Physiotherapists pain belief and their influence on the management of patients with chronic low back pain - Assignment Example

? “Physiotherapist’s pain belief and their influence on the management of patients with chronic low back pain” Qualitative data handling Assignment Critical appraisal Critical Appraisal In order to assess the validity and effectiveness of results, its strengths and weaknesses are investigated by critical appraisal (Young and Solomon, 2009) and the key facets of this critical appraisal are an assessment of the method and an evaluation of the design of the study (Young and Solomon, 2009). The goal of critical appraisal is to help practitioners to find the most appropriate research to help them in their practice and evidence-based medicine. Information relevant to clinical practice about patients’ experiences and beliefs can be gained through qualitative study (Young and Solomon, 2009). Qualitative study or research is important to look at the complex health issues that the health care practitioners are facing. These types of research studies are able to explore personal experiences and different perspectives to implement quality assurance programmes in the clinical settings. With the increasing number of qualitative research, it is mandatory to appraise in order to examine the new models of the evidence based practice and enhancing the quality of the health care system. This essay will utilise the Critical Appraisal Skill Programme (CASP). Critical appraisal skills programme (CASP) is a tool which is used to appraise qualitative studies and thereby relating to our clinical practice and through this, several different areas of research including question, method, analysis and major findings are evaluated to determine their appropriateness (CASP-UK, 2012). Introduction of the study The research questions whether physiotherapists base their treatments on their underlying beliefs on the causes of pain. It is a fact that the biomedical model suggests that pain is caused by tissue damage and so treatments to promote tissue healing will result in a positive outcome. The biopsychosocial model of pain suggests that there are multiple causes of pain, including patients’ attitudes to pain and its effects on their life. Therefore, if there is a mismatch between the physiotherapists' beliefs about the causes of pain and the actual pain mechanisms experienced by the patient then treatment choices could well be inappropriate. To make the article easily accessible by anyone, it includes full details of the authors, volume and page number of the journal in which it was published in addition to the article's title (Ryan et al., 2007). Those that are mentioned in this article are experts in this field that hold credible experience and qualifications. Abstract In research, an abstract is used in order to briefly describe the study and this information includes the method of the study, how data was gathered and analysed and sample details, as well as any important results and implications (Letts et al., 2007). This study starts with a clear and brief statement the purpose of the study, but the authors failed to give the information regarding the Sample Exclusion Criteria and the last statement in the abstract gave general conclusion. Introduction and Aims of study The introduction of the research was well structured and described the general definition of pain belief. The aim of the research, to examine the physiotherapists’ pain beliefs in the therapeutic encounter, was clearly stated. According to the researchers’ view, the physiotherapist’s pain belief could potentially influence their behaviour, affecting their decision- making plan or advice given to the patient. The researcher describes a frame work about the interdependency of the beliefs and behaviour. He claims that beliefs provide fundamental concepts which determine the behaviour which in turn influences the choice of treatment. Thus, the importance and relevance the research seeks to address has been identified. Literature Review This study, funded by professional organisations and published in the peer reviewed journal Spine fills in gaps in the literature and improves the understanding of experience-based practice. Despite the fact that the article regarding the pain belief of physiotherapists by Daykin and Richardson (2004) contributed valuable information to the literature, additional studies utilising larger samples would help to advance the therapeutic practice. Daykin and Richardson (2004) cited two earlier studies in which one of them proved the importance of the biopsychological model while the other showed the biomedical approach of a physiotherapist in relation to the therapeutic intervention of pain. However, the study misses on the implications of the biopsychological model despite the fact that references were used throughout. In the construction of this study, the authors have made use of previous reviews, focussing on psychological and social factors affecting the treatment of lower back pain. Conversely, they also made reference to a study by Foster et al., (1999) in which the researcher leaned towards the biomedical approach, not the bio-psychological. Daykin and Richardson (2004) stated that there was a wide variety of literature sources, which concentrated in on patient's perception of pain and few, which did the same