits such as reduced load. Three key categories of physiotherapist barriers, contextual barriers, and patient barriers emerged. Time, knowledge, confidence, lack of expertise, and limited formal training, were the main barriers, specifically a lack of practical training, and for more complex strategies. Physiotherapists acknowledged patient barriers such as patient resistance, lack of understanding, and complex mental health needs. Conclusions: These findings contribute novel information with regard to the benefits and barriers of psychosocial approaches from a physiotherapist perspective. Physiotherapists may benefit from further support in their use of psychosocial approaches, to emphasize the benefits for their own practice. Furthermore, to potentially reduce patient barriers and improve outcomes, patient education concerning a biopsychosocial model of care could be valuable.
... Key aspects of a person's rehabilitation are to facilitate an understanding of their problem and provide strategies that promote independence. These, can be achieved by establishing a strong therapeutic alliance, facilitating the patient's development of body awareness and helping the patient to gain control over the pain condition [55]. The intended purpose of a posture-correcting shirt seems to signal the opposite as pain is attributed to a "postural fault" and the user becomes passively dependent on the shirt to "correct" this fault. ...
Article
Background and aims The concept of bad posture being a dominant driver of pain is commonly held belief in the society. This may explain the significant attention supportive clothing such as posture-correcting shirts has recently gained in Scandinavia and the USA. The aim of this scoping review was to present an overview and synthesis of the available evidence for the use of posture-correcting shirts aimed at reducing pain or postural discomfort and optimising function/posture. Methods A systematic search was conducted for literature investigating the effect of posture-correcting shirts on musculoskeletal pain or function. PubMed, Embase, CINAHL, PEDro and the Cochrane Library were searched for relevant literature. Results of the searches were evaluated by two independent reviewers in three separate steps based on title, abstract and full text. For data synthesis, the population, intervention, comparator and outcome were extracted. The quality of the literature was evaluated using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the risk of bias was assessed using the Risk Of Bias In Non-randomized Studies – of Interventions (ROBINS-I) assessment tool or the RoB 2.0 tool for individually randomized, parallel group trials. The overall confidence in the literature was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results A total of 136 articles were identified and six of these were included in the review. These studies were heterogeneous with regards to aims, outcomes and methods, presenting contrasting results. The overall findings were that posture-correcting shirts change posture and subjectively have a positive effect on discomfort, energy levels and productivity. The quality of the included literature was poor to fair with only one study being of good quality. The risk of bias was serious or critical for the included studies. Overall, this resulted in very low confidence in available evidence. An important limitation of all studies was that they were conducted in pain-free individuals. Conclusions The contrasting findings and the low quality of current literature, questions the intended effect of posture-correcting shirts and whether the changes it creates are in fact useful for clinical practice. Moreover, the findings are contrasted by the available evidence regarding posture and pain with a particular focus on whether this management strategy may have a detrimental effect on people living with musculoskeletal pain. A major limitation to the existing literature on the effect of posture-correcting shirts is that no studies have investigated their effect in clinical populations. Implications Based on the available literature and the major limitation of no studies investigating clinical populations, there is no good quality evidence to support recommendation of posture-correcting shirts as a management strategy for musculoskeletal pain. Promotion of this product may reinforce the inaccurate and unhelpful message that poor posture leads to pain. The efficacy of such garments should be tested in clinical populations and not only in pain-free individuals, to assess whether there is any meaningful benefit of this management approach. Until then, the use of posture-correcting shirts for musculoskeletal pain is not supported by current evidence.
... There are only a few studies looking at patient's accounts after participating in physiotherapy delivered by physiotherapists who have been trained in biopsychosocially oriented interventions, but the results seem promising. At best, the patients report receiving care that is in line with what the research says about what the patients value in physiotherapy encounters, delivered within biopsychosocial framework [12][13][14]. Although the biopsychosocially oriented care is relatively new and different for both patients and physiotherapists, it requires a change in understanding pain and the focus of care. ...
... Research supports the value of the psychological focus in patients with CLBP, because it enables a change in pain beliefs and promotes independence, which helps to improve disability and health conditions. 35 Patients with CLBP who had experienced a biopsychosocial intervention in which HCPs offered personal and realistic strategies, suggestions, and focus on psychological factors believed the intervention supported a positive change in how they coped with their life situation. 36,37 Thus, previous research supports the findings of the present study by indicating that focus on psychological and social factors greatly supports the positive effects of multidisciplinary rehabilitation in patients with CLBP. ...
Article
Purpose: To examine how an integrated, multidisciplinary rehabilitation program was experienced by patients with chronic low back pain and to gain insight into how these patients integrated knowledge, skills, and behaviors obtained by the program into their everyday lives.Materials and Methods: A phenomenological hermeneutic design using Ricoeur's interpretation theory was used in the analysis. Data were generated through nine semi-structured interviews in patients with chronic low back pain. The study adhered to the Consolidated criteria for reporting qualitative research (COREQ) checklist.Results: Standardized rehabilitation efforts adapted to individual needs and provided by a highly professional healthcare team in a combination of inpatient stay and home-based activities was experienced as beneficial, because the patients were able to integrate the obtained knowledge, skills, and behaviors into their everyday lives.Conclusions: The findings revealed that the multidisciplinary holistic approach led to higher bodily awareness, greater mental health, and increased social interaction, which improved happiness and quality of life among the patients. This study emphasizes and highlights a rehabilitation approach that promotes home-based activities to provide a base for co-creation across professions regarding rehabilitation initiatives for patients with chronic low back pain.
... Studies investigating patients' views of their own condition, have shown that adults who harbor pathoanatomical views of their spinal pain, report higher levels of disability [42]. In fact, it seems that difficulty in abandoning biomedical beliefs related to back pain is a barrier for recovery [43]. It is understandable that patients seek answers from healthcare professionals regarding underlying reasons for their pain, especially when it persists [44]. ...
Article
Full-text available
Spinal pain in adults is a significant burden, from an individual and societal perspective. According to epidemiologic data, spinal pain is commonly found in children and adolescents, where evidence emerging over the past decade has demonstrated that spinal pain in adults can, in many cases, be traced back to childhood or adolescence. Nevertheless, very little focus has been on how to best manage spinal pain in younger age groups. The purpose of this article is to put the focus on spinal pain in children and adolescents and highlight how and where these problems emerge and how they are commonly dealt with. We will draw on findings from the relevant literature from adults to highlight potential common pathways that can be used in the management of spinal pain in children and adolescents. The overall focus is on how healthcare professionals can best support children and adolescents and their caregivers in making sense of spinal pain (when present) and support them in the self-management of the condition.
