HOW DO PHYSIOTHERAPISTS EXPLAIN PERSISTENT PAIN? A CONSTRUCTIVIST GROUNDED THEORY

C.A. Summers¹, H. van Griensven¹

¹University of Hertfordshire, Allied Health Professionals, Midwifery and Social Work, Hatfield, United Kingdom

Background: Physiotherapy rehabilitation for persistent pain should address the patient’s fear avoidance beliefs and gradually increase confidence, working towards functional goals (O’Sullivan et al., 2018).However, Bishop et al. (2008) showed that physiotherapists believed that activity avoidance is required when experiencing low back pain. Qualitative studies further identified that fear avoidance beliefs of health care practitioners affect their management of patients (Darlow et al., 2012; Gardner et al., 2017). These discrepancies suggest a need to further explore physiotherapists’ belief systems regarding persistent pain and the way they communicate with patients.

Purpose: To generate a theory of how musculoskeletal physiotherapists explain why pain persists in an initial assessment scenario. To utilise a Constructivist Grounded Theory approach to explore the language used by physiotherapists when explaining persistent pain and consider underlying belief systems that may influence their use of language.

Methods: Six in-depth interviews were carried out, which employed a unique design to elicit realistic responses from participants, recruited through convenience sampling. The main section of the interview consisted of a role play in which the researcher played the part of the patient, thus basing the data collection on a strong interaction between researcher and participant. Interviews and analysis took place concurrently, which allowed emerging concepts to guide further data collection (Charmaz, 2014). Data included initial transcripts, recordings and a record of memos written after each interview.

Results: Physiotherapists with less experience of explaining persistent pain from a biopsychosocial perspective, reported barriers such as ‘the confusion it can bring’and ‘heading down a rabbit hole’. They found explaining pain difficult, resulting in avoidance. This interconnected with their underlying belief systems. Some physiotherapists questioned whether further pain explanation would be beneficial, preferring to focus on function. Other physiotherapists placed higher value on the patient’s understanding of persistent pain, frequently using it for patient education. They still described barriers, but these were external, relating to patient beliefs or communication from other professionals, as opposed to low self-efficacy.

Conclusions: Data suggests wide variability in how physiotherapists explain pain to their patients in initial assessments. Role play was used as a novel technique and qualitatively identified this variability. Physiotherapists underlying beliefs, professional background and experience, and perceived barriers to explaining persistent pain emerged as interconnecting contributing factors, which influenced language. The variation in use of language appears to be associated with the therapist’s health model, which ranges from a biomedical to biopsychosocial approach.

Implications: The variation in physiotherapist preferred approaches to explaining persistent pain may reflect a dilemma in the profession, balancing the importance of physiotherapist autonomy in patient communication, with best practice recommendations. This insight regarding factors that influence persistent pain explanation, could be incorporated in development of pain education in physiotherapy. Role play was a key aspect in identifying differences in language utilised within pain explanations, suggesting this could be a useful training tool, and, used to identify gaps in clinicians’ alignment to a biopsychosocial approach.

Funding acknowledgements: None

Keywords:
Persistent Pain
Communication
Beliefs

Topics:
Pain & pain management
Musculoskeletal
Professional practice: other

Did this work require ethics approval? Yes

Institution: University of Hertfordshire

Committee: University of Hertfordshire Ethics Committee

Ethics number: HSK/PGR/UH/04461