Background
Materials and methods
Aims
Research design
Participants
Inclusion criteria | Exclusion criteria |
---|---|
Qualified Physiotherapists, Chiropractors, Osteopaths, or Sports Therapists | Non-qualified/student manual and physical therapists |
Three or more years’ clinical experience in providing regular care for patients with cLBP | Fewer than three years’ clinical experience in providing regular care for patients with cLBP |
Currently practising in the United Kingdom | Practising outside the United Kingdom or healthcare practitioners who do not primarily provide manual and physical therapy (e.g., General Practitioners, Psychologists, Orthopaedic surgeons) |
Able and willing to respond to an online survey in English |
Materials: survey development and piloting
Data collection procedure
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Below is a list of care approaches for patients with chronic or persistent low back pain (LBP).
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Please indicate whether you have intentionally used each approach believing it could influence patient’s LBP outcome(s).
Data analysis
Results
Response rates
Panel characteristics
Demographic information | Round 1 (n = 39) | Round 2 (n = 23) | Total dropouts (%) | ||
---|---|---|---|---|---|
Frequency | % | Frequency | % | ||
Gender | |||||
Male | 22 | 56.4 | 14 | 60.9 | 8 (20.5) |
Female | 17 | 43.6 | 9 | 39.1 | 8 (20.5) |
Practitioner type | |||||
Chiropractor | 23 | 59.0 | 16 | 69.6 | 7 (17.9) |
Physiotherapist | 10 | 25.6 | 4 | 17.4 | 6 (15.4) |
Osteopath | 4 | 10.3 | 3 | 13.0 | 1 (2.6) |
Othera | 2 | 5.1 | 0 | 0 | 2 (5.1) |
Practice setting | |||||
Private practice | 28 | 71.8 | 18 | 78.3 | 10 (25.6) |
Public (NHS) | 5 | 12.8 | 4 | 17.4 | 1 (2.6) |
Combination | 3 | 7.7 | 0 | 0 | 3 (7.7) |
Otherb | 3 | 7.7 | 1 | 4.3 | 2 (5.1) |
Practice region | |||||
South West | 10 | 25.6 | 7 | 30.4 | 3 (7.7) |
London | 6 | 15.4 | 2 | 8.7 | 4 (10.3) |
South East | 6 | 15.4 | 4 | 17.4 | 2 (5.1) |
Wales | 5 | 12.8 | 4 | 17.4 | 1 (2.6) |
Scotland | 3 | 7.7 | 1 | 4.3 | 2 (5.1) |
East Midlands | 3 | 7.7 | 1 | 4.3 | 2 (5.1) |
Yorkshire and the Humber | 2 | 5.1 | 2 | 8.7 | 0 (0) |
Northern Ireland | 1 | 2.6 | 0 | 0 | 1 (2.6) |
North East and Cumbria | 1 | 2.6 | 0 | 0 | 1 (2.6) |
North West | 1 | 2.6 | 1 | 4.3 | 0 (0) |
West Midlands | 1 | 2.6 | 1 | 4.3 | 0 (0) |
Self-reported use and perceived influence of CFs
Patient-practitioner relationship
Self-reported use, perceived as clinically valid, and self-confidence
Rank | Sub-set | Statement | Self-reported use (%) | Valid (%) | Confidence (%) |
---|---|---|---|---|---|
Patient-practitioner relationship (k = 17 statements) | |||||
2 | Non-verbal behaviour | Being warm, confident, friendly, relaxed, and open during the appointment | 100 (n = 39) | 87.2 (n = 34) | 79.5 (n = 31) |
2 | Non-verbal behaviour | Using eye contact, smiling, caring expressions of support and interest to convey empathy and compassion | 100 (n = 39) | 87.2 (n = 34) | 76.9 (n = 30) |
2* | Using specific diagnostic approach | Providing effective reassurance via clear and understandable explanations | 100 (n = 39) | 87.2 (n = 34) | 71.8 (n = 28) |
4.5 | Using specific diagnostic approach | Examining the patient fully using appropriate therapeutic ‘hands on’ touch during the clinical examination | 97.4 (n = 38) | 87.2 (n = 34) | 76.9 (n = 30) |
4.5 | Person-centred care approach | Ensuring the patient feels listened to and heard (e.g., active listening or noting their responses) | 97.4 (n = 38) | 87.2 (n = 34) | 71.8 (n = 28) |
6.5 | Non-verbal behaviour | Not rushing or interrupting the patient; giving them time to tell their story | 94.9 (n = 37) | 89.7 (n = 35) | 66.7 (n = 26) |
6.5 | Person-centred care approach | Engaging in collaborative decision-making with patients (e.g., mutually agreed and flexible goals) | 94.9 (n = 37) | 82.1 (n = 32) | 66.7 (n = 26) |
8* | Person-centred care approach | Providing treatment choices and encouraging patients to choose option(s) if they so wish | 92.3 (n = 36) | 87.2 (n = 34) | 69.2 (n = 27) |
9.5 | Non-verbal behaviour | Using affirmative head nodding, forward leaning, open body postures/orientations | 89.7 (n = 35) | 84.6 (n = 33) | 69.2 (n = 27) |
9.5 | Person-centred care approach | Promoting the patient’s sense of relatedness and partnership with you (i.e., therapeutic alliance) | 89.7 (n = 35) | 82.1 (n = 32) | 64.1 (n = 25) |
12 | Person-centred care approach | Using verbal expressions of empathy, support, and language reciprocity (e.g., using the patient’s words/phrasing) | 84.6 (n = 33) | 92.3 (n = 36) | 69.2 (n = 27) |
