Background
Method
Aim
Design
Participants and data collection
Background variable | |
---|---|
Sex, female n | 12 |
Age, mean (range) | 50 (39-57) |
Years in the profession, mean (range) | 19 (10-35) |
Years in primary healthcare, mean (range) | 14 (3-28) |
Further education | |
Behavioral medicine or cognitive behavioral therapy, n | 6 |
Motivational interviewing, n | 5 |
Pain treatment/rehabilitation, acupuncture, n | 7 |
Orthopedic manual therapy, n | 8 |
Other coursesa, n | 12 |
Attitudes towards a behavioral medicine working model for clinical reasoning Md (IQR) | |
1. How important is it for you to work according to a behavioral medicine model for clinical reasoning? (NRS 0-10)b | 8.5 (2.5) |
2. How confident are you to work according to a behavioral medicine model of clinical reasoning? (NRS 0-10)b | 6.0 (2.7) |
3. How ready are you to work according to a behavioral medicine model of clinical reasoning? (NRS 0-10)b | 7.0 (4.5) |
Self-efficacy Md (IQR) | |
Managing patients with fear of movement and/ or catastrophizingc (0-90) | 60.0 (45.0) |
Managing patients without fear of movement and/ or catastrophizingd (0-70) | 45.0 (28.0) |
Data management and analyses
Definition of red flags | Examples of PTs’ questions to assess red flags |
---|---|
Trauma | Have you experienced any trauma related to your pain? |
Severe diagnosis | Have you had cancer or any other severe diagnosis? |
Severe spinal pathology | Have you experienced radiating leg pain? |
Patterns or symptoms not related to mechanical pain | How is your health in general? |
Numbness and paresthesia in the perianal region | Have you had any bowel and bladder disorders? |
Difficulty with micturition | |
Weakness or numbness in the legs related to back pain | Have you felt any weakness or numbness in your legs? |
Definition of yellow flags | Examples of PTs’ questions to assess yellow flags |
Beliefs, appraisal, and judgments | |
Unhelpful beliefs about pain | What are your thoughts about the pain? |
Expectations of poor treatment outcome | What are your thoughts about recovery? |
What do you think about your capability to work? | |
Which factors do you think affect your pain? | |
Emotional responses | |
Distress not meeting the criteria for diagnosis of mental disorder | Are you worried about your pain? |
How does the pain affect your mood? | |
Worry, fears and anxiety | Are you distressed about the pain? |
Are you avoiding doing any activities due to pain? | |
Pain behavior and coping strategies | |
Avoidance of activities due to expectations of pain and possible re-injury | Do you avoid activities due to pain? |
What are you doing when having pain? | |
Over-reliance on passive treatments | What are your thoughts about pain relief? |
What activities are difficult for you due to pain? |
Used BCT’s | Frequency of BCTs (=n) | Examples |
---|---|---|
1. Goals and planning
| ||
1.1 Goal setting (behavior) | 1 | The PT guided the patient in setting a goal for regular walking or bicycling in order to improve overall health. |
1.3 Goal setting (outcome) | 1 | The PT guided the patient in setting a goal in terms of weight loss. |
2. Feedback and monitoring
| ||
2.2 Feedback on behavior | 2 | The PT made suggestions to the patient, who had performed her aqua exercise at too high intensity. |
4. Shaping knowledge
| ||
4.1 Instruction on how to perform the behavior | 9 | The PT instructed the patient in a home-based exercise program. |
5. Natural consequences
| ||
5.1 Information about health consequences | 12 | The PT informed the patient about the positive consequences of muscle strength exercise in osteoarthritis. |
7. Associations
| ||
7.1 Prompts/cues | 1 | The PT discussed with the patient how to use a daily activity as a reminder of the home-exercises she was to perform |
8. Repetition and substitution
| ||
8.1 Behavioral practice/rehearsal | 1 | The PT asked the patient to repeat and demonstrate the exercises she had been instructed to do in order to remember them better. |
The deductive analysis
The inductive analysis
Ethical considerations
Results
Description of participants
Assessment of red and yellow flags
Pain site(s) | Assessment of red flags | Identification of red flags | Assessment of yellow flags | Identification of yellow flags | |
---|---|---|---|---|---|
n
|
n
|
n
|
n
|
n
| |
Low back | 3 | 4 | 0 | 2 | 0 |
Shoulder | 2 | 3 | 0 | 2 | 2 |
Hip | 4 | 1 | 0 | 3 | 1 |
Head | 1 | 1 | 0 | 1 | 1 |
Low back and foot | 1 | 0 | 0 | 0 | 0 |
Shoulder and elbow | 1 | 0 | 0 | 0 | 0 |
Total | 12 | 9 | 0 | 8 | 4 |
PT | Red flags | Yellow flags | Pain site | Functional behavioral analysis | Biopsycho- social analysis | Biomedical analysis | BCTsa | Time for consultation (minutes) | ||
---|---|---|---|---|---|---|---|---|---|---|
Assessment | Identification | Assessment | Identification | |||||||
