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Implementing psychosocial factors in physical therapy treatment for patients with musculoskeletal pain in primary care
Örebro University, School of Health and Medical Sciences.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This dissertation focuses on 2 parts: 1) Whether evidence-based guidelines are recognized and integrated into clinical practice in primary care and 2) Whether a university course aimed at teaching physical therapists to identify and address evidence-based psychosocial factors in primary care might change practice behaviour and patient outcome. To this end practising clinicians were surveyed and a course for physical therapists was developed.Concerning the first part, we showed that a relatively large proportion of clinicians in primary care were unfamiliar with the content of evidence-based guidelines and/or with the concept of “Red flags”. Yet, concerning the self-reported practice behaviour, the majority indicated they followed the key points in the guidelines. To enhance the impact of guidelines, interventions or tactics for teaching and implementing guidelines should include interactive education,discussion, feedback, and reminders which in research have shown to enhance knowledge,skills and change behaviour. Furthermore, the clinical applicability of the guidelines needs to be further developed. We could also show that psychosocial factors were integrated up to a certain point and that physical therapists in primary care were well aware of the importance of psychosocial risk factors, but it seemed physical therapists lack specificity about which factors are important. Physical therapists may have heard about risk factors but probably did not have a clear model or structure about how these factors work.Concerning the second part, the results showed that we, by means of a university course, managed to change attitudes and beliefs, increase knowledge, skills and competencies towards a more biopsychosocial standpoint. But despite these changes, the results did not show a behavioural change on behalf of the physical therapists or a better outcome for patients at risk of longterm pain and disability. Several possible explanations for this are discussed. First, the content of the course should be changed so it focuses more on behavioural change on behalf of the physical therapists. This would facilitate implementation of new behaviour in clinical practice and increase the likelihood that the new behaviour is maintained and thereby the possibility of improved patient outcome. Second, treating patients at risk for long-term pain and disability may also be too difficult for a single physical therapist in a clinical setting. This would imply large changes in the way patients are directed through the health care system compared to now. The main tasks of the physical therapists in primary care would then be to select patients at risk for long-term pain and disability. They would then treat the patients not at risk and refer the patients at risk for long-term pain and disability to more suitable treatment, for example CBT treatment delivered by a psychologist or multimodal treatment delivered by a team of experts.Since risk patients experience most suffering and are the most costly for the health care system, it is important they get the appropriate treatment at the earliest possible opportunity.In summary, this dissertation shows that integrating psychosocial factors in physical therapy is not an easy task.

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2010. , p. 69
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 44
Keyword [en]
Physical therapy, musculoskeletal pain, psychosocial factors, dissimilation, evidence based, education, primary health care
National Category
General Practice
Research subject
Rehabilitation Medicine
Identifiers
URN: urn:nbn:se:oru:diva-10426ISBN: 978-91-7668-727-7 (print)OAI: oai:DiVA.org:oru-10426DiVA, id: diva2:311284
Public defence
2010-05-28, Bomanssonsalen, Universitetssjukhuset Örebro, Örebro, 13:00 (English)
Opponent
Supervisors
Available from: 2010-04-21 Created: 2010-04-21 Last updated: 2018-01-12Bibliographically approved
List of papers
1. Do physical therapists recognise established risk factors?: Swedish physical therapists' evaluation in comparison to guidelines
Open this publication in new window or tab >>Do physical therapists recognise established risk factors?: Swedish physical therapists' evaluation in comparison to guidelines
2004 (English)In: Physiotherapy, ISSN 0031-9406, Vol. 90, no 1, p. 35-41Article in journal (Refereed) Published
Abstract [en]

Background and purpose The Swedish Council on Technology Assessment in Health Care has widely distributed the most recent Swedish evidence-based review on neck and back pain. In this review psychosocial factors were acknowledged as important risk factors for developing chronic pain. We surveyed physical therapists’ evaluation of risk factors for the development of chronic pain. The results were compared to the review of the Swedish Council on Technology Assessment in Health Care.

Methods A postal questionnaire was sent to all 117 physical therapists working in primary care in Örebro County, Sweden.

Results The survey was responded to by 102 physical therapists (87%). Over 50% of them indicated as important more than twice as many risk factors than are supported by the evidence-based review.

More than 50% of the physical therapists pointed out all eight evidence-based factors described in the evidence-based review but they also indicated a median of 10 additional factors with little or no support in the literature. More than 80% of the physical therapists responded according to the recommendations of the evidence-based review concerning sick leave and instructions to patients regarding activities and pain relief. Forty-four physical therapists (43%) indicated that they could predict which patients would develop chronic pain in the future.

Conclusions Physical therapists represented by this sample were well aware of the importance of psychosocial risk factors, but because of the large number of additional factors indicated it seems physical therapists lack specificity about which factors are important.

Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2004
Keyword
Psychosocial factors, physical therapy, evidence-based medicine, risk factors
National Category
General Practice
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:oru:diva-10395 (URN)10.1016/S0031-9406(03)00002-6 (DOI)
Available from: 2010-04-20 Created: 2010-04-20 Last updated: 2018-01-12Bibliographically approved
2. Do evidence-based guidelines have an impact in primary care?: A cross-sectional study of Swedish physicians and physiotherapists
Open this publication in new window or tab >>Do evidence-based guidelines have an impact in primary care?: A cross-sectional study of Swedish physicians and physiotherapists
Show others...
2005 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 30, no 1, p. 146-151Article in journal (Refereed) Published
Abstract [en]

Study Design. A cross-sectional study of physicians and physiotherapists in primary care.

Objectives. To survey how familiar clinicians were with evidence-based guidelines for back pain and their opinion about their clinical usefulness and to compare self-reported practice behavior with the guidelines.