... Studies demonstrating similar results include Scriven et al. (2019) , ( Li and Tse, 2020 ), Bunzli et al. (2016) , andNost et al. (2018) , citing clinically significant improvements in overall function, mood, physical activity, and pain levels. ( Jinnouchi et al., 2021 ) conducted a community-based RCT for the management of chronic low back pain (CLBP), revealing that an individualized self-exercise program and low-frequency 100minute direct teaching did not show additional improvement in pain intensity compared with material-based education but did enhance functional limitation, self-efficacy (PSEQ), and quality of life. ...
Article
Background: In 2020, the COVID-19 virus sparked a crisis constituting a nationwide public health emergency that rapidly altered the provision of healthcare services for all Americans. Infectious disease mitigation led to widespread lockdowns of perceived nonessential services, programs, and non-emergent healthcare interventions. This lockdown exacerbated the public health dyad of uncontrolled pain and the opioid epidemic, which was already in a crisis state. Current literature supports the management of uncontrolled pain with a biopsychosocial approach, empowering patients to explore self-care to enhance activities of daily living. Pain Coping Skills Training (PCST) delivers real-life strategies that improve quality of life and strengthen self-efficacy. Self-efficacy has been identified as a patient outcome measure that demonstrates improved patient-perceived function and quality of life despite pain intensity. Studies have shown that nurse practitioners (APRN) are well-positioned to provide PCST to chronic pain sufferers. Methods: A pretest-posttest design was utilized for this project to enhance pain self- efficacy through an APRN-led community-based intervention. Intervention: Community-dwelling adults treated in a specialty pain management practice were self-selected to participate in a 6-week telehealth delivered PCST Program. This APRN delivered program presented basic pain education and a broad range of evidence-based nonpharmacologic pain management self-care tools. The primary outcome was improved Pain Self-efficacy measured with the pain self-efficacy questionnaire (PSEQ), with secondary outcomes of improved perceived pain intensity and function measured with the pain, enjoyment, and general activity (PEG) scale tracked weekly. Results: Baseline PSEQ and weekly PEG scores were obtained and compared to scores after the program. Collateral data points included confidence in using complementary and alternative nonpharmacologic interventions, satisfaction with the program, and a qualitative patient statement regarding pre-and post-intervention participation. Conclusions: This project concluded that a Nurse Practitioner delivered PCST program via telehealth technology could provide community-dwelling adults with an intervention that improves pain self-efficacy, enhances self-reported PEG measures, and meets the social distancing requirements that continue to impact patients during the COVID-19 pandemic.
... In qualitative studies, physiotherapists who have participated in CFT training have reported developing enhanced communication skills for dealing with their complex patients with MSP [9,16,17]. Patients who have undergone CFT also report recognising the value of communication and therapeutic alliance [18,19]. However, to date, it is unknown whether the training results in changes in physiotherapists' communication behaviours with patients [9,16,17]. ...
Article
Full-text available
Objective The aim of this study was to investigate physiotherapists’ validating and invalidating communication, before and after brief Cognitive Functional Therapy (CFT) training that included a session on validation skills. Associations between validation/invalidation and the characteristics of the interviews and physiotherapists were also explored. Methods Eighteen physiotherapists treating patients with low back pain participated in the study. The study had a within-group design in which validation and invalidation for physiotherapists were rated before and after training using a reliable observational scale. We also collected data on interview length and physiotherapists’ and patients’ speech percentages. Results The physiotherapists’ validating responses increased and invalidating responses decreased from pre- to post-training. The within-group effect size was large for validating responses and medium for invalidating responses. The interview length increased from pre- to post-training (large effect size). However, the reason for this was related to factors other than validation and invalidation. The results indicate that increased validation is associated with an increase in physiotherapists’ speech percentage. Conclusions The results of this study show changes invalidating and invalidating communication among physiotherapists from pre- to post-CFT training. The study also found associations between specific interview characteristics and validating communication. Future studies with larger samples and control groups are needed.
... Considering the concerns reported by physiotherapists regarding their ability to deliver psychologically informed physiotherapy safely and effectively [46][47][48][49][50][51][52][53], the willingness of some patients to engage in such programmes [54,55] and the challenges inherent in completing RCTs, a nested qualitative study will evaluate the acceptability of the interventions and research processes to participants with persistent LBP and their treating physiotherapists. ...
Article
BACKGROUND: Combined physical and psychological programmes (CPPP) are recommended for people with disabling low back pain (LBP). Cognitive Functional Therapy (CFT) is a physiotherapist-led low intensity CPPP with positive effects in previous studies. The clinical and cost effectiveness of CFT has not previously been evaluated in a randomised controlled trial (RCT) in the United Kingdom (UK) National Health Service (NHS). Before a definitive RCT can be completed it is necessary to determine if completing such a study is possible. PURPOSE: To determine the feasibility of completing a definitive RCT, that will evaluate the clinical and cost-effectiveness of CFT in comparison to usual physiotherapy care for people with persistent LBP in the UK NHS. METHODS: A pragmatic two-arm parallel feasibility RCT comparing CFT with usual physiotherapy care for people with persistent LBP will be completed. Sixty participants will be randomly allocated to receive CFT or usual physiotherapy care. The primary outcome will be feasibility of completing a definitive RCT. Participant reported outcome measures will be recorded at baseline, three, six and twelve-month follow-up, including disability, pain intensity, quality of life and psychosocial function. Data will be analysed descriptively. A qualitative process evaluation will explore the acceptability of the research processes and interventions. DISCUSSION: The rationale and methodological design of a mixed methods feasibility RCT is presented. This study aims to inform the planning, design and completion of a future definitive RCT in the UK NHS. The results will be disseminated through peer reviewed open access journal publication.
... Hapids and Horst (2016, pp. [4][5] found there is a strong role of an interdisciplinary approach. Patients expressed some form of gratitude, staff had something positive to say about them. ...
