Interventions for improving adherence to airway clearance treatment and exercise in people with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a life-limiting genetic disorder predominantly affecting the lungs and pancreas. Airway clearance techniques (ACTs) and exercise therapy are key components of physiotherapy, which is considered integral in managing CF; however, low adherence is well-documented. Poor physiotherapy adherence may lead to repeated respiratory infections, reduced exercise tolerance, breathlessness, reduced quality of life, malaise and reduced life expectancy, as well as increased use of pharmacology, healthcare access and hospital admission. Therefore, evidence-based strategies to inform clinical practice and improve adherence to physiotherapy may improve quality of life and reduce treatment burden. OBJECTIVES: To assess the effects of interventions to enhance adherence to airway clearance treatment and exercise therapy in people with CF and their effects on health outcomes, such as pulmonary exacerbations, exercise capacity and health-related quality of life. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 1 March 2023. We also searched online trials registries and the reference lists of relevant articles and reviews. Date of last search: 28 March 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs of parallel design assessing any intervention aimed at enhancing adherence to physiotherapy in people with CF versus no intervention, another intervention or usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently checked search results for eligible studies and independently extracted data. We used standard procedures recommended by Cochrane and assessed the certainty of evidence using the GRADE system. MAIN RESULTS: Two RCTs (77 participants with CF; age range 2 to 20 years; 44 (57%) males) met the inclusion criteria of this review. One study employed an intervention to improve adherence to exercise and the second an intervention to improve adherence to ACT. Both studies measured outcomes at baseline and at three months, but neither study formally assessed our primary outcome of adherence in terms of our planned outcome measures, and results were dependent on self-reported data. Adherence to ACTs One RCT (43 participants) assessed using specifically-composed music alongside ACTs compared to self-selected or no music (usual care). The ACT process consisted of nebuliser inhalation treatment, ACTs and relaxation or antibiotic nebuliser treatment. We graded all evidence as very low certainty. This study reported adherence to ACTs using the Morisky-Green questionnaire and also participants' perception of treatment time and enjoyment, which may influence adherence (outcome not reported specifically in this review). We are uncertain whether participants who received specifically-composed music may be more likely to adhere at six and 12 weeks compared to those who received usual care, risk ratio (RR) 1.75 (95% confidence interval (CI) 1.07 to 2.86) and RR 1.56 (95% CI 1.01 to 2.40) respectively. There may not be any difference in adherence when comparing specifically-composed music to self-selected music at six weeks, RR 1.21 (95% CI 0.87 to 1.68) or 12 weeks, RR 1.52 (95% CI 0.97 to 2.38); or self-selected music to usual care at six weeks, RR 1.44 (95% CI 0.82 to 2.52) or 12 weeks, RR 1.03 (95% CI 0.57 to 1.86). The music study also reported the number of respiratory infections requiring hospitalisation at 12 weeks, with no difference seen in the risk of hospitalisation between all groups. Adherence to exercise One RCT (24 participants) compared the provision of a manual of aerobic exercises, recommended exercise prescription plus two-weekly follow-up phone calls to reinforce exercise practice over a period of three months to verbal instructions for aerobic exercise according to the CF centre's protocol. We graded all evidence as very low certainty. We are uncertain whether an educational intervention leads to more participants in the intervention group undertaking increased regular physical activity at three months (self-report), RR 3.67 (95% CI 1.24 to 10.85), and there was no reported difference between groups in the number undertaking physical activity three times per week or undertaking at least 40 minutes of physical activity. No effect was seen on secondary outcome measures of spirometry, exercise capacity or any CF quality of life domains. This study did not report on the frequency of respiratory infections (hospitalised or not) or adverse events. AUTHORS' CONCLUSIONS: We are uncertain whether a music-based motivational intervention may increase adherence to ACTs or affect the risk of hospitalisation for a respiratory infection. We are also uncertain whether an educational intervention increases adherence to exercise or reduces the frequency of respiratory infection-related hospital admission. However, these results are largely based on self-reported data and the impact of strategies to improve adherence to ACT and exercise in children and adolescents with stable CF remains inconclusive. Given that adherence to ACT and exercise therapy are fundamental to the clinical management of people with CF, there is an urgent need for well-designed, large-scale clinical trials in this area, which should conform to the CONSORT statement for standards of reporting and use appropriate, validated outcome measures. Studies should also ensure full disclosure of data for all important clinical outcomes.