12* | Person-centred care approach | Requesting the patient’s opinions and demonstrating you trust and respect them | 84.6 (n = 33) | 84.6 (n = 33) | 64.1 (n = 25) |
12 | Person-centred care approach | Individualising the interaction style according to a patient’s preference (e.g., collaborative or authoritative) | 84.6 (n = 33) | 87.2 (n = 34) | 59.0 (n = 23) |
14* | Using specific diagnostic approach | Providing a detailed, definitive, and confident diagnosis | 79.5 (n = 31) | 79.5 (n = 31) | 56.4 (n = 22) |
16 | Person-centred care approach | Adopting psychosocial talk or partnership statements (e.g., we, us, together) | 76.9 (n = 30) | 82.1 (n = 32) | 66.7 (n = 26) |
16 | Non-verbal behaviour | Applying different forms of touch (e.g., assistive touch, touch to prepare the patient, touch to provide information, touch to reassure the patient) | 76.9 (n = 30) | 76.9 (n = 30) | 66.7 (n = 26) |
16 | Using specific diagnostic approach | Asking questions about the meaning of the patient’s symptoms (i.e., what symptoms indicate to them) | 76.9 (n = 30) | 82.1 (n = 32) | 53.8 (n = 21) |
Perceived influence: panel consensus
Rank | Sub-set | Statement | Mean (S.D.) | [95% CIs] | Agreement levels | Panel consensus | Percentage Disagree |
---|---|---|---|---|---|---|---|
Patient-practitioner relationship (k = 19 statements) | |||||||
1.5 | Non-verbal behaviour | Using eye contact, smiling, caring expressions of support to convey empathy or compassion | 4.74 (± 0.45) | [4.54, 4.93] | 73.9% strongly agree 26.1% agree | Yes (100%) | 0% |
1.5 | Using specific diagnostic approach | Providing a meaningful explanation of the patient’s LBP (i.e., cognitive reassurance) which is clear, understandable, and can be referred to after treatment | 4.74 (± 0.45) | [4.54, 4.93] | 73.9% strongly agree. 26.1% agree | Yes (100%) | 0% |
3.5 | Person-centred care approach | Ensuring the patient feels listened to and heard (e.g., active listening or noting their responses) | 4.70 (± 0.56) | [4.45, 4.94] | 73.9% strongly agree 21.7% agree | Yes (95.7%) | 4.3% (unsure) |
3.5 | Person-centred care approach | Individualising the interaction style according to a patient’s preference (e.g., collaborative, or authoritative) | 4.70 (± 0.56) | [4.45, 4.94] | 73.9% strongly agree 21.7% agree | Yes (95.7%) | 4.3% (unsure) |
5 | Non-verbal behaviour | Being warm, friendly, and relaxed during the appointment | 4.65 (± 0.49) | [4.44, 4.86] | 65.2% strongly agree 34.8% agree | Yes (100%) | 0% |
6.5* | Person-centred care approach | Compassionately expressing your understanding of how LBP affects them (e.g., 'I understand how frustrating it is not to be able to walk your dog/go dancing/garden' etc.) | 4.61 (± 0.50) | [4.39, 4.82] | 60.9% strongly agree 39.1% agree | Yes (100%) | 0% |
6.5 | Person-centred care approach | Promoting the patient’s sense of relatedness and partnership with you (i.e., therapeutic alliance) | 4.61 (± 0.58) | [4.36, 4.86] | 65.2% strongly agree 30.4% agree | Yes (95.7%) | 4.3% (unsure) |
9* | Person-centred care approach | Confirming the patient not only heard but also understood the content of your communication | 4.57 (± 0.51) | [4.35, 4.78] | 56.5% strongly agree 43.5% Agree | Yes (100%) | 0% |
9 | Non-verbal behaviour | Not rushing or interrupting the patient; giving them time to tell their story | 4.57 (± 0.59) | [4.31, 4.82] | 60.9% strongly agree 34.8% agree | Yes (95.7%) | 4.3% (unsure) |
9 | Person-centred care approach | Engaging in collaborative decision-making together (e.g., mutually agreed, and flexible goals) | 4.57 (± 0.66) | [4.28, 4.85] | 65.2% strongly agree 26.1% agree | Yes (91.3%) | 8.7% (unsure) |
12.5 | Person-centred care approach | Using verbal expressions of empathy, support, and language reciprocity (e.g., using the patient’s words) | 4.52 (± 0.51) | [4.30, 4.74] | 52.2% strongly agree 47.8% agree | Yes (100%) | 0% |
12.5 | Using specific diagnostic approach | Examining the patient fully using appropriate therapeutic ‘hands on’ touch during the clinical examination | 4.52 (± 0.59) | [4.27, 4.78] | 56.5% strongly agree 39.1% agree | Yes (95.6%) | 4.3% (unsure) |
12.5 | Non-verbal behaviour | Using affirmative head nodding, forward leaning, open body postures/orientations | 4.52 (± 0.67) | [4.23, 4.81] | 60.9% strongly agree 30.4% agree | Yes (91.3%) | 8.7% (unsure) |
12.5* | Person-centred care approach | Demonstrating you trust or respect the patient and their opinions | 4.52 (± 0.67) | [4.23, 4.81] | 60.9% strongly agree 30.4% agree | Yes (91.3%) | 8.7% (unsure) |