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Research Question (RQ): Chronic musculoskeletal pain is a complex condition and one of the most important causes of suffering of modern times. Self-management refers to the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition. The research question is; what is the view on the selfmanagement of chronic musculoskeletal pain from the patient's perspective? Purpose: The purpose of this literature review was to review original articles that reported how selfmanagement educational programmes are viewed from the patient’s perspective. Method: We used an integrative review of the literature. The search was conducted from November 2019 to March 2020 on the PubMed, PEDro and OTseeker databases. We included original studies, written in English that examined the patients’ point of view on self-management. The included studies, needed to be conducted on adult patients of both sexes, that were suffering from chronic pain and were educated on self-management of their pain. Two authors independently searched for original studies. Results: Nine article were included in the review. Most of the studies included a multidisciplinary approach. Patients reported they more frequently used passive strategies to manage their pain. They want to be included in the management and be able to communicate with the provider of selfmanagement. There are several positive aspects of a multidisciplinary and groups approach. Organization: Health care providers can encourage an individual to proactively behave through ongoing processes of communication, partnerships and the creation of appropriate self-management plans over time. Society: We assume that the analysis will help to identify the social responsibility of the individual and society in the common concern for the health of the population and the individual within it. Originality: The research provides an up-to-date, new overview of the patients' perspective on self management on chronic pain. The review can be helpful to health care providers s they can compare their expectations with patients's. Limitations / further research: Further research would focus on high quality studies, and specific forms of multidisciplinary approach, and finding what patients use at a home setting and how to help them continue in the self management of their pain. Limitations of this review include the lack of risk of bias assessment and the fact that this is not a systematic review.
... 71,74 There is also some preliminary data that those who benefit most in terms of pain and disability display the most significant changes in pain-related cognitions. 75 As such, there is some evidence to suggest that reducing catastrophizing thoughts might be useful for a person with CLBP. In fact, improvements in pain catastrophizing have been associated with changes in prefrontal and parietal areas involved in topdown modulation of pain. ...
Article
Background: Previous studies have found a negative association between a conditioning pain modulating (CPM) response and pain catastrophizing among pain-free subjects. This study investigated the difference in CPM response between patients with chronic low back pain (CLBP) and healthy controls, and the association between pain catastrophizing and the CPM response. Methods: 22 CLBP patients and 22 gender and age-matched controls underwent a CPM protocol. Pressure pain thresholds (PPT) were measured on the lower leg and lower back. The CPM response was registered as the change in PPT from baseline to after a cold pressor test (CPT). Catastrophizing was assessed using the Pain Catastrophizing Scale (PCS) before the CPM protocol in both groups. Results: Analysis of variance showed no interactions in PPT between groups and test sites at baseline or post CPT. PPT increased significantly after CPT in the control group (P < 0.006) but not in the CLBP group. The results showed significantly less pain inhibition among CLBP patients compared to controls (P < 0.04). The CPM response was negatively associated with PCS scores in the CLBP group (rs = -0.67, P=0.0006) while no association was found in the control group. Discussion: This study demonstrated a reduced CPM response and a negative association between pain inhibition and pain catastrophizing in patients with CLBP. The results suggest that catastrophizing thoughts are associated with the efficiency of descending endogenous pain modulation in CLBP, although a causal relationship cannot be inferred.
Article
Exercise is recommended in clinical guidelines for the treatment of chronic whiplash associated disorders (WAD). However, randomised controlled trials have shown similar effects for comprehensive exercise programs and advice. To date, there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not. The aim of this study was to explore the experiences and self-reported characteristics of people with chronic whiplash identifying as ‘responders’ and ‘non-responders’ to exercise. Semi-structured interviews were conducted with 13 people with chronic whiplash (patients) and seven treating physiotherapists. Patients were asked whether they responded to the exercise program, and what contributed to this. Physiotherapists were asked to share their experiences about the characteristics of people that appear to respond to exercise, and those that do not. An interpretive descriptive approach was selected to facilitate the generation of discipline-specific knowledge. Four themes were generated from patient and physiotherapist interviews, including: (1) the therapeutic relationship, (2) exercise experiences and beliefs, (3) self-efficacy and acceptance, (4) physical and psychological determinants of responsiveness. Responsiveness to exercise is complex and multifaceted. Clinicians may seek to identify the presence of discrete physical impairment(s) (e.g., range of motion restriction), and where present, determine whether targeted exercise results in an immediate and positive response. Clinicians may also focus their efforts on developing aspects of the therapeutic relationship identified as important to patients, such as hope, partnership and rapport.
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Purpose To explore patient perspectives of the integrated intervention (intervention arm) of a recent randomised clinical trial that found clinically relevant and sustained benefits of a physiotherapist delivered integrated stress inoculation training (SIT) and exercise for people with acute whiplash-associated disorders (WAD) and at risk of poor recovery. Material and methods Twelve patients from the 53 who participated in the SIT and exercise arm of a randomised controlled trial (StressModex RCT) participated in semi-structured interviews. Data were analysed using inductive thematic analysis. Results Five main themes were identified: “balance between the physical and psychological components,” “dealing with stress,” “coping with the injury,” “pain relief and return to function,” and “elements enhancing therapeutic alliance.” Conclusions The majority of patients found the SIT techniques to be helpful in managing stress and pain, coping with their injury, and returning to function. The patients also found the exercises useful and acknowledged the importance of both the physical and the psychological aspects of whiplash injury. • IMPLICATIONS FOR REHABILITATION • Patients with acute WAD at risk of poor recovery welcomed the inclusion of psychological strategies as part of physiotherapy treatment. • The patients nominated both the psychological (SIT) component and exercise as assisting them with their stress, pain, and recovery. • Physiotherapists could consider including strategies targeting early stress responses in their management of patients with acute WAD.
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Objectives The purpose of this systematic review of qualitative studies is to explore patients’ perceived effectiveness of utilizing complementary and alternative medicine (CAM) for the treatment and/or management of low back pain (LBP). Methods MEDLINE, EMBASE, AMED, and CINAHL were systematically searched from database inception until May 2020. Eligible articles included qualitative data about LBP patients’ perceptions of using CAM. Results Of 1,567 items, 1,542 items were excluded; the remaining 25 articles were included in this review. Three themes emerged as follows: physical benefits; mental health benefits; and negative or no perceived effectiveness of CAM on patients with LBP. Conclusions This study explores perceptions of CAM effectiveness among patients with LBP. These findings provide valuable information to CAM and non-CAM practitioners regarding the importance of individualized patient care based on their preferences, values, needs, and perspectives. Further exploration could include practitioners’ perceptions of CAM and their impact on the patient-practitioner relationship.