1 | Red flags were assessed but not identified | No | Yes | Passive coping strategies | Headache | No | Yes, the analysis included yellow flags in relation to symptoms/pain problem but not to a specific behavior. | Included in the functional behavioral analysis |
1.1: Behavior goal setting
Regular physical activity (walking)
4.1: Instruction on to perform the behavior
Home exercise for headache
5.1: Info about health consequences
Physical exercise with headache, how muscle tension leads to headache | 24 |
2 | Red flags were assessed but not identified | No | Yes | Negative thoughts, avoiding behavior related to physical activity and the shoulder | Shoulder | No | No | Yes, short analyses during the consultation with focus on the shoulder pain. Yellow flags were not included in the analysis |
4.1: Instruction on how to perform the behavior
Exercises for the shoulder
5.1: Info about health consequences
Effect on pain and physical function of the exercises | 51 |
3 | Red flags were assessed but not identified | No | No | No | Hip joint | No | No | Yes, short analyses during the consultation |
2.2: Feedback on behavior
Performance of a specific exercise for the hip, walking pattern 4.1: Instruction on how to perform the behavior Exercise for the hip, circulation exercises, walking with crutches
5.1: Info about health consequences
How exercise affects the hip, pain and function
7.1: Prompts/cues
Connect the exercise with another daily activity
8.1: Behavioral practice/rehearsal
PT asked the patient to repeat the exercises she had instructed her in so that she would better remember them. | 25 |
4 | Red flags were assessed but not identified | No | No | No | Shoulder and elbow | No | No | No analysis related to the patient’s problem was performed, but there was a general explanation of the physical findings |
4.1: Instruction on to perform the behavior
Stretching of elbows, home exercises, posture, micro pauses
5.1: Info about health consequences
Factors that increase pain in the shoulder and elbow, how specific work tasks can affect shoulder pain and function | 61 |
5 | Red flags were assessed but not identified | No | Yes | No | Low back | No | No | Yes, a summarizing analysis related to the patients pain problem. Commentaries about the assessments and findings during the consultation. |
1.1: Outcome goal setting
Lose weight to decrease back pain
4.1: Instruction on to perform the behavior
Exercise for home-training
5.1: Info about health consequences
How physical activities may affect back pain, pain coping strategies, including exercises | 28 |
6 | No | No | Yes | Thoughts and worries regarding other possible causes of pain. | Hip joints | No | No | Yes, short analysis based on biomedical examination and the interview with the patient. |
2.2:Feedback on behavior
Discussion with the patient about how to adjust the intensity of the aquatic exercise following overuse. 2.7: Feedback on outcome Feedback on improving hip flexibility compared with earlier physical function and exercise
4.1:Instruction on to perform the behavior
Exercise for lower extremities
5.1: Info about health consequences
Consequences for hip and back of wearing high heels | 39 |
7 | Yes | No | No | No | Low back | No | No | Yes, analyses including online commentaries and a summary analysis. |
5.1: Info about health consequences
Factors that causes back pain and what the patient can do by herself to manage the pain | 25 |
8 | Yes | No | Yes | No | Low back and leg | No | No | Yes, short analyses during the examination and a summary analysis at the end. |
4.1: Instruction on to perform the behavior
Stretching exercises and posture
5.1: Info about health consequences
How running can affect back pain and general health how bad body position/posture behavior can affect back-pain | 19 |
9 | No | No | Yes | No | Hip joints | No | No | Yes, short analysis of hip pain during the examination and a summary analysis |
4.1: Instruction on to perform the behavior
Walking on stairs, exercises for hips
5.1: Info about health consequences
Effects of exercise and bicycling in osteoarthritis | 69 |
10 | Yes | No | Yes | Avoiding dancing and fear of increased pain in the shoulder | Shoulder | No | No | Yes, short analysis of shoulder pain during the examination and a summary analysis |
4.1: Instruction on how to perform the behavior
Exercise for shoulders
5.1: Info about health consequences
How heavy lifting and other work tasks affect shoulder pain | 47 |
11 | No | No | No | No | Feet and low back | No | No | Yes, analysis related to the patient’s foot pain |
5.1: Info about health consequences
How exercise and body weight affect foot problems, changes in foot status due to ageing and injuries have consequences in pain and medicine consumption 15.1: Verbal persuasion about capability Benefits of physical exercise, patients capabilities for exercise | 39 |