15 | Using specific diagnostic approach | Asking questions about the meaning of the patient’s symptoms (i.e., what symptoms indicate to them). (n = 22)a | 4.50 (± 0.60) | [4.24, 4.76] | 54.5% strongly agree 40.9% agree | Yes (95.4%) | 4.5% (unsure) |
16 | Using specific diagnostic approach | Providing a confident diagnosis (e.g., providing a diagram with simple explanations and/or notes) | 4.43 (± 0.73) | [4.12, 4.75] | 56.5% strongly agree 30.4% agree | Yes (86.9%) | 13.0% (unsure) |
17* | Using specific diagnostic approach | Explaining improvement(s) can be dynamic, and their condition/symptoms may change throughout treatment | 4.39 (± 0.72) | [4.08, 4.70] | 52.2% strongly agree 34.8% agree | Yes (87.0%) | 13.0% (unsure) |
18 | Person-centred care approach | Adopting psychosocial talk or partnership statements (e.g., we, us, together) | 4.22 (± 0.67) | [3.93, 4.51] | 34.8% strongly agree 52.2% agree | Yes (87.0%) | 13.0% (unsure) |
19 | Non-verbal behaviour | Applying different forms of touch (e.g., assistive touch, touch to prepare the patient, touch to provide information, touch to reassure the patient) | 3.96 (± 0.83) | [3.60, 4.31] | 26.1% strongly agree 47.8% agree | No (73.9%) | 21.7% (unsure) 4.3% disagree |
Patient’s beliefs and characteristics
Self-reported use, perceived as clinically valid, and self-confidence
Rank | Sub-set | Statement | Self-reported use (%) | Valid (%) | Confidence (%) |
---|---|---|---|---|---|
Patient’s beliefs and characteristics (k = 23 statements) | |||||
1.5 | Patient’s treatment history | Actively investigating patient’s needs, feelings, preferences, and previous experiences | 100 (n = 39) | 89.7 (n = 35) | 74.4 (n = 29) |
1.5 | Patient’s treatment history | Supporting the patient in reframing negative memories (e.g., reinterpret an X-ray/scan or explain radiological reports/GP letters) | 100 (n = 39) | 89.7 (n = 35) | 64.1 (n = 25) |
3.5* | Cognitive behavioural approach | Reframing patient’s prior misconceptions about low back pain (e.g., ‘pain is not always a sign of physical tissue damage,’ ‘your spine is flexible not fragile’) | 97.4 (n = 38) | 87.2 (n = 34) | 71.8 (n = 28) |
3.5* | Patient’s treatment history | Taking note of inaccurate knowledge from previous treatment experiences (e.g., ‘my spine is crumbling’ or ‘my back is worn out’) | 97.4 (n = 38) | 89.7 (n = 35) | 69.2 (n = 27) |
6.5 | Cognitive behavioural approach | Reframing patient’s prior misconceptions about treatment (e.g., ‘bed rest does not usually help patients recover faster but modified activity can’) | 94.9 (n = 37) | 84.6 (n = 33) | 71.8 (n = 28) |
6.5 | Reducing negative outcomes | Reinforcing a shift in patient’s negative thoughts to positive ones (e.g., outcomes to highlight progress) | 94.9 (n = 37) | 87.2 (n = 34) | 59.0 (n = 23) |
6.5 | Cognitive behavioural approach | Clarifying maladaptive perceptions (e.g., catastrophising: ‘My vertebrae are out of line. I stopped gardening, so I won’t end up in wheelchair’) | 94.9 (n = 37) | 84.6 (n = 33) | 59.0 (n = 23) |
6.5* | Cognitive behavioural approach | Assisting in decreasing fear-avoidance and harm beliefs along with avoidant behaviours | 94.9 (n = 37) | 87.2 (n = 34) | 59.0 (n = 23) |
9 | Creating positive outcomes | Communicating to patients an intervention is likely to be effective (e.g., ‘this treatment usually works for most people with low back pain’) | 92.3 (n = 36) | 89.7 (n = 35) | 74.4 (n = 29) |
11.5 | Creating positive outcomes | Being optimistic during the consultation and regarding their dysfunction (e.g., ‘I believe you will get back to your usual level of functioning again’) | 89.7 (n = 35) | 89.7 (n = 35) | 76.9 (n = 30) |
11.5 | Reducing negative outcomes | Allocating time for patients to ask about negative aspects of treatment | 89.7 (n = 35) | 89.7 (n = 35) | 66.7 (n = 26) |
11.5 | Cognitive behavioural approach | Explaining the multi-dimensional nature (biopsychosocial aspects) of pain (i.e., beliefs, emotions, and behaviours (movement and lifestyle)) via suitable educational materials | 89.7(n = 35) | 87.2 (n = 34) | 61.5 (n = 24) |
11.5 | Cognitive behavioural approach | Developing patient’s self-confidence in performing and persisting with a new behaviour to pursue a goal | 89.7 (n = 35) | 89.7 (n = 35) | 51.3 (n = 20) |
14 | Reducing negative outcomes | Anticipating and helping reduce patient’s anxiety about the treatment/procedure | 87.2 (n = 34) | 92.3 (n = 36) | 56.4 (n = 22) |