Article
Objective: The meaning of recovery from musculoskeletal injury is complex, and understanding recovery from whiplash may be particularly important given the chronic, often recalcitrant nature of the condition. Gaining a better understanding of recovery may also aid in the development and interpretation of future clinical trials. The aim of this study was to define the meaning of recovery from whiplash, and the factors influencing recovery, by exploring the perceptions of people with chronic whiplash, and their treating physiotherapists. Method: This qualitative study was embedded within a larger randomized controlled trial, and consisted of semi-structured interviews. Interviews were conducted with 13 patient participants with chronic whiplash and seven physiotherapists. Patient participants were asked what recovery meant to them, and perceptions around barriers and facilitators to recovery were explored. Physiotherapists were also asked to share their beliefs on the meaning of recovery, and what they believe recovery means to their patients. Results: Both patient participants and physiotherapists perceived recovery to be defined within the themes of pain, function and emotional wellbeing. Patient participants also identified self-perception as important, whilst physiotherapists identified ownership on the part of the patient, and the multidimensional nature of recovery, including cultural values and beliefs, as important. Several themes relating to barriers and facilitators to recovery were also identified, and included personal and social characteristics and aspects of the therapeutic relationship. Discussion: Recovery is a multidimensional and complex construct. In addition to pain intensity and disability, measurement and conceptualization of recovery should focus on emotional wellbeing, self-perception, and the cultural values and beliefs of the individual. A positive therapeutic relationship, with attention to psychological and social influences, appears important in facilitating recovery and wellbeing.
Article
Zusammenfassung Laut Studien liegt die Adhärenz von Patienten für Eigenübungen unter 50 Prozent. Als Therapeuten müssen wir diesem ernüchternden Ergebnis aber nicht hilflos gegenüberstehen. In Interviews geben Patienten klare Hinweise darauf, was sie in der Therapie benötigen, um auf lange Sicht die Übungen auszuführen. Wir sollten auf sie hören.
Article
Purpose: To understand the process of change at an individual level, this study used a single-case experimental design to evaluate how change in potential mediators related to change in disability over time, during an exposure-based behavioural intervention in four people with chronic low back pain and high pain-related fear. A second aim was to evaluate whether the change (sequential or simultaneous) in mediators and disability occurred at the same timepoint for all individuals. Results: For all participants, visual and statistical analyses indicated that changes in disability and proposed mediators were clearly related to the commencement of Cognitive Functional Therapy. This was supported by standard outcome assessments at pre-post timepoints. Cross-lag correlation analysis determined that, for all participants, most of the proposed mediators (pain intensity, pain controllability, and fear) were most strongly associated with disability at lag zero, suggesting that mediators changed concomitantly and not before disability. Importantly, these changes occurred at different rates and patterns for different individuals, highlighting the individual temporal variability of change. Conclusion: This study demonstrated the interplay of factors associated with treatment response, highlighting 'how change unfolded' uniquely for each individual. The findings that factors underpinning treatment response and the outcome changed simultaneously, challenge the traditional understanding of therapeutic change.
Article
Synopsis Pain-related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physiotherapy intervention. The current understanding of pain-related fear is that it is a psychopathological problem where people who catastrophise about the meaning of pain become trapped in a vicious cycle of avoidance behaviour, pain and disability, as recognised in the Fear Avoidance Model. However there is evidence that pain-related fear can also be seen as a common sense response to deal with low back pain, for example, when one is told that their back is vulnerable, degenerating or damaged. In this instance avoidance is a common sense response to protect a 'damaged' back. While the Fear Avoidance Model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophising leads to recovery, the pathway to recovery for individuals trapped in the fear avoidance cycle is less clear. Understanding pain-related fear from a common sense perspective enables physiotherapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience of pain-related fear in people with low back pain, this Clinical Commentary illustrates how Leventhal's Common Sense Model may assist Physiotherapists to understand the broader sense-making processes involved in the fear avoidance cycle and how they can be altered to facilitate fear reduction by applying strategies established in the behavioural medicine literature. J Orthop Sports Phys Ther, Epub 13 Jul 2017. doi:10.2519/jospt.2017.7434.
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Background: Chronic low back pain (cLBP) is a complex condition that is physically and psychologically debilitating, with vulnerable populations experiencing more severe outcomes. Physical therapy (PT) includes evidence-based treatments that can reduce disability, however the experience of PT can vary amongst different populations. Empirical evidence is largely based on majority samples that are predominantly white with high educational attainment. Little is known regarding how people from vulnerable groups (e.g. low income and racial minority) experience physical therapy treatment for low back pain. Objective: To describe the experience of physical therapy in a predominantly low-income and minority population with cLBP. Methods: This qualitative study was embedded within a randomized controlled trial for patients with cLBP in urban, underserved communities. We used a convenience sample to interview 12 participants from the 102 who participated in the PT arm of the trial and then performed thematic analysis to describe their experience. Results: Three major themes emerged: 1) Empowerment through education and exercise; 2) Interconnectedness to providers and other patients; and 3) Improvements in pain, body mechanics, and mood. Divergent cases were few however centered around a lack of improvement in pain or an absence of connection with the therapist. Within the first theme a prevailing sub-theme emerged that aligned with Bandura's theory of self-efficacy: 1) Mastery of experience; 2) Verbal persuasion; 3) Vicarious experience; and 4) Physiological state. Conclusions: Our participants' insight highlighted the value of cognitive-emotional and interpersonal dimensions of PT. These may be particularly important components of PT in populations that have experienced systemic distrust in providers and disparities in services. Future work could use Bandura's model of self-efficacy to build a PT intervention comprised of fear-based movement exercises, interconnectedness, a strong therapeutic alliance, and mindfulness techniques.