Summary of Background Data. Guidelines, based on empirical evidence, are meant to ensure that patients get the most effective treatment. These evidence-based guidelines should steer clinical praxis, but clinicians may not read, let alone heed, them.

Methods. Using a questionnaire, the authors surveyed all physicians and physiotherapists in primary health care in Örebro County, Sweden (N = 235).

Results. Forty-two percent of the physicians and 37% of the physiotherapists were unfamiliar with the content of the guidelines, and 40% of the physicians and 25% of the physiotherapists were unfamiliar with the concept of 'red flags.' Less than half of the clinicians, 47%, were familiar both with the content of the guidelines and the concept of red flags. Their opinion about the guidelines showed that 54% of the physicians and 56% of the physiotherapists agreed that the guidelines were useful in clinical praxis. Concerning the self-reported practice behavior, the majority indicated that they followed the key points in the guidelines.

Conclusions. A relatively large proportion of clinicians were unfamiliar with the content of evidence-based guidelines and/or with the concept of red flags. The process of implementing research into clinical practice is in need of an overhaul, and the impact of guidelines on clinical practice may be questioned.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2005
Keyword
Back pain, primary health care, implementation, evidence-based medicine
National Category
General Practice
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:oru:diva-10396 (URN)
Available from: 2010-04-20 Created: 2010-04-20 Last updated: 2018-01-12Bibliographically approved
3. Do physical therapists change their beliefs, attitudes,knowledge, skills and behaviour after a biopsychosocially orientated university course?
Open this publication in new window or tab >>Do physical therapists change their beliefs, attitudes,knowledge, skills and behaviour after a biopsychosocially orientated university course?
2009 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 15, no 4, p. 724-732Article in journal (Refereed) Published
Abstract [en]

Aim The aim of this study is to examine the effects of an 8-day university-based training course, aimed at identifying and addressing psychosocial prognostic factors during physiotherapy treatment, in shifting therapists towards a more biopsychosocial orientation as measured by changes in beliefs/attitudes, knowledge, skills and behaviour.MethodWe combined a randomized controlled trail with a pre-post design. Forty-two physiotherapists applied for a university-accredited training course designed to enhance knowledge and management of psychosocial factors in their practice with patients suffering from musculoskeletal pain. The course participants were randomized either to receiving the course or to a waiting list for training. Attitudes and beliefs towards, and knowledge of psychosocial factors, patient vignettes and a video of an imaginary patient were tested before and after training. The patients of the course participants were asked to fill out a questionnaire with background questions at treatment start. The patients also received a questionnaire about the physical therapists' behaviour and patient satisfaction 6 weeks after treatment start.ResultsThe results show that physical therapists' attitudes and believes became more biopsychosocially and less biomedically orientated, they were less convinced that pain justifies disability and limitation of activities, and their knowledge and skills on psychosocial risk factors increased after a university-accredited training course. Yet despite these changes their patients perceived their practice behaviour before and after the course as similar and were equally satisfied with their treatment and treatment result.ConclusionA course, which enhanced biopsychosocial attitudes and beliefs, as well as increased such knowledge and skills did not change the way patients perceived their physical therapists. A future question is whether it improves patient outcome.

Place, publisher, year, edition, pages
Oxford: Blackwell, 2009
National Category
General Practice
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:oru:diva-9128 (URN)10.1111/j.1365-2753.2008.01089.x (DOI)000268271000021 ()
Available from: 2010-01-18 Created: 2010-01-18 Last updated: 2018-01-12Bibliographically approved
4. Does teaching physical therapists to deliver a biopsychosocial treatment program result in better patient outcomes?: A randomized controlled trial
Open this publication in new window or tab >>Does teaching physical therapists to deliver a biopsychosocial treatment program result in better patient outcomes?: A randomized controlled trial
2011 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 91, no 5, p. 804-819Article in journal (Refereed) Published
Abstract [en]

Background: Psychosocial risk factors are important in the development of chronic pain but treatment providers often lack knowledge and skills to assess and address these risk factors.

Objectives: We examined the effects of a course on psychosocial factors for physical therapists on patient outcome in terms of pain and disability.

Design: A randomised controlled trail.

Participants: Forty-two primary care physical therapists attended an eight-day university course over eight weeks aimed at identifying and addressing psychosocial risk factors.

Methods: They were randomised to either the course or a waiting list. The physical therapists collected consecutive acute and sub-acute patients with musculoskeletal pain both before and after the course.

Results: There were no significant differences in outcome for pain or disability for all

patients of physical therapists who had participated in the course or for risk patients with higher levels of catastrophizing or depression compared to patients of physical therapists who had not participated in the course. Outcome for low risk patients on pain and disability and for high risk patients on pain was not dependent on if their physical therapists changed their attitudes and beliefs during the course. Yet, outcome on disability for high risk patients may have been influenced if their physical therapists change their attitudes and beliefs.

Limitations: no measure of actual practice behaviour.

Conclusions: An eight-day university course for physiotherapists did not improve outcome for the group of patients as a whole or patients at risk of developing long term disability. Yet, risk patients with higher levels of catastrophizing or depression may have had a greater improvement in disability if their physical therapist changed attitudes and beliefs during the course.

Place, publisher, year, edition, pages
Oxford University Press, 2011
Keyword
Physical therapy, musculoskeletal pain, psychosocial factors, dissimilation, evidence based, education
National Category
General Practice
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:oru:diva-10398 (URN)10.2522/​ptj.20100079 (DOI)000289961000020 ()21451098 (PubMedID)2-s2.0-79960955694 (Scopus ID)
Available from: 2010-04-20 Created: 2010-04-20 Last updated: 2018-01-12Bibliographically approved

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