15.5 | Creating positive outcomes | Emphasising positive outcomes such as overall pain-reducing effects (e.g., ‘manual or physical therapies are often as effective as painkillers’) | 82.1 (n = 32) | 79.5 (n = 31) | 66.7 (n = 26) |
15.5* | Sociocultural contexta | Displaying a balanced attitude to patient’s alternative or cultural beliefs if not harmful (e.g., acupuncture) | 82.1 (n = 32) | 82.1 (n = 32) | 53.8 (n = 21) |
17 | Reducing negative outcomes | Avoiding negative phrases (e.g., ‘wear and tear,’ ‘damage’, ‘degeneration’, ‘ongoing’ instead of ‘chronic’ pain, ‘plan activities’ instead of ‘do exercise’) | 79.5 (n = 31) | 87.2 (n = 34) | 56.4 (n = 22) |
18 | Reducing negative outcomes | Rephrasing negative information (e.g., during leg flexion test: ‘this procedure may lead to a slight increase in pain’ rather say instead: ‘this procedure might be a bit uncomfortable but only temporarily’) | 76.9 (n = 30) | 89.7 (n = 35) | 59.0 (n = 23) |
19.5* | Cognitive behavioural approach | Helping patients plan and monitor treatment success (e.g., SMART goals, motivational interviewing) | 71.8 (n = 28) | 87.2 (n = 34) | 35.9 (n = 14) |
19.5* | Cognitive behavioural approach | Empowering patients to self-care and anticipate barriers (e.g., reminders, implementation intentions, journal/logbook, NHS online self-care resources) | 71.8 (n = 28) | 89.7 (n = 35) | 33.3 (n = 13) |
21* | Sociocultural contexta | Involving significant others and/or primary carers in treatment | 69.2 (n = 27) | 79.5 (n = 31) | 46.2 (n = 18) |
22.5* | Creating positive outcomes | Helping patients associate hands on techniques with positive outcomes using positive verbal instructions (e.g., ‘I expect your pain will improve after this manipulation’) | 51.3 (n = 20) | 61.5 (n = 24) | 51.3 (n = 20) |
22.5* | Reducing negative outcomes | Describing how (un)common side effects are numerically (e.g., 1 in 100 people) | 51.3 (n = 20) | 76.9 (n = 30) | 38.5 (n = 15) |
Perceived influence: panel consensus
Rank | Sub-set | Statement | Mean (S.D.) | [95% CIs] | Agreement levels | Panel consensus | Percentage Disagree |
---|---|---|---|---|---|---|---|
Patient’s beliefs and characteristics (k = 25 statements) | |||||||
1 | Patient’s treatment history | Reframing misinformed beliefs from previous healthcare experiences (e.g., 'my spine is crumbling', 'my spinal curve is abnormal', 'my back is worn out') | 4.91 (± 0.29) | [4.79, 5.04] | 91.3% Strongly Agree 8.7% Agree | Yes (100%) | 0% |
2 | Patient’s treatment history | Actively investigating patient’s needs, feelings, preferences, and previous experiences | 4.83 (± 0.39) | [4.66, 4.99] | 82.6% Strongly Agree 17.4% Agree | Yes (100%) | 0% |
3 | Patient’s treatment history | Supporting the patient in reframing negative memories (e.g., reinterpret an X-ray/scan or explain radiology reports/GP letters) | 4.78 (± 0.42) | [4.60, 4.96] | 78.3% Strongly Agree 21.7% Agree | Yes (100%) | 0% |
4.5 | Reducing negative outcomes | Allocating time for patients to ask about negative aspects of treatment to address their concerns openly and honestly | 4.70 (± 0.47) | [4.49, 4.90] | 69.6% Strongly Agree 30.4% Agree | Yes (100%) | 0% |
4.5 | Reducing negative outcomes | Anticipating and helping reduce patient’s anxiety about the treatment/procedure | 4.70 (± 0.64) | [4.42, 4.97] | 78.3% Strongly Agree 13.0% Agree | Yes (91.3%) | 8.7% (unsure) |
7* | Cognitive behavioural approach | Explaining routine activities, movement, or exercise can help 'rewire' perceived pain pathways (e.g., some pain or discomfort is normal but is not a sign their LBP is "worsening") | 4.65 (± 0.57) | [4.40, 4.90] | 69.6% Strongly Agree 26.1% Agree | Yes (95.7%) | 4.3% (unsure) |
7 | Cognitive behavioural approach | Clarifying maladaptive perceptions (e.g., catastrophising: ‘My vertebrae are out of line. I stopped gardening, so I won’t end up in a wheelchair’) | 4.65 (± 0.57) | [4.40, 4.90] | 69.6% Strongly Agree 26.1% Agree | Yes (95.7%) | 4.3% (unsure) |
7 | Cognitive behavioural approach | Developing patient’s self-confidence in performing or persisting with a new behaviour or goal | 4.65 (± 0.65) | [4.37, 4.93] | 73.9% Strongly Agree 17.4% Agree | Yes (91.3%) | 8.7% (unsure) |
10* | Patient’s treatment history | Exploring the patient’s current or pre-existing beliefs about the cause(s) of their LBP | 4.61 (± 0.50) | [4.39, 4.82] | 60.9% Strongly Agree 39.1% Agree | Yes (100%) | 0% |
10 | Cognitive behavioural approach | Reframing patient’s prior misconceptions about treatment (e.g., ‘bed rest does not usually help patients recover faster but modified activity can’) | 4.61 (± 0.58) | [4.36, 4.86] | 65.2% Strongly Agree 30.4% Agree | Yes (95.7%) | 4.3% (unsure) |