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Multiple dimensions across the biopsychosocial spectrum are relevant in the management of non-specific chronic low back pain (NSCLBP). Cognitive functional therapy is a behaviourally targeted intervention which combines normalisation of movement and abolition of pain behaviours with cognitive reconceptualisation of the NSCLBP problem, while also targeting psychosocial and lifestyle barriers to recovery. To examine the effectiveness of cognitive functional therapy for people with disabling NSCLBP who are awaiting an appointment with a specialist medical consultant. A multiple case (n=26) cohort study consisting of 3 phases (A1-B-A2). Measurement phase A1 was a baseline phase during which pain and functional disability were collected on three occasions over three months for all participants. During phase B, participants entered a cognitive functional therapy intervention program, involving approximately eight treatments over an average of 12 weeks. Finally, phase A2 was a 12 month no-treatment follow-up period. Outcomes were analysed using repeated measures ANOVA or Friedman's test (with post-hoc Bonferroni) across seven time intervals, depending on normality of data distribution. Statistically significant improvements in both functional disability (p<0.001) and pain (p<0.001) were observed immediately post-intervention, and maintained over the 12 months follow-up period. These reductions reached clinical significance for both disability and pain. Secondary psychosocial outcomes were significantly (p<0.01) improved after the intervention, including depression, anxiety, back beliefs, fear of physical activity, catastrophising and self-efficacy. Not a randomised controlled trial. While primary outcome data was self-reported, the assessor was not blinded. These promising results suggest that cognitive functional therapy should be compared to other conservative interventions for the management of disabling NSCLBP in secondary care settings in large randomised clinical trials. © 2015 American Physical Therapy Association.
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The past decade has witnessed remarkable evolution within qualitative health research as scholars have moved beyond initial adherence to the specific methods of phenomenology, grounded theory, and ethnography to develop methods more responsive to the experience-based questions of interest to a practice-based discipline. Interpretive description (Thorne, Reimer Kirkham, & MacDonald-Emes, 1997) is an inductive analytic approaches designed to create ways of understanding clinical phenomena that yield applications implications. In this article, we further develop our understanding of this methodological alternative by elaborating on the objective and mechanisms of its analytic processes and by expanding our consideration of its interpretive products.
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Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another. Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59). Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
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Drawing on the foundational theories of John Dewey and Kurt Lewin, we examine recent developments in theory and research on experiential learning and explore how this work can enhance experiential learning in higher education. We introduce the concept of learning space as a framework for understanding the interface between student learning styles and the institutional learning environment. We illustrate the use of the learning space framework in three case studies of longitudinal institutional development. Finally, we present principles for the enhancement of experiential learning in higher education and suggest how experiential learning can be applied throughout the educational environment by institutional development programs, including longitudinal outcome assessment, curriculum development, student development, and faculty development.
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Previous studies have found illness representations to be associated with the degree to which patients adopt health behaviours. Surprisingly, pain representations, especially those in a work rehabilitation context, have rarely been explored. To conduct a thorough investigation of the pain representations held by workers who were on sick leave due to persistent musculoskeletal pain during the process of an intensive work rehabilitation program. Qualitative semi-structured interviews were conducted with 16 participants (male, female), three times during the program and one month after discharge. Data analysis was based on a narrative approach. Throughout the process, pain representation was an indicator of the type of action the participants were ready to take to control the immediate or possible consequences of their pain. Using the context of a work rehabilitation trajectory we identified the differential impact of reconstruction or status quo in pain representations that eventually led to a return to work, or not. This study highlights the importance of identifying and acknowledging workers' pain representations in facilitating their return to work.
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The prevalence of low back pain was assessed in relation to physical activity, for both work and leisure activities, in a randomly selected population in the northern part of Sweden. Additionally, the associations between age, sex, level of education, lifestyle factors, demographic characteristics, and low back pain were evaluated. A total of 5798 subjects aged 25-79 years were selected randomly from a geographically well-defined area in northern Sweden. Additional questions concerning people's experience of low back pain were added to the questionnaire of the World Health Organization MONICA (MONItoring of trends and determinants in CArdiovascular disease) health survey with the aim of investigating prevalence rates and factors associated with low back pain. Forty-one percent of the participants reported having low back pain (of these 55% were women and 45% men). The prevalence rate was highest in the age group 55-64 years. Chronic low back pain was the most frequent occurring problem. Of those with low back pain, 43% of the women and 37% of the men reported having continuous low back pain for more than 6 months. Individuals with low back pain often experienced a more physically heavy workload at work and lower physical activity during leisure time, and they were also more likely to have been smokers, have had higher body mass index, lived in smaller communities, and were less educated than people without low back pain. Low back pain seems to be associated with physical activity at work and in leisure time, certain lifestyle factors and demographic characteristics.
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Low back pain (LBP) is currently the most prevalent and costly musculoskeletal problem in modern societies. Screening instruments for the identification of prognostic factors in LBP may help to identify patients with an unfavourable outcome. In this systematic review screening instruments published between 1970 and 2007 were identified by a literature search. Nine different instruments were analysed and their different items grouped into ten structures. Finally, the predictive effectiveness of these structures was examined for the dependent variables including "work status", "functional limitation", and "pain". The strongest predictors for "work status" were psychosocial and occupational structures, whereas for "functional limitation" and "pain" psychological structures were dominating. Psychological and occupational factors show a high reliability for the prognosis of patients with LBP. Screening instruments for the identification of prognostic factors in patients with LBP should include these factors as a minimum core set.
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Qualitative research methods have a long history in the social sciences and deserve to be an essential component in health and health services research. Qualitative and quantitative approaches to research tend to be portrayed as antithetical; the aim of this series of papers is to show the value of a range of qualitative techniques and how they can complement quantitative research.
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Much qualitative research is interview based, and this paper provides an outline of qualitative interview techniques and their application in medical settings. It explains the rationale for these techniques and shows how they can be used to research kinds of questions that are different from those dealt with by quantitative methods. Different types of qualitative interviews are described, and the way in which they differ from clinical consultations is emphasised. Practical guidance for conducting such interviews is given.
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Recent evidence indicates that the influence of psychosocial factors on low back disability is as great as, if not greater than, ergonomic aspects; negative attitudes and beliefs are likely to be related to absenteeism. To measure workers attitudes and beliefs about low-back trouble, pain, work and activity five questionnaires were used. Two new instruments (Back Beliefs Questionnaire and Psychosocial Aspects of Work questionnaire) were developed and tested. The attitudes and beliefs were measured among workers in a biscuit manufacturing factory, and the responses related to absenteeism. Workers who had taken in excess of one week's absence due to low-back trouble had significantly more negative attitudes and beliefs when compared with workers who had taken shorter absence (or indeed those reporting no history of back trouble). A subset of the psychosocial parameters accounted for 32% of the variance in absence. Interventions designed to reduce negative attitudes and promote positive beliefs may help to reduce detrimental, inappropriate longer-term absenteeism due to low-back trouble.
