Physical therapists’ perspectives of patient values and their place in clinical practice:a qualitative study

Background: In physical therapy practice patients and therapists exchange their perspectives on musculoskeletal health problems and their meaning for both of them. However, literature indicates that physical therapists find it difficult to enquire about the patients’ values during clinical encounters. Objectives: The aim of this study was to gain deeper insight into the perspectives of physical therapists about patient values. Design:Explorative qualitative focus group study. Method: Twenty-three physical therapists were interviewed in the Netherlands from March to May 2021. Two researchers analyzed the interviews and derived relevant codes. After an iterative process of comparing, analyzing, conceptualizing and discussing the codes, themes were identified through a thematic framework, illustrated with meaningful quotes. Results: Three major themes were identified: Humane, Tacit, and Responsive. It appeared that patient values play unconsciously a major role in daily practice and are associated with humanity, not technical or procedural aspects of the encounter. Responsive denotes that all values require interaction in which aligning with the individual patient forms the basis of treatment. Barriers for being responsive are identified as subthemes: Choices, Trust, Diverseness, and Boundaries. Conclusion: The concept of patient values appeared to be implicit. The professional intuitively attunes as a fellow human being to values and expectations of the individual patient. This study contributes to finding a balance and mutual reinforcement of implicit and explicit knowledge. With all found experiences and insights the concept of patient values became more explicit in physical therapy to create a framework for education and research in the future.</p

Patient values in physiotherapy practice, a qualitative study

Objectives: Physiotherapy is, like all healthcare professions, relational and value-laden. Patient-centred care, evidence-based practice and value-based practices are concepts in which patient values lie at the heart of high-quality healthcare practices. Nevertheless, physiotherapists have limited awareness of what patient values are in the physiotherapy encounter. The purpose of this study is to explore these patient values. Methods: A qualitative study design using content analysis was used involving 17 adult participants with chronic or recurrent musculoskeletal pain. Data were collected during July 2015–July 2016 in three primary care physiotherapy facilities in Rotterdam, The Netherlands. Two researchers analysed the interviews and derived relevant codes from the data. After an iterative process of comparing, analysing, conceptualizing, and discussing the data, a pre-existing analytic framework was refined in which distinct values were delineated. Results: Emerging patient values were encompassed in three themes, each consisting of two to four elements: (1) values about oneself (uniqueness and autonomy), (2) values regarding actions of the professional (technically skilled professional, conscientious professional, compassionate professional, responsive professional) and (3) values regarding interactions between patients and the professionals (partnership and empowerment). Conclusion: This study emphasizes the need for discussing patient values in the clinical encounter and helps physiotherapists to understand what deems to be important for patients with musculoskeletal pain in physiotherapy practice. The results of this study contribute to the existing body of knowledge of this important aspect of the quality of physiotherapy practice and may inspire clinicians and educators to actively implement patient values in clinical practice and the physiotherapy education

Unravelling Impaired Hypoalgesia at Rest and in Response to Exercise in Patients with Chronic Whiplash-Associated Disorders:Effects of a Single Administration of Selective Serotonin Reuptake Inhibitor versus Selective Norepinephrine Reuptake Inhibitor

(1) Background: Noradrenaline and serotonin have modulatory roles in pain signaling and in exercise-induced hypoalgesia. Patients with chronic whiplash-associated disorders often show impaired exercise-induced hypoalgesia. Therefore, this study aimed to examine the isolated effect of activating serotonergic or noradrenergic descending pathways on hypoalgesia at rest and in response to exercise in patients with chronic WAD by using respectively a single dose of a selective serotonin reuptake inhibitor (SSRI) and a selective norepinephrine reuptake inhibitor (NRI). (2) Methods: Twenty-five people with chronic WAD participated in this double-blind randomized controlled crossover experiment. Serotonin and noradrenaline concentrations were modulated by the oral ingestion of a single dose of citalopram (i.e., SSRI) or atomoxetine (i.e., SNRI). Quantitative sensory testing (including pressure pain thresholds and conditioned pain modulation) was measured before and after exercise in combination with no medication (1), atomoxetine (2), or citalopram (3) at three different test days. (3) Results: Random-intercept linear mixed models analysis was used to analyze pain outcomes (i.e., pain at rest and exercise-induced hypoalgesia) before and after exercise over the three conditions in patients with chronic WAD. No differences in pain at rest were found between the three conditions before exercise. The effect of exercise on pain outcome measures was not influenced by medication intake. The occupational status of the participants had a significant influence on the effect of exercise and medication on pain outcomes (p &lt; 0.05). Patients working full-time had some positive effect of atomoxetine on pain facilitation (p &lt; 0.05). Unemployed patients had some negative effect of citalopram on pain tolerance and experienced exercise-induced hypoalgesia (p &lt; 0.05). (4) Conclusions: A single dose of citalopram or atomoxetine did not result in changes in hypoalgesia at rest and in response to exercise. These results do not support the use of SSRI or selective NRI to overcome impaired hypoalgesia at rest or in response to exercise in people with chronic WAD. Effect of exercise and medication on pain in patients with chronic WAD is influenced by the occupational status.</p