10 | Cognitive behavioural approach | Assisting in decreasing fear-avoidance and harm beliefs by recognising, confronting, and correcting them | 4.61 (± 0.58) | [4.36, 4.86] | 65.2% Strongly Agree 30.4% Agree | Yes (95.7%) | 4.3% (unsure) |
12.5 | Cognitive behavioural approach | Helping patients plan and monitor treatment success (e.g., explain outcome measures; co-create short-term and long-term goals or target-driven stages of improvement) | 4.57 (± 0.59) | [4.31, 4.82] | 60.9% Strongly Agree 34.8% Agree | Yes (95.7%) | 4.3% (unsure) |
12.5 | Creating positive outcomes | Communicating an intervention is likely to be effective using positive verbal instructions (e.g., 'I expect your pain will improve after treatment') | 4.57 (± 0.59) | [4.31, 4.82] | 60.9% Strongly Agree 34.8% Agree | Yes (95.7%) | 4.3% (unsure) |
14 | Cognitive behavioural approach | Reframing patient’s prior misconceptions about their anatomy/physiology (e.g., ‘your spine is flexible not fragile’) | 4.52 (± 0.67) | [4.23, 4.81] | 60.9% Strongly Agree 30.4% Agree | Yes (91.3%) | 8.7% (unsure) |
16 | Reducing negative outcomes | Reinforcing a shift in patient’s negative thoughts to positive ones (e.g., monitor outcomes to highlight progress) | 4.48 (± 0.59) | [4.22, 4.73] | 52.2% Strongly Agree 43.5% Agree | Yes (95.7%) | 4.3% (unsure) |
16 | Creating positive outcomes | Being optimistic during treatment by providing a prognosis (e.g., 'I believe you will recover and get back to your usual level of functioning') | 4.48 (± 0.67) | [4.19, 4.77] | 56.5% Strongly Agree 34.8% Agree | Yes (91.3%) | 8.7% (unsure) |
16* | Creating positive outcomes | Instilling genuine hope in patients regarding how their life can change for the better | 4.48 (± 1.08) | [4.01,4.95] | 65.2% Strongly Agree 30.4% Agree | No (95.6%) | 4.3% Not Valid |
18* | Reducing negative outcomes | Explaining that calming their stress response is a part of everyday self-care for physical pain and healing. (n = 22)a | 4.45 (± 0.91) | [4.05, 4.86] | 59.1% Strongly Agree 36.4% Agree | No (95.5%) | 4.5% Strongly Disagree |
20* | Cognitive behavioural approach | Explaining basic pain science (i.e., perceived pain is not necessarily actual physical pain from nerve or tissue damage, but whilst very real, is more of a 'learned' response to prior experiences) | 4.43 (± 0.59) | [4.18, 4.69] | 47.8% Strongly Agree 47.8% Agree | Yes (95.7%) | 4.3% (unsure) |
20 | Cognitive behavioural approach | Explaining the multi-dimensional nature (biopsychosocial aspects) of pain (i.e., beliefs, emotions, and behaviours (movement and lifestyle)) via suitable educational materials | 4.43 (± 0.79) | [4.09, 4.78] | 60.9% Strongly Agree 21.7% Agree | Yes (82.6%) | 17.4% (unsure) |
20* | Reducing negative outcomes | Using simple, everyday analogies to alter patient's negative illness perceptions (e.g., ‘rusty hinges often work well despite their appearance’) | 4.43 (± 0.79) | [4.09, 4.78] | 60.9% Strongly Agree 21.7% Agree | Yes (82.6%) | 17.4% (unsure) |
22 | Reducing negative outcomes | Avoiding negative phrases (e.g., ‘wear and tear’, ‘damage’, ‘degeneration’, 'abnormal') | 4.35 (± 0.71) | [4.04, 4.66] | 47.8% Strongly Agree 39.1% Agree | Yes (87.0%) | 13.0% (unsure) |
23.5 | Reducing negative outcomes | Rephrasing negative information (e.g., leg flexion test: ‘this procedure might be a bit uncomfortable but only temporarily’) | 4.26 (± 0.69) | [3.96, 4.56] | 39.1% Strongly Agree 47.8% Agree | Yes (87.0%) | 13.0% (unsure) |
23.5* | Reducing negative outcomes | Explaining imaging is usually unnecessary because scans may not explain the extent of their pain and/or dysfunction | 4.26 (± 0.96) | [3.84, 4.68] | 47.8% Strongly Agree 39.1% Agree | No (87.0%) | 8.7% (unsure) 4.3% Strongly Disagree |
25 | Creating positive outcomes | Emphasising positive outcomes such as overall pain-reducing effects (e.g., ‘manual or physical therapies are often as effective as painkillers’) | 4.22 (± 0.85) | [3.85, 4.59] | 47.8% Strongly Agree 26.1% Agree | No (73.9%) | 26.1% (unsure) |
Practitioner’s beliefs and characteristics
Self-reported use, perceived as clinically valid, and perceived treatment effects
Rank | Sub-set | Statement | Self-reported use (%) | Valid (%) | Enhance Treatment (%) |
---|---|---|---|---|---|
Practitioner’s beliefs and characteristics (k = 7 statements) | |||||
1.5 | Mindset/attitude | Remaining attentive and fully focused on the patient throughout the appointment | 100 (n = 39) | 89.7 (n = 35) | 84.6 (n = 33) |
