How physiotherapists attend to the human aspects of care when working with people with low back pain: a thematic analysis.

Pain is a multidimensional experience. Physiotherapy has attempted to enhance earlier biomedical approaches to patient care through approaches like the 'biopsychosocial' model. Nevertheless, physiotherapy continues to focus on biomedical and/or behavioural aspects of care. We critically investigated how physiotherapists attend to human (psychosocial, emotional, existential, and moral) aspects of low back pain care. We co-analysed ethnographic data with researchers, patients, and physiotherapists using concepts of conforming, tinkering and abandoning 'scripts'. Data included observations of 28 physiotherapy interactions between 26 patients and 10 physiotherapists and 7 researcher-clinician dialogues. Analysis suggests when conforming to scripts, clinicians have difficulty recognising and responding to emotions; time pressure limited clinicians focus, and a biological focus often distracted from psychosocial aspects of people's back pain experiences. In contrast, tinkering with or abandoning scripts allowed space to broaden the focus. Drawing from theorists such as Butler (1999) and Gibson et al. (2020) our analysis contributes to health sociology, arguing that 'tinkering' with or 'abandoning' scripts can foster more humanistic, flexible and reflexive approaches to care. Although health sociologists have explored tinkering, abandoning is new; within physiotherapy, it encapsulates being able to respond with agility to non-physical elements of care without constraint from traditional ways of thinking and doing.

Uncertainty in low back pain care - insights from an ethnographic study.

PURPOSE: To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions. MATERIALS AND METHODS: We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions). RESULTS: We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks. CONCLUSIONS: Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.