A loaded self-managed exercise programme for patellofemoral pain: a mixed methods feasibility study.

BACKGROUND: A novel loaded self-managed exercise programme that includes pain education and self-management strategies may result in better outcomes for people with patellofemoral pain (PFP). However, establishing program feasibility is an essential first step before testing efficacy. The purpose of this study was to evaluate the feasibility and acceptability of conducting a definitive RCT which will evaluate the clinical and cost-effectiveness of a loaded self-managed exercise programme for people with PFP compared with usual physiotherapy. METHODS: In a mixed methods, pragmatic, randomised controlled feasibility study, 60 participants with PFP (57% female; mean age 29 years) were recruited from a physiotherapy clinic within a large UK teaching hospital. They were randomly allocated to receive either a loaded self-managed exercise programme (n = 30) or usual physiotherapy (n = 30). Feasibility indicators of process, resources, and management were collected through follow-up of standardised questionnaires six months after recruitment and semi-structured interviews with 20 participants and physiotherapists. RESULTS: Recruitment rate was 5 participants per month; consent rate was 99%; adherence to intervention appointments was 87%; completeness of questionnaire data was 100%; and adherence to intervention delivery was 95%. Three exercise diaries were returned at six months (5%). At six months, 25 questionnaire booklets were returned (9 in the loaded self-managed group, 16 in the usual physiotherapy group), with a total retention rate of 42%. At six months, 56% (5/9) of respondents in the loaded self-managed group and 56% (9/16) in the usual physiotherapy group were classified as 'recovered'. Both groups demonstrated improvements in average pain (VAS), kinesiophobia, pain catastrophizing, general self-efficacy and EQ-5D-5 L from baseline to six months. CONCLUSION: The results of this feasibility study confirm that it is feasible and acceptable to deliver a loaded self-managed exercise programme to adults with PFP in an NHS physiotherapy outpatient setting. However, between group differences in lost to follow up and poor exercise diary completion mean we are uncertain on some feasibility aspects. These methodological issues need addressing prior to conducting a definitive RCT. TRIAL REGISTRATION: ISRCTN 35272486 . Registered 19th December 2016.

Current management strategies for patellofemoral pain: an online survey of 99 practising UK physiotherapists.

BACKGROUND: Patellofemoral pain (PFP) is considered one of the commonest forms of knee pain. This study aimed to identify how physiotherapists in the United Kingdom (UK) currently manage patellofemoral pain (PFP), particularly in relation to exercise prescription, and response to pain. METHODS: An anonymous survey was designed with reference to previous surveys and recent systematic reviews. Practising UK physiotherapists who treat patients with PFP were invited to take part via an invitation email sent through professional networks, the 'interactive Chartered Society of Physiotherapy (iCSP)' message board, and social media (Twitter). Descriptive statistics were used to analyse the data. RESULTS: A total of 99 surveys were completed. Responders reported a wide range of management strategies, including a broad selection of type and dose of exercise prescription. The five most common management strategies chosen were: closed chain strengthening exercises (98%); education and advice (96%); open chain strengthening exercises (76%); taping (70%) and stretches (65%). Physiotherapists with a special interest in treating PFP were statistically more likely to manage patients with orthotics (P = 0.02) and bracing (P = 0.01) compared to physiotherapists without a special interest. Approximately 55% would not prescribe an exercise if it was painful. Thirty-one percent of physiotherapists would advise patients not to continue with leisure and/or sporting activity if they experienced any pain. CONCLUSION: Current UK practice in the management strategies of PFP is variable. Further high quality research on which to inform physiotherapy practice is warranted for this troublesome musculoskeletal condition.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis.

BACKGROUND: Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient's pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials. METHODS: Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence. RESULTS: The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference. CONCLUSION: Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders. PROSPERO REGISTRATION: CRD42016038882.

ED healthcare professionals and their notions of productivity.

OBJECTIVE: The combination of constrained resources, patient complexity and rapidly increasing demand has meant that healthcare productivity constitutes a significant problem for emergency medicine. However, healthcare productivity remains a contentious issue, with some criticising the level of professional engagement. This paper will propose that productivity improvements in healthcare could occur (and be sustained) if professionals' perceptions and views of productivity were better understood. METHODS: An 8-month ethnographic study was conducted in a large UK ED, using semistructured interviews with healthcare professionals (HCPs) (n=26), a focus group and observation. Thematic analysis of the data was undertaken based on an interpretivist philosophy. RESULTS: The data demonstrate that HCPs accept productivity improvement as part of their contemporary professional role. In particular, their understanding of productivity is focused around five key domains: the patient; the professional; the culture; the process of work and the economic. CONCLUSIONS: By exploring how these HCPs experienced and made sense of productivity improvement and productive healthcare, the data reveals how HCPs may reconcile a culture of caring with one of efficiency. Understanding healthcare productivity from this perspective has potential implications for service improvement design and performance measurement.