1.5 | Mindset/attitude | Being genuine and honest to instil a sense of trustworthiness and authenticity | 100 (n = 39) | 87.2 (n = 34) | 82.1 (n = 32) |
3* | Mindset/attitude | Displaying self-confidence without appearing arrogant or dismissive | 97.4 (n = 38) | 84.6 (n = 33) | 79.5 (n = 31) |
4 | Expertise/credibility | Clearly communicating your expectations (i.e., what you anticipate will occur) whilst administering care | 94.9 (n = 37) | 84.6 (n = 33) | 74.4 (n = 29) |
5* | Expertise/credibility | Prescribing or administering treatments you believe and expect to be effective | 92.3 (n = 36) | 82.1 (n = 32) | 76.9 (n = 30) |
6* | Expertise/credibility | Wearing a laboratory coat/medical apparel or tailored/formal clothing to symbolise professionalism | 59.0 (n = 23) | 53.8 (n = 21) | 59.0 (n = 23) |
7* | Expertise/credibility | Using indicators of expertise/high status (e.g., health qualifications, professional memberships) in offices or correspondence | 56.4 (n = 22) | 59.0 (n = 23) | 66.7 (n = 26) |
Perceived influence: panel consensus
Rank | Sub-set | Statement | Mean (S.D.) | [95% CIs] | Agreement levels | Panel consensus | Percentage Disagree |
---|---|---|---|---|---|---|---|
3) Practitioner’s beliefs and characteristics (k = 11 statements) | |||||||
1 | Mindset/attitude | Remaining attentive and fully focused on the patient throughout the appointment | 4.87 (± 0.34) | [4.72, 5.02] | 87.0% Strongly Agree 13.0% Agree | Yes (100%) | 0% |
2 | Mindset/attitude | Being genuine and honest to instil a sense of trustworthiness and authenticity | 4.83 (± 0.39) | [4.66, 4.99] | 82.6% Strongly Agree 17.4% Agree | Yes (100%) | 0% |
3* | Mindset/attitude | Displaying a professional and caring (not only "curing") attitude | 4.78 (± 0.42) | [4.60, 4.96] | 78.3% Strongly Agree 21.7% Agree | Yes (100%) | 0% |
4.5* | Mindset/attitude | Being calm and compassionate throughout the appointment | 4.70 (± 0.56) | [4.45, 4.94] | 73.9% Strongly Agree 21.7% Agree | Yes (95.7%) | 4.3% (unsure) |
4.5 | Expertise/credibility | Clearly communicating your expectations (i.e., what you anticipate will occur) whilst administering care | 4.70 (± 0.64) | [4.42, 4.97] | 78.3% Strongly Agree 13.0% Agree | Yes (91.3%) | 8.7% (unsure) |
6.5 | Expertise/credibility | Administering treatments you expect to be effective | 4.61 (± 0.58) | [4.36, 4.86] | 65.2% Strongly Agree 30.4% Agree | Yes (95.7%) | 4.3% (unsure) |
6.5 | Mindset/attitude | Displaying self-confidence without appearing dismissive | 4.61 (± 0.58) | [4.36, 4.86] | 65.2% Strongly Agree 30.4% Agree | Yes (95.7%) | 4.3% (unsure) |
8* | Mindset/attitude | Creating a caring atmosphere (e.g., appear to have all the time in the world; ensure each patient feels like a priority) | 4.52 (± 0.59) | [4.27, 4.78] | 56.5% Strongly Agree 39.1% Agree | Yes (95.7%) | 4.3% (unsure) |
9.5 | Expertise/credibility | Demonstrating professionalism through your general appearance (i.e., being clean, tidy, smart, and presentable) | 4.48 (± 0.59) | [4.22, 4.73] | 52.2% Strongly Agree 43.5% Agree | Yes (95.7%) | 4.3% (unsure) |
9.5* | Mindset/attitude | Actively build rapport with each patient (e.g., discuss common interests/hobbies; enquire about their lives) | 4.48 (± 0.67) | [4.19, 4.77] | 56.5% Strongly Agree 34.8% Agree | Yes (91.3%) | 8.7% (unsure) |
11 | Expertise/credibility | Using indicators to display your expertise or credibility (e.g., qualifications, insurance, professional memberships) in reception/office, website, or correspondence. (n = 21)a | 4.00 (± 0.89) | [3.59, 4.41] | 33.3% Strongly Agree 38.1% Agree | No (71.4%) | 23.8% (unsure) 4.8% Disagree |
Treatment characteristics
Self-reported use, perceived as clinically valid, and perceived treatment effects
Rank | Sub-set | Statement | Self-reported use (%) | Valid (%) | Enhance Treatment (%) |
---|---|---|---|---|---|
Treatment characteristics (k = 8 statements) | |||||
1 | Appointment features | Ensuring the patient is cared for by the same practitioner/therapist (i.e., continuity of care) | 89.7 (n = 35) | 87.2 (n = 34) | 79.5 (n = 31) |
2.5 | Treatment advice or options | Overtly encouraging patients to engage in therapy/exercise with an optimistic mindset to try establish positive associations with pain relief | 84.6 (n = 33) | 87.2 (n = 34) | 76.9 (n = 30) |
2.5 | Treatment advice or options | Encouraging patients to find suitable incentives/reinforcement strategies to increase daily activity (e.g., personalised activities, exercise partners) | 84.6 (n = 33) | 89.7 (n = 35) | 69.2 (n = 27) |