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A systematic review within the Cochrane Collaboration Back Review Group. To assess the effectiveness of back schools for patients with nonspecific low back pain (LBP). Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating patients with LBP. However, the content of back schools has changed and appears to vary widely today. We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials to November 2004 for relevant trials reported in English, Dutch, French, or German. We also screened references from relevant reviews and included trials. Randomized controlled trials that reported on any type of back school for nonspecific LBP were included. Four reviewers, blinded to authors, institution, and journal, independently extracted the data and assessed the quality of the trials. We set the high-quality level, a priori, at a trial meeting six or more of 11 internal validity criteria. Because data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a qualitative review (best evidence synthesis) to summarize the results. The evidence was classified into four levels (strong, moderate, limited, or no evidence), taking into account the methodologic quality of the studies. We also evaluated the clinical relevance of the studies. Nineteen randomized controlled trials (3,584 patients) were included in this updated review. Overall, the methodologic quality was low, with only six trials considered to be high-quality. It was not possible to perform relevant subgroup analyses for LBP with radiation versus LBP without radiation. The results indicate that there is moderate evidence suggesting that back schools have better short- and intermediate-term effects on pain and functional status than other treatments for patients with recurrent and chronic LBP. There is moderate evidence suggesting that back schools for chronic LBP in an occupational setting are more effective than other treatments and placebo or waiting list controls on pain, functional status, and return to work during short- and intermediate-term follow-up. In general, the clinical relevance of the studies was rated as insufficient. There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain and improve function and return-to-work status, in the short- and intermediate-term, compared with exercises, manipulation, myofascial therapy, advice, placebo, or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodologic quality and clinical relevance and evaluate the cost-effectiveness of back schools.
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The experience of chronic pain can be associated with significant distress and disability; however, this is not always the case. Although attempts to control or reduce pain can be helpful for many pain sufferers, on some occasions this is not an effective option and a different response is required. This different response can include a flexible mix of control and acceptance. The acceptance part of this mix entails a willingness to have pain, or other uncomfortable private experiences, without taking action to control or eliminate them. At least 15 laboratory and clinical studies make the growing case for the role of acceptance in the functioning of people with chronic pain, and evidence from treatment outcome studies is promising. It appears that acceptance-related processes will at least expand our range of psychologic treatment methods for chronic pain sufferers and, at best, significantly improve them.
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Presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from 4 principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Factors influencing the cognitive processing of efficacy information arise from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. (21/2 p ref)
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Study Design. A systematic review within the Cochrane Collaboration Back Review Group. Objectives. To assess the effectiveness of back schools for patients with nonspecific low back pain (LBP). Summary of Background Data. Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating patients with LBP. However, the content of back schools has changed and appears to vary widely today. Methods. We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials to November 2004 for relevant trials reported in English, Dutch, French, or German. We also screened references from relevant reviews and included trials. Randomized controlled trials that reported on any type of back school for nonspecific LBP were included. Four reviewers, blinded to authors, institution, and journal, independently extracted the data and assessed the quality of the trials. We set the high-quality level, a priori, at a trial meeting six or more of 11 internal validity criteria. Because data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a qualitative review (best evidence synthesis) to summarize the results. The evidence was classified into four levels (strong, moderate, limited, or no evidence), taking into account the methodologic quality of the studies. We also evaluated the clinical relevance of the studies. Results. Nineteen randomized controlled trials (3,584 patients) were included in this updated review. Overall, the methodologic quality was low, with only six trials considered to be high-quality. It was not possible to perform relevant subgroup analyses for LBP with radiation versus LBP without radiation. The results indicate that there is moderate evidence suggesting that back schools have better short- and intermediate-term effects on pain and functional status than other treatments for patients with recurrent and chronic LBP. There is moderate evidence suggesting that back schools for chronic LBP in an occupational setting are more effective than other treatments and placebo or waiting list controls on pain, functional status, and return to work during short- and intermediate-term follow-up. In general, the clinical relevance of the studies was rated as insufficient. Conclusion. There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain and improve function and return-to-work status, in the short- and intermediate-term, compared with exercises, manipulation, myofascial therapy, advice, placebo, or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodologic quality and clinical relevance and evaluate the cost-effectiveness of back schools.
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Aim: To discuss the methodological and epistemological challenges experienced when conducting a longitudinal interpretative phenomenological analysis (IPA) of patients' experiences of chronic low back pain (CLBP). Background: The author draws on experiences of managing interpretive analysis while undertaking an IPA of patients with CLBP for more than two years. Data sources: Semi-structured interviews were conducted at three points in time from a purposeful sample of ten patients. Review method: There was a recognition that prolonged contact between researcher and participant increases the challenges related to minimising bias and managing researcher emotionality and empathy. Discussion: Two main challenges are discussed: the usefulness of 'bracketing' in longitudinal qualitative research and maintaining an inductive approach; and consideration of the emotionality of interviewing and the role of empathy. Conclusion: A longitudinal design adds potential analytical pitfalls, including a priori theorising and emotional involvement. Interpretative and emotional safeguarding included reflection and reflexivity, an iterative approach and the role of phenomenological strategies such as the hermeneutic circle. The efficacy of these is discussed, along with the ambiguity surrounding concepts such as bracketing. Implications for research/practice: Although the topics discussed relate specifically to this methodology and a particular research project sample, they are applicable to qualitative research designs in similar populations.
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Objectives: The Tampa Scale of Kinesiophobia (TSK) has been used to identify people with back pain who have high levels of "fear of movement" to direct them into fear reduction interventions. However, there is considerable debate as to what construct(s) the scale measures. Somatic Focus and Activity Avoidance subscales identified in factor analytic studies remain poorly defined. Using a mixed methods design, this study sought to understand the beliefs that underlie high scores on the TSK to better understand what construct(s) it measures. Methods: In-depth qualitative interviews with 36 adults with chronic nonspecific low back pain (average duration=7 y), scoring highly on the TSK (average score=47/68), were conducted. Following inductive analysis of transcripts, individuals were classified into groups on the basis of underlying beliefs. Associations between groups and itemized scores on the TSK and subscales were explored. Frequencies of response for each item were evaluated. Findings: Two main beliefs were identified: (1) The belief that painful activity will result in damage; and (2) The belief that painful activity will increase suffering and/or functional loss. The Somatic Focus subscale was able to discriminate between the 2 belief groups lending construct validity to the subscale. Ambiguous wording of the Activity Avoidance subscale may explain limitations in discriminate ability. Discussion: The TSK may be better described as a measure of the "beliefs that painful activity will result in damage and/or increased suffering and/or functional loss."