Constructing notions of healthcare productivity: the call for a new professionalism?

Improving performance is an imperative for most healthcare systems in industrialised countries. This article considers one such system, the UK's National Health Service (NHS). Recent NHS reforms and strategies have advocated improved healthcare productivity as a fundamental objective of policy and professional work. This article explores the construction of productivity in contemporary NHS discourse, analysing it via the Foucauldian concept of governmentality. In this manner it is possible to investigate claims that the commodification of health work constitutes a threat to autonomy, and counter that with an alternative view from a perspective of neoliberal self-governance. Contemporary policy documents pertaining to NHS productivity were analysed using discourse analysis to examine the way in which productivity was framed and how responsibility for inefficient resource use, and possible solutions, were constructed. Data reveals the notion of productivity as problematic, with professionals as key protagonists. A common narrative identifies traditional NHS command/control principles as having failed to engage professionals or having been actively obstructed by them. In contrast, new productivity narratives are framed as direct appeals to professionalism. These new narratives do not support deprofessionalisation, but rather reconstruct responsibilities, what might be called 'new professionalism', in which productivity is identified as an individualised professional duty.

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study.

PURPOSE: Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study. MATERIAL AND METHODS: This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study. RESULTS: Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists. CONCLUSION: The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

A biopsychosocial approach to managing chronic low back pain offers a promising alternative to patients and physiotherapists in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to improve physiotherapists' thoughts and attitudes, and have a positive influence on their professional development in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to reverse patients' maladaptive beliefs, improve their understanding of their condition, improve outcomes in Ghana.

'Specialist before physiotherapist': physicians' and physiotherapists' beliefs and management of chronic low back pain in Ghana - A qualitative study.

PURPOSE: This study provides an understanding of the chronic low back pain (CLBP) beliefs and management practices of physicians/doctors and physiotherapists in Ghana, and the mechanisms underlying their beliefs and practices. MATERIALS/METHODS: Thirty-three individual semi-structured interviews, involving eighteen physio-therapists and fifteen physicians involved with CLBP management, were carried out. Interviews were audio recorded, transcribed, and analysed using Straussian grounded theory principles and critical realist philosophy. RESULTS: Five categories were derived: The predominance of bio-medical/mechanical beliefs, maladaptive beliefs, maladaptive practices, limited involvement of physiotherapists and other healthcare professionals (HCPs) and evidence-based beliefs and practices. The predominant mechanisms underlying the HCPs beliefs and practices were: the healthcare environment (professional roles/identity hinged around paternalistic and biomedical care, fragmented CLBP management, limited physiotherapy/HCPs' knowledge) and sociocultural environment (sociocultural/patients' expectations of passive therapy and paternalism). CONCLUSION: The CLBP beliefs and practices of HCPs involved with CLBP in Ghana is modelled around a professional identity that is largely hinged on paternalism and bio-medical/mechanical understandings. Lack of collaboration and sociocultural expectations also play a significant role. There is the need for a reconstitution of Ghanaian HCPs' CLBP beliefs and management approaches to align with evidenced-based approaches (e.g., imaging should not be universally prescribed, biopsychosocial and patient-centred care).

The burden of low back pain is substantial globally, with an increasing burden identified in low-to-middle income countries.This study highlights a predominance of non-evidence-based understandings around chronic low back pain and its management among Ghanaian healthcare professionals, although some evidence-based approaches were also identified.Ghanaian healthcare professionals need to engage with current evidence for chronic low back pain management, incorporate psychological factors and consider non-specific chronic low back pain as a possible diagnostic label.Professional, structural, and sociocultural inclinations towards paternalism, passive therapies, biomedical and fragmented approaches to chronic low back pain management need to be addressed.

Development of an intervention for patients following an anterior cruciate ligament rupture: an online nominal group technique consensus study.