4* | Treatment advice or options | To show and tell the patient that as a therapy is applied it helps (e.g., ‘I am applying pressure here because it helps…’) | 66.7 (n = 26) | 61.5 (n = 24) | 66.7 (n = 26) |
5* | Appointment features | Verbalising future treatment plans by stating the number of appointments and/or follow-ups (e.g., ‘I will treat you every second week for 30 min’) | 61.5 (n = 24) | 66.7 (n = 26) | 64.1 (n = 25) |
6 | Appointment features | Increasing the frequency and/or duration of appointments (i.e., provide extra time/attention) | 59.0 (n = 23) | 53.8 (n = 21) | 64.1 (n = 25) |
7 | Alternative feedback | Administering treatments along with visual feedback (e.g., using mirrors during exercises) | 41.0 (n = 16) | 71.8 (n = 28) | 61.5 (n = 24) |
8* | Alternative feedback | Enabling patients to engage with other patients undergoing treatment with positive results (e.g., group exercise classes, sharing success stories/testimonials, informally in the waiting area) | 30.8 (n = 12) | 59.0 (n = 23) | 51.3 (n = 20) |
Perceived influence: panel consensus
Rank | Sub-set | Statement | Mean (S.D.) | [95% CIs] | Agreement levels | Panel consensus | Percentage Disagree |
---|---|---|---|---|---|---|---|
Treatment characteristics (k = 12 statements) | |||||||
1 | Treatment advice or options | Encouraging patients to find suitable incentives/reinforcement strategies to increase daily activity (e.g., personalised activities, exercise partners) | 4.52 (± 0.51) | [4.30, 4.74] | 52.2% Strongly Agree 47.8% Agree | Yes (100%) | 0% |
2* | Treatment advice or options | Explaining your treatment advice in line with the patient's treatment expectations | 4.48 (± 0.67) | [4.19, 4.77] | 56.5% Strongly Agree 34.8% Agree | Yes (91.3%) | 8.7% (unsure) |
3 | Treatment advice or options | Overtly encouraging patients to engage in therapy/exercise with an optimistic mindset to try establish positive associations with pain relief. (n = 22)a | 4.45 (± 0.74) | [4.13, 4.78] | 59.1% Strongly Agree 27.3% Agree | Yes (86.4%) | 13.6% (unsure) |
4* | Treatment advice or options | Demonstrating whether functional change has occurred immediately after treatment (e.g., pain, range of motion, or strength) | 4.39 (± 0.67) | [4.11, 4.68] | 47.8% Strongly Agree 43.5% Agree | Yes (91.3%) | 8.7% (unsure) |
5* | Treatment advice or options | Providing self-management materials (e.g., videos, rehabilitation booklets) or email/telephone support to promote a patient's engagement in physical activities. (n = 22)a | 4.32 (± 0.65) | [4.03, 4.60] | 40.9% Strongly Agree 50.0% Agree | Yes (90.9%) | 9.1% (unsure) |
6.5 | Alternative feedback | Providing patients with clear milestones or signposting to indicate their progression through the treatment programme | 4.22 (± 0.74) | [3.90, 4.54] | 39.1% Strongly Agree 43.5% Agree | Yes (82.6%) | 17.4% (unsure) |
6.5 | Appointment features | Ensuring the patient is cared for by the same practitioner/therapist (i.e., continuity of care) | 4.22 (± 1.20) | [3.70, 4.74] | 52.2% Strongly Agree 34.8% Agree | No (87.0%) | 4.3% (unsure) |
4.3% Disagree | |||||||
4.3% Not Valid | |||||||
8 | Alternative feedback | Displaying feedback from other patients to provide reassurance (i.e., testimonials displayed on TV in waiting area, or online via website). (n = 17)a | 3.88 (± 0.99) | [3.37, 4.39] | 29.4% Strongly Agree 41.2% Agree | No (70.6%) | 17.6% (unsure) |
11.8% Disagree | |||||||
9* | Alternative feedback | Sharing positive stories of other (anonymous) patients with similar problems or goals. (n = 22)a | 3.86 (± 1.08) | [3.38, 4.34] | 22.7% Strongly Agree 54.5% Agree | No (77.3%) | 18.2% (unsure) |
4.5% Not Valid | |||||||
10 | Alternative feedback | Administering treatments along with visual feedback (e.g., using mirrors during exercises). (n = 20)a | 3.80 (± 1.06) | [3.31, 4.29] | 30.0% Strongly Agree 35.0% Agree | No (65.0%) | 20.0% (unsure) |
15.0% Disagree | |||||||
11 | Appointment features | Increasing the frequency and/or duration of appointments (i.e., provide extra time/attention). (n = 22)a | 3.64 (± 1.43) | [3.00, 4.27] | 36.4% Strongly Agree 22.7% Agree | No (59.1%) | 22.7% (unsure) |
9.1% Disagree | |||||||
4.5% Strongly Disagree | |||||||
4.5% Not Valid | |||||||
12* | Treatment advice or options | Clearly explaining the difference between a clinical examination and treatment. (n = 21)a | 3.62 (± 0.97) | [3.18, 4.06] | 23.8% Strongly Agree 23.8% Agree | No (47.6%) | 42.9% (unsure) |
9.5% Disagree |
Treatment environment/setting