Discontinuation of the PACE Plus trial: Problems in patient recruitment in general practice

Background: The PACE Plus trial was a multi-center, double-blinded, superiority randomized controlled trial (RCT) conducted in patients from Dutch general practice to investigate the efficacy of paracetamol and NSAIDs in acute non-specific low back pain (LBP). Because insufficient numbers of patients could be recruited (only four out of the required 800 patients could be recruited over a period of 6 months), the trial was prematurely terminated in February 2017, 6 months after the start of recruitment. This article aims to transparently communicate the discontinuation of PACE Plus and to make recommendations for future studies. Methods: General Practitioners (GPs) from 36 participating practices received a one-question survey in which they were asked to give the three most important factors that in their opinion contributed to failure of patient recruitment. Results: GPs of 33 out of 36 (92%) participating practices sent a response. A total of 81 factors were reported. These have been categorized into patient factors (26 out of 81 comments, 32%), GP factors (39 out of 81 comments, 48%) and research factors (16 out of 81 comments, 20%). Discussion: Patient recruitment in the PACE Plus trial may have failed due to inefficient medication distribution, recruitment of incident rather than prevalent cases, a design that was too complicated, adequate self-management of LBP, patient expectations different from the trial's scope and lack of time of participating GPs. Substantial differences in design may explain why the preceding PACE trial did manage to successfully complete patient recruitment. Conclusion: Although the PACE Plus trial was terminated as a result of insufficient patient inclusion, the research questions addressed in this trial remain relevant but unanswered. We hope that lessons learned from the discontinuation of PACE Plus and corresponding recommendations may be helpful in the design of upcoming research projects in LBP in general practice. Trial registration: Dutch Trial Registration NTR6089, registered September 14th 2016

Exercise-Induced Hypoalgesia in Patients with Chronic Whiplash-Associated Disorders:Differences between Subgroups Based on the Central Sensitization Inventory

Background: Physical exercise is an important element in the rehabilitation of chronic whiplash-associated disorders, with the physiological process underlying pain reduction called exercise-induced hypoalgesia. In chronic whiplash-associated disorders, exemetorcise-induced hypoalgesia appears impaired, and the research suggests a relationship with symptoms of dysfunctional nociceptive processing, such as central sensitization. This study improves our understanding of exercise-induced hypoalgesia in chronic whiplash-associated disorders by examining the differences between the extent of exercise-induced hypoalgesia in subgroups based on scores on the central sensitization inventory (CSI). Methods: Data were collected from 135 participants with chronic whiplash-associated disorders who completed a set of questionnaires. Pain pressure thresholds and temporal summations were assessed before and after a submaximal aerobic bicycle exercise test. Results: We observed no interaction effect between exercise-induced hypoalgesia and the CSI scores for both pain pressure threshold and temporal summation. No overall statistical effect was measured in the analysis of the effect of time. The pain pressure threshold significantly related to the CSI. The temporal summation showed no correlation. Conclusions: During this study, we did not find evidence for a difference in the presence of exercise-induced hypoalgesia when the subgroups were created based on the central sensitization cluster calculator. Limited evidence was found for the influence of CSI scores on the delta pain pressure threshold.</p

Visual feedback manipulation in virtual reality to influence pain-free range of motion. Are people with non-specific neck pain who are fearful of movement more susceptible?