for the pain belief of the physiotherapist. Therefore, by looking at the physiotherapist's perception of pain and the effect this has on management given to the patient, this study clearly identified the gap which they wanted to fill. Appropriateness of Qualitative Research Method Vishnevsky and Beanlands (2004) stated that qualitative methods are connected to experiences and emotions rather than measurement and analysis. The research method selected by Daykin and Richardson is further supported by the grounded theory, which is used as a tool for formation of defined themes leading to formation of a theoretical framework. Therefore, the researcher used an appropriate method because this paper explored the relationship between behaviour and beliefs. Results from Strauss and Corbin (1990) stated that ground theory was evolving into something more objective and suggested an interpretive approach that permits a researcher to give their attention to human action, social and subjective meaning and problem solving. Sampling Strategy The researcher recruited interaction between physiotherapists and patients, where the interaction took place before and after assessment, and after patient’s discharge. Qualitative research encourages a small sample size using purposive sampling. Purposive sampling permitted the author to choose physiotherapists with substantial experience and also novice physiotherapists. In the present study purposive sampling of the participants was carried out which contributed to a rich source of data (Ryan et al., 2007), however the researcher failed to warrant for choosing only female participants. Purposive sampling often causes a selection bias which can distort the findings. Physiotherapists’ profiles with regards to their field of interests and their experience in pain management should have been mentioned to prove the appropriateness of selecting the participants. The method of sample was described clearly - six physiotherapists are working in an NHS trust outpatient physiotherapy department with different levels of experiences (from 5 years to 17 years). The range of experience and ages of the physiotherapists involved was likely to have created both commonalities and differences in beliefs, which were appropriate for the study. Having experience in physiotherapy induces efficient evaluation methods, both subjective and objective (Rebbeck et al., 2006), and lack of this experience can result in less efficient skills, thereby affecting the outcome and treatment plan. The sample size (6 physiotherapists) is small and the study failed to mention the reasons for this as well as why the sample is suitable for the research aim. Conseuently, generalising this research to other systems of health care could have been difficult because of the small sample size, almost the entire sample utilised the biomedical approach, and the researchers neglected to consider the chance of the population relating more strongly to the biopsychological approach leading to changes in the interventions they used. Another weakness of the research comes from its location - the sampling occurred only in NHS environments and included physiotherapists using biomedical approach, their experience, age and qualification year and this meant that it would be difficult to generalise the findings to other settings. Patients were selected for the study that had been on the outpatient waiting list for the physiotherapy department for longer than three months for a lower back pain complaint. These patients are all deemed ‘chronic’ patients by the International Association for the Study of Pain and therefore, all the patients were having the same level of pain. Twelve patients took part, a male and a female for each physiotherapist involved. Two patients did not complete the course of intervention and one patient left due to not having benefitted from the intervention and the other because they were satisfied with the intervention and wanted to give others a chance to benefit from the course of intervention. This demonstrates that the authors followed the correct recruitment strategy for selection of patients with this type of pain. Rational and Ethical consideration Despite the study's intention to focus on the pain perception of the physiotherapist as opposed to the patient, half as many physiotherapists as patients participated. This appears to deviate from the proposed aim of the study and leans more towards the patients' pain perception than the professionals'. The selection criteria, in part, fills a perceived gap in the literature by providing an insight into the physiotherapist's perception, although narrowly. Prior to the research, ethical approval was sought and granted from the local joint ethics committee in May 1999, while on the other hand, ethical consent has taken from the participants of the research. The use of pseudonyms ensured that the information of the participants had kept confidential from the recipients of this research. Data collection The primary data collection method was based on semi-structured interviews and this was perfect for this study as semi-structured interviews are good for collecting data for inductive systems such as grounded theory (Denzin and Lincoln, 2005). However, they can be too long, since these types of interviews make use of open-ended questions, the responses of which can vary