Self-reported use, perceived as clinically valid, and perceived treatment effects
Rank | Sub-set | Statement | Self-reported use (%) | Valid (%) | Enhance Treatment (%) |
---|---|---|---|---|---|
Treatment environment/setting (k = 9 statements) | |||||
1 | Interior design/layout | Ensuring treatment facilities have privacy provisions (e.g., private changing area and treatment room, curtains/blinds on windows) | 92.3 (n = 36) | 82.1 (n = 32) | 61.5 (n = 24) |
2* | Interior design/layout | Considering seating provisions in treatment office (e.g., relative position to desk, additional chairs for carer) | 87.2 (n = 34) | 79.5 (n = 31) | 59.0 (n = 23) |
3.5 | Setting’s décor | Waiting areas and treatment facilities are uncluttered and tidy | 84.6 (n = 33) | 71.8 (n = 28) | 59.0 (n = 23) |
3.5* | Setting’s décor | Decorating the waiting area with cheerful ornamentation (e.g., healthy indoor plants, leisure reading materials, comfortable cushions) | 84.6 (n = 33) | 71.8 (n = 28) | 59.0 (n = 23) |
5 | Interior design/layout | Ensuring facilities have ample natural light or windows, and are suitably heated/ventilated (i.e., comfortable temperature) | 79.5 (n = 31) | 79.5 (n = 31) | 69.2 (n = 27) |
6 | Setting’s décor | Providing visual indicators or cues to signify it is a medical setting (e.g., model of spine, patient information brochures, medicalised décor) | 71.8 (n = 28) | 64.1 (n = 25) | 53.8 (n = 21) |
7* | Interior design/layout | Considering seating provisions in the waiting areas (e.g., quantity, varying chair sizes, general arrangement) | 64.1 (n = 25) | 74.4 (n = 29) | 59.0 (n = 23) |
8* | Setting’s décor | Using nature artworks that include green vegetation, flowers, or water may help to reduce anxiety | 48.7 (n = 19) | 59.0 (n = 23) | 59.0 (n = 23) |
9* | Setting’s décor | Combining positive distractors such as soft or soothing music, nice aromas, hot or cold beverages | 46.2 (n = 18) | 56.4 (n = 22) | 59.0 (n = 23) |
Perceived influence: panel consensus
Rank | Sub-set | Statement | Mean (S.D.) | [95% CIs] | Agreement levels | Panel consensus | Percentage Disagree |
---|---|---|---|---|---|---|---|
Treatment environment/setting (k = 7 statements) | |||||||
1 | Interior design/layout | Ensuring treatment facilities have privacy provisions (e.g., private changing area and treatment room, curtains/blinds on windows) | 4.52 (± 0.67) | [4.23, 4.81] | 60.9% Strongly Agree 30.4% Agree | Yes (91.3%) | 8.7% (unsure) |
2 | Interior design/layout | Rearranging the furniture or seating provisions in the treatment office (e.g., relative position to desk, additional chairs for carer) | 4.35 (± 0.89) | [3.97, 4.73] | 56.5% Strongly Agree 26.1% Agree | No (82.6%) | 13.0% (unsure) 4.3% Disagree |
3 | Setting’s décor | Ensuring waiting areas and treatment facilities are uncluttered and tidy | 4.22 (± 0.67) | [3.93, 4.51] | 34.8% Strongly Agree 52.2% Agree | Yes (87.0%) | 13.0% (unsure) |
4 | Interior design/layout | Ensuring treatment facilities have ample natural light or windows, and are suitably heated/ventilated (i.e., comfortable temperature) | 4.13 (± 0.55) | [3.89, 4.37] | 21.7% Strongly Agree 69.6% Agree | Yes (91.3%) | 8.7% (unsure) |
5 | Setting’s décor | Creating a positive ambience or atmosphere (e.g., flowers, plants, interesting magazines, friendly staff, relaxing background music, warm lighting) | 3.87 (± 1.22) | [3.34, 4.40] | 34.8% Strongly Agree 34.8% Agree | No (69.6%) | 21.7% (unsure) 4.3% Disagree 4.3% Not Valid |
6 | Setting’s décor | Providing visual indicators or cues to signify it is a medical setting (e.g., model of spine, patient information brochures, medicalised décor) | 3.61 (± 1.27) | [3.06, 4.16] | 30.4% Strongly Agree 21.7% Agree | No (52.1%) | 34.8% (unsure) 8.7% Disagree 4.3% Not Valid |
7 | Setting’s décor | Using nature artworks that include green vegetation, flowers, or water features. (n = 22)a | 3.36 (± 1.14) | [2.86, 3.87] | 18.2% Strongly Agree 18.2% Agree | No (36.4%) | 54.5% (unsure) 4.5% Disagree 4.5% Not Valid |
Perceived importance of CFs
Rank | Main CF domain | Mean (S.D.) | 95% Confidence Interval | Median; Interquartile Range (Min–Max) |
---|---|---|---|---|
1 | Patient-practitioner relationship | 6.17 (± 0.65) | 5.89–6.46 | 6.00; 1 (5–7) |
2 | Patient’s beliefs and characteristics | 6.09 (± 0.73) | 5.77–6.40 | 6.00; 1 (5–7) |
3 | Practitioner’s beliefs and characteristics | 5.78 (± 0.74) | 5.46–6.10 | 6.00; 1 (4–7) |
4 | Treatment characteristics | 5.48 (± 1.08) | 5.01–5.95 | 6.00; 1 (2–7) |
5 | Treatment environment/setting | 4.91 (± 1.00) | 4.48–5.34 | 5.00; 2 (3–7) |