Background Movement-evoked pain may have a protective or learned component, influenced by visual cues which suggest that the person is moving towards a position that may be perceived as threatening. We investigated whether visual feedback manipulation in virtual reality (VR) had a different effect on cervical pain-free range of motion (ROM) in people with fear of movement. Method In this cross-sectional study, seventy-five people with non-specific neck pain (i.e., neck pain without a specific underlying pathology) rotated their head until the onset of pain, while wearing a VR-headset. Visual feedback about the amount of movement was equal, 30% smaller or 30% larger than their actual rotation. ROM was measured using the VR-headset sensors. The effect of VR manipulation in fearful (N = 19 using the Tampa Scale for Kinesiophobia (TSK) and N = 18 using the Fear Avoidance Beliefs Questionnaire-physical activity (FABQpa)) and non-fearful (N = 46; non-fearful on both scales) people was compared using mixed-design ANOVAs. Results Fear of movement, influenced the effect of visual feedback manipulation on cervical pain-free ROM (TSK: p = 0.036, Ƞp2 = 0.060; FABQpa: p = 0.020, Ƞp2 = 0.077); a greater amplitude of pain-free movement was found when visual feedback reduced the perceived rotation angle compared to the control condition (TSK: p = 0.090, Ƞp2 = 0.104; FABQpa: p = 0.030, Ƞp2 = 0.073). Independent of the presence of fear, visual feedback manipulation reduced the cervical pain-free ROM in the overstated condition (TSK: p&lt; 0.001, Ƞp2 = 0.195; FABQpa: p&lt;0.001, Ƞp2 = 0.329). Discussion Cervical pain-free ROM can be influenced by visual perception of the amount of rotation and people with fear of movement seem to be more susceptible to this effect. Further research in people with moderate/severe fear is needed to determine whether manipulating visual feedback may have clinical applicability to make patients aware that ROM may be influenced more by fear than tissue pathology.</p

Analgesic effects of manual therapy in patients with musculoskeletal pain: A systematic review

Background: Current evidence shows that manual therapy elicits analgesic effect in different populations (healthy, pain inflicted and patients with musculoskeletal pain) when carried out at the spinal column, although the clinical significance of these effects remains unclear. Also the analgesic effects of manual therapy on peripheral joints have not been systematically reviewed. Methods: A systematic review was carried out following the PRISMA-guidelines. Manual therapy was defined as any manual induced articular motion with the aim of inducing analgesic effects. Outcome measure was pain threshold. Results: A total of 13 randomized trials were included in the review. In 10 studies a significant effect was found. Pressure pain thresholds increased following spinal or peripheral manual techniques. In three studies both a local and widespread analgesic effect was found. No significant effect was found on thermal pain threshold. Discussion: Moderate evidence indicated that manual therapy increased local pressure pain thresholds in musculoskeletal pain, immediately following the intervention. No consistent result was found on remote pressure pain threshold. No significant changes occured on thermal pain threshold values. The clinical relevance of these effects remains contradictory and therefore unclear. (C) 2014 Elsevier Ltd. All rights reserved

Analgesic effects of manual therapy in patients with musculoskeletal pain : a systematic review

BACKGROUND: Current evidence shows that manual therapy elicits analgesic effect in different populations (healthy, pain inflicted and patients with musculoskeletal pain) when carried out at the spinal column, although the clinical significance of these effects remains unclear. Also the analgesic effects of manual therapy on peripheral joints have not been systematically reviewed. METHODS: A systematic review was carried out following the PRISMA-guidelines. Manual therapy was defined as any manual induced articular motion with the aim of inducing analgesic effects. Outcome measure was pain threshold. RESULTS: A total of 13 randomized trials were included in the review. In 10 studies a significant effect was found. Pressure pain thresholds increased following spinal or peripheral manual techniques. In three studies both a local and widespread analgesic effect was found. No significant effect was found on thermal pain threshold. DISCUSSION: Moderate evidence indicated that manual therapy increased local pressure pain thresholds in musculoskeletal pain, immediately following the intervention. No consistent result was found on remote pressure pain threshold. No significant changes occured on thermal pain threshold values. The clinical relevance of these effects remains contradictory and therefore unclear