Article
Objectives: Chronic nonspecific low-back pain (CLBP) is a prevalent, costly condition that is remarkably resistant to intervention. Substantial evidence suggests that a mismatch exists between the biomedical beliefs held by clinicians and patients and the biopsychosocial nature of CLBP experience. The aim of this metasynthesis of qualitative studies was to provide clinicians with a richer understanding of their patients' CLBP experience to highlight the importance of moving away from biomedical paradigms in the clinical management of CLBP. Methods: Qualitative studies exploring the CLBP experience from the perspective of the individual were included. Twenty-five articles representing 18 studies involving 713 participants were subjected to the 3-stage analytic process of extraction/coding, grouping, and abstraction. Results: Three main themes emerged: the social construction of CLBP; the psychosocial impact of the nature of CLBP; and coping with CLBP. Discussion: The authors conceptualize the experience of CLBP as biographical suspension in which 3 aspects of suspension are described: suspended "wellness," suspended "self," and suspended "future". The implications of improved clinician understanding of the CLBP experience and directions for future research are discussed.
Article
Study Design. Systematic review of interventions.Objective. To assess the effects of spinal manipulative therapy (SMT) for acute low-back pain.Summary of Background Data. SMT is one of many therapies for the treatment of low-back pain, which is a worldwide, extensively practised intervention.Methods. Search methods. An experienced librarian searched for randomised controlled trials (RCTs) in multiple databases up to 31 March 2011. Selection criteria. RCTs which examined manipulation or mobilisation in adults with acute low-back pain (< six weeks duration) were included. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. The effects were examined for: SMT vs. 1) inert interventions, 2) sham SMT, 3) other interventions, and 4) SMT as adjunct therapy.Results. We identified 20 RCTs (total participants = 2674), twelve (60%) of which were not included in the previous review. In total, six trials (30% of all included studies) had a low risk of bias. In general, for the outcomes of pain and functional status, there is low to very low quality evidence suggesting no difference in effect for SMT when compared to inert interventions, sham SMT or as adjunct therapy. There was varying quality of evidence (from very low to moderate) suggesting no difference in effect for SMT when compared with other interventions. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.Conclusions. SMT is no more effective for acute low-back pain than inert interventions, sham SMT or as adjunct therapy. SMT also appears to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.
Article
Background: The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain (LBP) has not been previously investigated. Objective: The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes. Design: This was a retrospective observational study nested within a randomized controlled trial. Methods: One hundred eighty-two patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment. Results: The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts (general exercise versus motor control exercise, spinal manipulative therapy versus motor control exercise). There was no treatment effect modification when outcome was measured with function, pain, and disability measures. Limitations: Therapeutic alliance was measured at the second treatment session, which might have biased the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks. Conclusions: Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.
Article
Study design: Retrospective cohort study of health care costs associated with the treatment of chronic low back pain (CLBP) in the United Kingdom. Objective: To assess 12-month health care costs associated with the treatment of CLBP, using the UK General Practice Research Database. Summary of background data: CLBP is a common health problem. Methods: Data were obtained from the General Practice Research Database, a computerized database of UK primary care patient data. Patients with CLBP were identified for the study period (January 1, 2007, to December 31, 2009) using diagnostic records and pain relief prescriptions (n = 64,167), and 1:1 matched to patients without CLBP (n = 52,986) on the basis of age, sex, and general practitioner's practice. Index date was defined as the first date of CLBP record; the same index date was assigned to matched controls. Multivariate analyses were performed to compare resource use costs (2009 values) in the 12 months after the index date between patients with and without CLBP. A sensitivity analysis was carried out with a more stringent definition for the control group by excluding a broad range of pain conditions. Results: Total health care costs for patients with CLBP were double those of the matched controls (£1074 vs. £516; P < 0.05). Of the cost difference, 58.8% was accounted for by general practitioner's consultations, 22.3% by referrals to secondary care, and the rest by pain relief medications. The sensitivity analysis revealed an even greater cost difference between the 2 groups (£1052 vs. £304; P < 0.05). Because of the use of a retrospective administrative claims database, this study is subject to selection bias between study cohorts, misidentification of comorbidities, and an inability to confirm adherence to therapy or assess indirect costs and costs of over-the-counter medications. Conclusion: Our findings confirm the substantial economic burden of CLBP, even with direct costs only.
Article
This paper describes a process of guided reflection that aims to facilitate and structure reflection and provide a framework for the assessment of reflective practice within the discipline of physiotherapy. Arguments are presented for moving away from an approach which encourages reflecting on beliefs, values, and attitudes to an approach that is linked more closely to systematic critical enquiry, problem solving, and clinical reasoning. The importance of linking reflection to higher order cognitive processes, specifically the development of memory schema, "illness scripts", and clinical knowledge, are stressed. Emphasis is placed on gathering evidence of reflection to allow knowledge that is normally tacit to become more explicit and available for critical appraisal. Therefore, the framework, which is intended to facilitate reflection in clinical practice, asks students to write a personal reflective account, supported by evidence. The framework builds on the thinking and the decision-making process associated with the physiotherapy student's examination of the patient and as such it is embedded within clinical reasoning.
Article
Chronic pain is prevalent, costly, and is associated with profound psychological effects. Although pain is prevalent in returning veterans of the recent military conflicts in Afghanistan and Iraq (Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn [OEF/OIF/OND] Veterans), little is known about chronic pain in these patients. This study's objective was to ascertain perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (Evaluation of Stepped Care for Chronic Pain [ESCAPE]). Qualitative interviews were conducted with 26 patients in the intervention arm of ESCAPE (21% of total intervention patients) to determine patients' experiences with and perceptions of the intervention. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity), nonresponders, and noncompleters (completed <50% of trial). Qualitative analysis was guided by grounded theory. Both responders and nonresponders discussed the importance of the self-management education they received. Of particular significance, patients identified the nurse care manager who administered the intervention as being integral to patients' ability to self-manage their chronic pain. Patients described important ways in which the nurse facilitated their self-management, reported under three themes: 1) helping patients find what works for their pain; 2) holding patients accountable for their pain management; 3) motivating and providing emotional support to patients. Results corroborate previous work and suggest that current conceptualizations of self-management are incomplete. A model is proposed that not only depicts self-management as involving more than activities and strategies, but also acknowledges the central role of relationships and support in pain self-management.