OBJECTIVES: (1) To develop an intervention for to support patients diagnosed with an anterior cruciate ligament (ACL) rupture with decision-making regarding treatment. (2) To define evidence-based recommendations for the treatment of patients following an ACL rupture. DESIGN: Nominal group technique consensus study. SETTING: Online meetings with patients and key stakeholders working and receiving treatment in the National Health Service, UK. PARTICIPANTS: Consensus meetings composed of eight voting participants and five non-voting facilitators. Voting participants included five clinicians, one outpatient therapy manager and two patients with experience in an ACL rupture and reconstructive surgery. Non-voting facilitators supported group discussions and/or observed study procedures. This included a clinical academic expert, two methodology experts and two patient representatives. METHOD: Two online meetings were held. Pre-elicitation material was distributed ahead of the first meeting. Premeeting voting was conducted ahead of both meetings. A draft of the shared decision-making intervention and recommendations were shared ahead of the second meeting. Components were discussed and ranked for inclusion based on a 70% agreement threshold. RESULTS: The meetings led to the development of a shared decision-making intervention to support treatment decision-making following an ACL rupture. The intervention includes two components: (1) a patient information leaflet and key questions diagram and (2) option grid. The evidence-based recommendations encompass core components of treatment reaching the 70% threshold agreed by the group. The recommendations cover: (1) advice and education, (2) exercise guidance, (3) intervention delivery, (4) outcome measure use and (5) shared decision-making. CONCLUSION: This study has successfully developed a shared decision-making intervention to support ACL treatment decision-making, ready for testing in a future feasibility study. Evidence-based recommendations for the treatment of patients following ACL injury, ready for testing in a National Health Service (UK) setting, are also presented. TRIAL REGISTRATION NUMBER: NCT05529511.

Implementing a shared decision-making intervention to support treatment decisions for patients following an anterior cruciate ligament rupture - a protocol for the POP-ACLR feasibility study.

BACKGROUND: Treatment for anterior cruciate ligament (ACL) rupture may follow a surgical or nonsurgical pathway. At present, there is uncertainty around treatment choice. Two shared decision-making tools have been codesigned to support patients to make a decision about treatment following an ACL rupture. The shared decision-making tools include a patient information leaflet and an option grid. We report the protocol for a mixed-methods feasibility study, with nested qualitative interviews, to understand feasibility, acceptability, indicators of effectiveness and implementation factors of these shared decision-making tools (combined to form one shared decision-making intervention). METHODS: A single-centre non-randomised feasibility study will be conducted with 20 patients. Patients diagnosed with an ACL rupture following magnetic resonance imaging will be identified from an orthopaedic clinic. The shared decision-making intervention will be delivered during a clinical consultation with a physiotherapist. The primary feasibility outcomes include the following: recruitment rate, fidelity, acceptability and follow-up questionnaire completion. The secondary outcome is the satisfaction with decision scale. The nested qualitative interview will explore experience of using the shared decision-making intervention to understand acceptability, implementation factors and areas for further refinement. DISCUSSION: This study will determine the feasibility of using a newly developed shared decision-making intervention designed to support patients to make a decision about treatment of their ACL rupture. The acceptability and indicators of effectiveness will also be explored. In the long term, the shared decision-making intervention may improve service and patient outcomes and ensure cost-effectiveness for the NHS; ensuring those most likely to benefit from surgical treatment proceed along this pathway. TRIAL REGISTRATION: Pending registration on ISRCTN.

Stroke Survivor's Satisfaction and Experience with Rehabilitation Services: A Qualitative Systematic Review.

Research in healthcare is increasingly focused on quality assurance and continuous quality improvement aiming to promote service quality. Satisfaction is a key endpoint in outcomes research and service benchmarking, along with "traditional" clinical outcomes. What controls stroke survivors' satisfaction differs among qualitative studies' conclusions, but there is general consensus on the importance of communication, improvement in activity, and engagement in goal setting. This review aims to collect and synthesise studies of the satisfaction of stroke survivors with rehabilitation services. A systematic search was conducted in seven electronic databases, including CINAHL, OVID, Pedro, Scopus Midline, Web of Science, and PubMed. The database search yielded 1339 studies, while one additional work was identified through hand searching. After removing duplicates, 74 studies were read in full, and after resultant exclusions, 12 qualitative studies were systematically reviewed, extracted, and appraised by two reviewers independently (HAS and RT) and the third reviewer (CS) was available for any disagreement. Five analytical themes were identified: Healthcare Professional-Patient Relationship (HCP), Delivery Service, Perceived Patient Autonomy (PPA), Expectations Shape Satisfaction, and Culture Influences Satisfaction. The studies of survivors' satisfaction, experiences, and their rehabilitative needs with the services they receive have provided different factors that influence their satisfaction during rehabilitation in different countries worldwide. However, the context in which the studies were conducted is quite limited, and more detailed studies are required for many underexplored contexts.