between participants. This is because of ambiguity, which may exist in the questions and the interpretations of each individual. In addition, the interviewer must simultaneously remember the question and keep the conversation with the interviewee proceeding naturally that can be difficult. For this study, no definite instructions were given for how these interviews were conducted, the setting in which they were held, or the topic guide used for the interview. In qualitative research, the most common method used to collect data is individual interview or group interviews consisting of a focus group (Ryan et al., 2007). Daykin and Richardson, (2004) in the present study used semi structured interview advocating the aim to gain participant beliefs, perceptions and accounts of chronic pain. Semi structured interview provided the researcher a clear picture about the attitudes and behaviour of the physiotherapists (Jeanfreau and Jack, 2010). The researcher believed that the data yielded from the interview means something to the interviewee and it is a mere reflection of beliefs of the participants. There is possibility that the information given by the participants is not demonstrated during their therapeutic encounter, which was acknowledge by the author. Daykin and Richardson (2004) believe that participant's response to an interview question should have a significant meaning for them and so there must be a link between that response and their perception. Nevertheless, it has also suggested that participants in a therapeutic intervention might not provide honest answers, thereby indicating that results are contingent on changes in behaviour that might occur during the intervention. A combination of data collection methods were utilised in this study: interviews and observation and consequently, the researchers have ensured that the study is complete and representative (Denzin and Lincoln, 2005). Data collection and a triangulation of methods results in more detailed data handling and add credibility to the results and evidences gathered (Jeanfreau and Jack Jr., 2010). This triangulation makes certain that themes and patterns that relate to the goal of the research are defined and uncommon themes, which may appear during the assessment, are noted for analysing. A diverse number of interviews were carried out at different stages, which included pre- and post- assessment and post-discharge, with both the patient and the physiotherapist. No mention was made, however, as to how long the intervention provided to the patient lasted. In order to obtain a deeper understanding of a participant's pain belief, a watch was kept on any alterations in behaviour in either patient or physiotherapist, and a focus maintained in understanding this behaviour and dialogue during the therapeutic intervention. A combination of semi-structured interviews and observation allows for the comparison of reliability of the data collected but more time is needed to gain more insight (Denzin and Lincoln, 2000) .In qualitative interview strategy, it is very important to record the data gained in an interview in a structured way. For this study, the data was arranged using field notes (covering 18 hours of observational study) and over 60 hours of interview on audio tape. Compiling field notes is a highly effective way of capturing important parts of an interview such as the mood and expressions of the interviewee. In addition, the researcher can note down issues to consider later. The advantage of this is to avoid distracting the interviewee and missing important points of the study, which might have an impact on the data, collected (Pope and Mays, 2000). Data Analysis Grounded theory was used as an analysis tool for the interview transcripts and observations of the intervention. Charmaz (2006) states that grounded theory shows intense and detailed analysis through which data passes and themes are produced after focused coding. The description of the intervention unit was vague and could have been clearer as the researchers did not say how they would apply or why they would be beneficial. The data as made into open codes and then grouped together to make focused codes. Focus codes are made simpler by sorting them by their attributes, how they are formed and their connection to other focused codes (Daykin and Richardson 2004). The primary goal of the analysis was to look closely at physiotherapists’ pain belief and the data collected from patients was used simply to get a deeper insight in this aim and its impact on the intervention. Once the focused codes were obtained, regular comparison method was used to identify appearing themes in regards to the perception of the physiotherapists, which can be connected to theory or form a basis of clinical practice. Tables and mind maps were used to display these themes. While the negative elements, which appeared during the analysis, were taken into consideration, it was not made clear to what extent. Due to failing to mention the researchers' roles in analysing the data, the results may be subject to bias. Grounded theory revealed the themes in the results if the study and these included 'Developing knowledge of the craft', 'Good patients and challenges of difficult patients' (in which the effects of treating difficult patients was outlined) and 'Pain belief in the therapeutic encounter.' Craft