12 | Yes | No | Yes | No | Hip joints | No | No | Yes, a summary analysis at the end and a short online commentaries during the consultation |
2.2: Feedback on behavior
How to do yoga exercises
4.1: Instruction on how to perform the behavior
Stretching of hip muscles, home exercises
5.1: Info about health consequences
How physical exercise and activity affect the cartilage in the hip
7.1: Prompts/cues
How to use daily activities as a cue to action (home exercises) | 36 |
Model for analysis
Use of behavior change techniques
Variations in clinical practice
Case 1: High degree of patient involvement and a biopsychosocial analysis
-
PT: “ That’s the way it works with tension headache…tension is stored in the muscles and tightens up without you noticing it…then there won’t be any clearing of waste products in the muscles; rather, waste stays and causes pain instead. But then there is also the other thing you talked about…the situation in the family that is also affecting the pain…”
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Patient: “ Yes, that’s correct… and maybe it is good then to be able to relax a little?”
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PT: “ Absolutely, but it may not work to start with all the physical activity at once… But something you can do…try to recognize what is happening in the body when it is tense. It seems to be in the evening that it is triggered, is that correct?”
-
PT: “Are you usually physically active?”
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Patient: ” Not as much I would like”
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PT: “How much would you be able to do?”
-
Patient: “To be able to take a walk around the area where I live…maybe 20 minutes”
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PT: “Is that a goal you would like to work for?”
-
Patient: “Yes, it is absolutely a goal”
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PT: “How would you be able to do that? Can you find situations where that would work?”
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Patient: “I suppose it is just to do it…Just leave everything at home…maybe my son could cycle beside me…if I cannot leave him alone”
-
PT: “It might be a good strategy”
Case 2: Some patient involvement and a biomedical analysis
-
PT: “Is there anything you can do that would improve your shoulder problem?”
-
Patient: “No, I don’t think so… I have tried everything”
-
PT: “What have you tried?”
-
Patient: “I have had my arm tied on to my body when I walk around at home…because when hanging it down, it starts to ache. I keep it still and use the right arm instead.”
-
PT: “Do you use the left arm at all?”
-
Patient: “No, it’s just there…I’d rather just cut it off”
-
PT: “Did you meet any rehab personnel at the hospital?”
-
Patient: “No, I came to the trauma section…with the ambulance…and then I was discharged after 3 days, and after that, nothing much happened…it is really as if no one ever listened to my problems…”
-
PT: “It sounds as if you are rather disappointed”
-
Patient: “Yes, I am quite bitter about it really… but now so much time has gone by that nothing can be done, but I am worried that it may happen again”
Case 3: Minor patient involvement and a biomedical analysis
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PT: “When would it work to do the exercises?…Is there any particular instance in relation to something else that you are doing and that recurs during the day?”
-
Patient: “It could work if I do it the same time as when I get ready in the evening…”
-
PT: ”If we summarize the exercises we have just gone through, can you repeat what we have done and see what you can remember? What did we do now? What will you think about? Can you repeat what we have done and tell me what you should remember about it?”
Case 4: Very low degree of patient involvement and no analysis
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PT: “I have good exercises that I can give you for both the shoulder and the elbow…but it is like this with us humans that the more we can prevent development of pain, the easier it is to feel good and be able to feel good for a long time. By only fixing the pain you will not get better in the long run.”
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Patient: “Hmm”
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PT: “It is like having a blister and just putting on a plaster and avoiding using the shoes that causing it. It is the same principle, isn’t it?”
-
Patient: “Hmm”
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PT: “Imagine that overloading the shoulder is like having a blister…, you have to think in the same way. Then, I know of course…that in both your and my jobs, it is not possible to take away all the activities that are too strenuous. If you do, you may not have a job to go to after that (laugh).”