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Research Review By Dr. Brynne Stainsby©


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Date Posted:

August 2018

Study Title:

A qualitative study of doctors of chiropractic in a Nova Scotian practice-based research network: Barriers and facilitators to the screening and management of psychosocial factors for patients with low back pain


Stilwell P, Hayden JA, Des Rosiers et al.

Author's Affiliations:

Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada; Community Health & Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Physiotherapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada; School of Rehabilitation Therapy, Faculty of Health Sciences, Queens University, Kingston, Ontario, Canada; Chiropractic, Faculty of Science and Engineering, Macquarie University, New South Wales, Australia; Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada; Health and Human Performance, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2018; 41: 25-33.

Background Information:

As a leading cause of disability, psychosocial factors are commonly linked to chronicity and poor outcomes with many conditions, including low back pain (LBP) (1, 2). Given this relationship, clinical practice guidelines (CPGs) often recommend screening for psychosocial factors using screening tools such as the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale or the STarT Back risk assessment tool (4-7). Evidence-based strategies to manage identified psychosocial factors include reassurance, education, advice to stay active, and avoiding excessive anatomical focus or patient labelling (6, 8). While these strategies are found in guidelines specific to chiropractic practice, little is known about chiropractors’ beliefs, behaviours and abilities to address these psychosocial factors (9, 10). In order to better understand this challenge, the Theoretical Domains Framework can be used to help us understand health care practitioners’ decision-making and identify specific barriers and facilitators to desired behavior, essentially investigating and explaining problems from the perspective of behavioural change (11). This framework can then be used to inform the design of interventions aimed at changing professional behaviours (11).

The objective of this qualitative study was to examine chiropractors’ awareness and understanding of CPGs for LBP, and to identify barriers and facilitators of screening for, and management of, psychosocial factors using the Theoretical Domains Framework.

Pertinent Results:

Study Participants:
  • Fourteen (out of 18) eligible chiropractors expressed interest in participating. One was excluded due to a possible conflict of interest, given their close work-related connections to members on the research team. Ten participants completed the full interview, and no new themes were identified in interviews 8-10, thus no further interviews were completed. Six participants were female, all had graduated from the Canadian Memorial Chiropractic College and nine were in practice for less than five years.
  • No participants expressed disagreement with the preliminary themes shared via email. Five participants attended the in-person group session, and none expressed concern that the results misrepresented their beliefs or experiences.
Interview Results:
  • None of the participants could name specific CPGs for LBP, but most were confident their practice was evidence-informed.
  • All perceived their practice was suboptimal as it related to screening and management of psychosocial factors, and reported limited awareness of management techniques.
  • Participants identified the following factors which may impact patient outcomes: preference for passive care, work- or home-related stress, job or home-life satisfaction, social isolation, low mood, litigation, fear avoidance, catastrophizing, belief they will not get better, focus on pain or anatomy, widespread pain, concern about the future, positive Waddell signs, unusual pain diagrams.
Following coding, six themes regarding barriers were identified from the data:
  1. Therapeutic alliance and patient-centred care: perception that patients expect mechanical treatment to “fix” LBP; concern that psychosocial questionnaires could negatively impact patient rapport.
  2. Screening and management training: perception that chiropractors lack knowledge and skills to manage psychosocial factors; lack of intentional application (unaware of the management techniques that are actually being used).
  3. Professional role and identity uncertainty: concerns regarding scope of practice.
  4. Cognitive dissonance and priorities: perception that managing psychosocial factors takes more time (and therefore costs more money).
  5. Environmental context and resources: lack of awareness of simple and short, research-based screening questionnaires and concern that they will raise negative emotional responses, resistance towards more paperwork.
  6. Social context and resources: anatomical and biomechanical culture, patients being negatively impacted by others (including other health care providers) which could promote inactivity and fear.
Following coding, the same six themes regarding facilitators were identified from the data:
  1. Therapeutic alliance and patient-centred care: ability to fulfill patients’ expectations while building rapport and addressing psychosocial factors; helping patients view education and exercise as “actual” treatment.
  2. Screening and management training: feeling that chiropractors can identify psychosocial features even without questionnaires.
  3. Professional role and identity uncertainty: belief that chiropractors should address psychosocial factors within the context of LBP and that it is the role of all health care practitioners to screen and manage psychosocial risk factors to improve patient outcomes.
  4. Cognitive dissonance and priorities: belief that patients will not get better if psychosocial factors are not appropriately addressed.
  5. Environmental context and resources: access to private treatment rooms to discuss psychosocial factors; access to gym/space to address fear avoidance behaviours; access to educational content for patients.
  6. Social context and resources: supportive administrative staff to relay consistent messages; clinical mentorships with those interested in managing psychosocial factors.

Clinical Application & Conclusions:

This was the first qualitative study to use a theory-informed qualitative research design to investigate chiropractors’ beliefs and behaviours as they relate to psychosocial factors in the context of LBP. Although participants appeared to practice in a biomechanical/anatomical manner, they understood the value in addressing these factors. Though they could not identify CPG-recommended nor specific techniques used intentionally in practice to address psychosocial factors, it was commonly reported that they were used unintentionally or subconsciously. This correlated with a Dutch chiropractic survey (12), which found that chiropractors reported a lack of confidence relating to, and limited routine management of, psychosocial factors.