knowledge was taken from the practitioners skills to treat a patient in this study and was influenced by experience (both in developing their skills and their own understanding of pain). Finally, pain belief in the therapeutic encounter relates to the management of pain, and the perception of both the physiotherapist and the patient I regards to the treatment. These themes as outlines include the opinions of physiotherapists and determine that each theme has previously moulded by the perception of physiotherapists. In expanding on the themes, the study uses carefully selected quotes from interviews to make the theme clearer. Discussion In the discussion, more attention is given to the previously identified themes and to explaining how evidence from clinical settings leans more towards the biomedical than biopsychological approach. This has done through highlighting how the focus on the biomedical approach by senior members of staff can influence the novice physiotherapist's approach. Flow charts have been developed to explain the notions of 'good' and 'difficult' patients depending on how annoying and discouraging difficult patients can be, this was important when referring them to another practitioner and could serve to reinforce their back pain and related inabilities. The completely therapeutic encounter was analysed by the researcher (one positive outcome, one negative) and so the study referred to both factors of the study. It has also taken into account that full and articulate clarification from the physiotherapist was vital for successful interventions in that this would enable patients to take part in their treatment. However, some parts of the discussion were repetitive so causing some variance from typical presentation while, on the other hand, the themes were discussed fully. Strengths and weakness It was suggested for this study that acquiring new biopsychological clinical skills would be more difficult for experienced physiotherapists as they will have to begin as if they are novices (Denzin and Lincoln, 2005). In order to avert this, the researchers recommend biopsychological skills are broached earlier in the career of physiotherapists and this provides a decent basis for future research. It was concluded that the pain belief of a physiotherapist has an effect on the therapeutic encounter and gave further insight into these perceptions. It was, therefore, decided that practice should be subject to assessment of these perceptions in order to see how to perceptions can influence the intervention, but given the small sample size (6 physiotherapists) the strength of the results is not high so limiting the usefulness of these findings. Recommendations The authors gave some recommendations for further research, which are appropriate for the National Health Service to help improve those that are referred to the pain clinic as well as physiotherapy. Furthermore, it is apparent that to become more effective physiotherapists they need to draw a plan and hence the treatment for LBP will be improved. It is also imperative physiotherapists evolve and transition from just a biomedical perspective to a biopsychosocial perspective to be more thorough in their practice. Conclusion The conclusion is brief and provides the reader with the finding of the study; also give some recommendation for further research. The results provide a more detailed knowledge of the pain belief of physiotherapists' influenced by their experience and the response to the treatment. It appears that to boost satisfaction of patients and physiotherapists and improve the results of intervention, in a clinical environment, the biopsychological approach should be encouraged. The article is a good instance of physiotherapists providing a starting point for additional research in the future. However, the findings gained from six physiotherapists cannot reasonably be said to apply to every physiotherapist therefore, any future research should include a larger sample size for more reliable and applicable results. References All references used in the study followed scientific style guidelines, and chronologically reviewed interested and related topics. Words account 3138 References CASP-UK. (2012) Critical Appraisal Skills Programme-Making sense of evidence about clinical effectiveness [Online] [Accessed 31 January 2013] Available at: http://www.casp-uk.net/wp-content/uploads/2011/11/CASP_Qualitative_Appraisal_Checklist_14oct10.pdf Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage. Daykin, A.R., Richardson, B.( 2004) ‘Physiotherapists’ Pain Beliefs and Their Influence on the Management of Patients With Chronic Low Back Pain’. Spine, 29(7) pp. 783-795. Denzin, N.K., Lincoln, Y.S. (2005). The sage Handbook of Qualitative Research. London: Sage. Foster, N., Thompson, K., Baxter, G.,( 1999)’ Management of nonspecific low back pain by physiotherapists in Britain and Ireland’. Spine, 24, pp. 1332-1342 Jeanfreau, S.G., and Jack, L. (2010) ‘Appraising Qualitative Research in Health Education: Guidelines for Public Health Educators’. 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Vishnevsky, T., Beanlands, H.(2004) ‘ Qualitative research.’ Nephrology Nursing Journal, 31(2) pp. 234-238 Young, J., and Solomon, M.(2009)’ How to crtically apprasise an article.’ Natural Clinical Practice Gastroentrology& Heapatology,6(2) PP. 82-91 Read More