Article
Unlabelled: Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/OND [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed <50% of the trial) were also sampled. Qualitative analysis was guided by grounded theory, using constant comparative methodology. Both responders and non-responders spoke about their evolving understanding of their pain experience during the trial, and how this new understanding helped them to manage their pain more effectively. This evolution is reported under 2 themes: 1) learning to recognize physical and psychosocial factors related to pain; and 2) learning to manage pain through actions and thoughts. Perspective: Responders and non-responders both described making connections between their pain and other factors in their lives, and how these connections positively influenced how they managed their pain. Traditional quantitative measures of response to pain interventions may not capture the full benefits that patients report experiencing.
Article
Our previous research suggests the importance of perceived competence for coping with chronic pain indicating that perceived competence determines how intensely persons experience pain, how much they are disturbed by pain, and whether they engage in adaptive or maladaptive coping behavior. The Present study was designed to test the validity of our pain regulation model expanded by trait anxiety using 201 persons suffering from various types of chronic pain. Structural equation model analyses revealed that maladaptive behavior was affected by trait anxiety only indirectly through pain emotions (pain-related anxiety and depression), whereas perceived competence had an indirect effect on maladaptive pain coping through its effect on pain emotions as well as pain intensity. Adaptive pain coping behavior, on the other hand, was directly affected only by perceived competence, that is, neither trait anxiety nor pain intensity or pain emotions contributed to adaptive behavior. Our results confirm the central importance of perceived competence in determining coping behavior and indicate that perceived competence has a more pronounced effect on pain coping processes than trait anxiety. Persons with high anxiety, however, suffer more from chronic pain that persons with low anxiety. Finally, we discuss implications of our findings for pain management programs.
Article
SummaryA small qualitative study was carried out to gain an in-depth understanding of individual patients' experiences of chronic low back pain (CLBP), and active rehabilitation. Semi-structured, in-depth interviews were conducted with seven individuals who had attended an outpatient back rehabilitation group (BRG). The audio-taped interviews were transcribed, and analysed to develop coding categories. These data were illuminated by detailed field notes kept by the researcher throughout the study.The emergent themes were the participants' perceptions of their health and quality of life, the group culture and dynamics of the treatment programme, and their experiences outside the hospital environment.Participants continued to express dependence on the healthcare professions, and despite improved physical fitness and an increased sense of well-being, experienced no improvement in feelings of control over pain.Encouraging physical activity did not appear to promote self-reliance. Further research, and our clinical practice, should continue to address the cognitive aspects of CLBP, which so influence the outcome of treatment.
Article
To explore the differences in narrative between patients with persistent non-specific low back pain (PLBP) who benefited from a pain management programme, and those who did not benefit. We conducted interviews with 20 patients attending a pain management programme; prior to attending the programme, immediately following the programme and at one year. Our analysis focused on a theoretical sample of patients who either described dramatic life improvements at one year, and who described themselves as much worse. We used the methods of grounded theory. We found that finding hope was central to good outcome. Patients restored hope by making certain changes; (a) deconstructing specific fears, (b) constructing an acceptable explanatory model (c) reconstructing self identity by making acceptable changes. Those who had not restored hope retained fears of loss of self, remained committed to the biomedical model and were unable to make acceptable changes. Our findings may help to operationalise the restoration of hope in patients with PLBP. Firstly, health care professionals need to identify and resolve any specific fears of movement. Secondly, patients need an acceptable explanatory model that fits their experience and personal narrative. Finally our study confirms the centrality of self concept to recovery.
Article
To investigate the psychometric properties of the Working Alliance Inventory Theory of Change Inventory (WATOCI) in physical rehabilitation. RASCH analysis was used to examine the validity, internal consistency, reliability and discriminative properties of the 16-item WATOCI. Data was obtained from a randomized controlled trial, which employed the WATOCI to measure the alliance between physical therapists and patients with chronic low back pain. The results indicated that 7 items on the 16-item WATOCI should need to be improved for use in physiotherapy settings. The resulting 9-item version of the WATOCI was found to be a uni-dimensional tool for measuring alliance, however, demonstrated a ceiling effect. There are several items in the WATOCI that require re-wording and/or re-contextualization prior to its use in clinical practice. Specifically, items relating more to the element social interaction did not discriminate well in this population and one solution may be to provide a therapy-specific context. Items regarding how well the patient understood the purpose of the treatment discriminated best between patients and this area is recommended for further development in the tool's assessment. It is recommended that future research address these issues prior to its use in clinical settings.
Article
To assess the influence of pain severity, catastrophizing, anger, anxiety, and depression on nonspecific low back pain (LBP)-related disability in Spanish patients with chronic LBP. Study Design.  Cross-sectional correlation between psychological variables and disability. Methods.  One hundred twenty-three patients treated for chronic LBP in pain units within nine Spanish National Health Service Hospitals, in eight cities, were included in this study. Intensity of LBP and pain referred to the leg, disability, catastrophizing, anger, state anxiety, trait anxiety, and depression were assessed through previously validated questionnaires. The association of disability with these variables, as well as gender, age, academic level, work status, and use of antidepressants, was analyzed through linear regression models. Correlations between LBP, referred pain, disability, catastrophizing, anger, state anxiety, trait anxiety, and depression were significant, except for the ones between anger and LBP and between anger and referred pain. The multivariate regression model showed that when variations of trait anxiety were taken into account, the association of the other psychological variables with disability was no longer significant. The final model explained 49% of the variability of disability. Standardized coefficients were 0.452 for trait anxiety, 0.362 for intensity of LBP, 0.253 for failed back surgery, and -0.140 for higher academic level. Among Spanish chronic LBP patients treated at pain units, the correlation of catastrophizing, state anxiety, anger, and depression with disability ceases to be significant when variations of trait anxiety are taken into account. Further studies with LBP patients should determine whether anxiety trait mediates the effects of the other variables, explore its prognostic value, and assess the therapeutic effect of reducing it.