One of the critical findings of this study was the use of strategies such as education, reassurance, graded exercise, goal setting or relaxation techniques. Though these strategies were not formally implanted to cognitively address psychosocial factors, they are being used in practice commonly. As such, there may be an opportunity to formalize what chiropractors are already doing in practice through continuing education programs. It is also important to address chiropractors’ awareness of clinical resources (such as the STarT Back Screening Tool [13] or neuroscience education flashcards [14]). Relatively simple and inexpensive interventions could improve adherence to CPGs and improve patient outcomes. This information is particularly helpful in the design of educational programs, as evidence suggests that interventions are more likely to be effective when they are designed to address the relevant barriers and facilitators to change (15).

Study Methods:

  • This study conducted semi-structured interviews following consolidated criteria for reporting qualitative research (16). These interviews were focused on assessing chiropractors’ awareness of CPG recommendations related to screening and managing psychosocial risk factors in patients with LBP; and identifying barriers and facilitators to this.
  • Participants were recruited from the Nova Scotian Chiropractic Practice-Based Research Network (Canada). A sample size of 10-13 participants was estimated a priori to reach saturation.
  • A pilot test of the adapted Theoretical Domains Framework interview template was conducted on two physiotherapists, followed by modifications before study interviews were conducted.
  • Demographic information was collected after obtaining informed consent. The first author conducted face-to-face interviews which were audio-recorded and transcribed verbatim.
  • Analysis was ongoing using NVivo 11 software for Mac (17) and themes were generated and then coded in order to assign segments of text to the 14 domains of the framework.
  • Participating chiropractors were sent a summary of the preliminary themes and provided with the option to provide feedback. They were also invited to attend an in-person group session where the results of the study were discussed, and again provided with the opportunity to provide feedback.

Study Strengths / Weaknesses:

  • A theory-based, semi-structured interview was conducted based on the Theoretical Domains Framework. This framework allowed for the analysis of text into themes for analysis.
  • The authors were able to determine saturation after the first seven interviews, and confirmed this after the eighth, ninth and tenth, thus it is not expected that themes were not captured in this sample.
  • The authors identified both barriers and facilitators for guideline-based management of psychosocial factors, and suggested these could be used to inform educational programs.
  • The authors allowed the participants to outline their clinical approaches and recognized guideline-based management, even when clinicians did not explicitly report they were doing so.
  • Participants were provided with opportunities to provide feedback and ensure the themes and data reflected their opinions.
  • This preliminary study sampled chiropractors from a practice-based research network, and it may be assumed that these chiropractors are focused on, or at least interested in, evidence-based practice. As such, they may not be generalizable to the entire population of chiropractors. However, given this group does have an assumed interest in research, this weakness can be alternatively interpreted to demonstrate a greater need for all field chiropractors to have access to additional training in order to feel comfortable implementing guideline-based management strategies for psychosocial risk factors.
  • This study was focused only on Nova Scotian chiropractors and may not be generalizable to all Canadian or international chiropractors, however, with most research and many continuing education programs being found electronically, it is likely these findings are not geographically biased.
  • The pilot testing for the interviews was done on physiotherapists given the small available sample of chiropractors. Given guidelines are not profession-specific, this was not expected to have impacted the study results.

Additional References:

  1. Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990 – 2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386(9995): 743-800.
  2. Kendall NA. Psychosocial approaches to the prevention of chronic pain: The low back paradigm. Baillieres Best Pract Res Clin Rheumatol 1999; 13(3): 545-554.
  3. Hayden JA, Chou R, Hogg-Johnson S et al. Systematic reviews of low back pain prognosis had variable methods and results-guidance for future prognosis reviews. J Clin Epidemiol 2009; 62(8): 781-796.
  4. Koes BW, van Tulder M, Lin CW et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010; 19(12): 2075-2094.
  5. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010; 10(6): 514-529.
  6. Rossignol M, Aresenault B, Dionne C, et al. Clinic on Low-Back Pain in Interdisciplinary Practice (CLIP) guidelines; Montreal Public Health Department, Montreal Health and Social Services Agency. 2007; 1-43.
  7. National Institute for Health and Care Excellence (NICE). Low Back Pain and Sciatica in Over 16s: Assessment and Management. London, England: National Institute for Health and Care Excellence (UK); 2016: 1-18.
  8. Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain 2017; 21(2): 201-216.
  9. Globe G, Farabaugh RJ, Hawk C, et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther 2016; 39(1): 1-22.
  10. Synnott A, O’Keeffe M, Bunzli S et al. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. J Physiother 2015; 61(2): 68-76.
  11. Michie S, Johnston M, Abraham C et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care 2005; 14(1): 26-33.
  12. Haanstra T, Miller J. Dutch chiropractors’ perceptions on including psychosocial factors in the evaluation and management of patients: A survey. Clin Chiropr 2011; 14(3): 112-121.
  13. STarT Back Tool Online, Keele University. Available at: https://www.keele.ac.uk/sbst/startbacktool/sbtoolonline/ Accessed May 23, 2017.
  14. Louw A, Puentedura E. Why You Hurt: Therapeutic Neuroscience Education System. OPTP. 2014. Available at: http://www.optp.com/Why-You-Hurt-Therapeutic-Neuroscience-Education-System#.WCZPTxIrJE4. Accessed May 23, 2017.
  15. Michie S, Johnston M, Francis J et al. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Appl Psychol 2008; 57(4): 660-680.
  16. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus group. International J Qual Health Care 2007; 19(6): 349-357.
  17. © QSR International Pty Ltd. NVivo for Mac | QSR International. Available at http://www.qsrinternational.com/nvivo-product/nvivo-mac. Accessed August 4, 2016.

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