A Qualitative Investigation of the Psychosocial Impact of Chronic Low Back Pain in Ghana.

INTRODUCTION: Chronic low back pain (CLBP) is a global health concern associated with multidimensional/biopsychosocial levels of affectation in developed countries, with holistic management requiring consideration of these factors. There has been minimal research exploring the psychosocial impact of CLBP, and the factors influencing it, in African contexts, with none in Ghana. OBJECTIVES: To explore the psychosocial impact of CLBP among patients with CLBP in Ghana. DESIGN: Qualitative study using individual semistructured face-to-face interviews, underpinned by Straussian grounded theory principles and critical realist philosophy. PARTICIPANTS: Thirty patients with CLBP attending physiotherapy at two hospitals in Ghana. RESULTS: Five categories: loss of self and roles, emotional distress, fear, stigmatisation and marginalisation, financial burden, and social support and three mechanisms: acquired biomedical/mechanical beliefs from healthcare professionals (HCPs), sociocultural beliefs and the socioeconomic impact of CLBP were derived. CONCLUSION: CLBP adversely affects multidimensional/biopsychosocial aspects of individuals experiencing CLBP in Ghana. This delineates the need for a biopsychosocial approach to care. There is the need for HCPs in Ghana to reassess current CLBP management strategies to address the influence of adverse HCPs biomedical inclinations on patients' psychosocial consequences. Population-based education strategies and consideration of formal support systems for persons with disabling CLBP may also be beneficial.

Using normalisation process theory for intervention development, implementation and refinement in musculoskeletal and orthopaedic interventions: a qualitative systematic review.

BACKGROUND: Normalisation process theory (NPT) provides researchers with a set of tools to support the understanding of the implementation, normalisation and sustainment of an intervention in practice. Previous reviews of published research have explored NPT's use in the implementation processes of healthcare interventions. However, its utility in intervention research, specifically in orthopaedic and musculoskeletal interventions, remains unclear. The aim of this review is to explore how NPT (including extended NPT, ENPT) has been used in orthopaedic/musculoskeletal intervention research. METHODS: A qualitative systematic review was conducted. Two bibliographic databases (Scopus and Web of Science) and a search engine (Google Scholar) were searched for peer-reviewed journal articles citing key papers outlining the development of NPT, related methods, tools or the web-based toolkit. We included studies of any method, including protocols, and did not exclude based on published language. A data extraction tool was developed, and data were analysed using a framework approach. RESULTS: Citation searches, of the 12 key studies, revealed 10,420 citations. Following duplicate removal, title, abstract and full-text screening, 14 papers from 12 studies were included. There were 8 key findings assessed against GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research). Five were of high confidence supporting NPT/ENPT's use in the implementation process for interventions targeting a range of MSK/orthopaedic conditions. NPT/ENPT offers a useful analytical lens to focus attention and consider implementation factors robustly. There is limited evidence for the selection of NPT/ENPT and for the use of the Normalisation Measure Development instrument. Three findings of moderate confidence suggest that coherence is seen as a fundamental initial step in implementation, there is limited evidence that study population limits NPT's utility and the application of ENPT may pose a challenge to researchers. CONCLUSION: This review demonstrates NPT's utility in supporting intervention implementation for orthopaedic and musculoskeletal conditions. We have theorised the benefits ENPT offers to intervention development and refinement and recommend future researchers consider its use. We also encourage future researchers to offer clear justification for NPT's use in their methodology. TRIAL REGISTRATION: The review protocol is registered with PROSPERO (CRD42022358558).

Austerity on the frontline- a preliminary study of physiotherapists working in the National Health Service in the UK.

BACKGROUND: Organizational reform has been commonplace in the response to global socio-economic changes. Rising managerialism, consumerism and marketization has accelerated reforms; providing challenges for the healthcare professions. The latest socio-economic challenge, austerity, and its professional implications have scarcely been researched. This study aims to explore the lived reality of austerity as experienced by physiotherapists working on the frontline of the National Health Service (NHS) in the UK. METHODS: Ethical approval was granted by the University of Nottingham; the study was advertised via the Chartered Society of Physiotherapy online network. Two participants took part; semi-structured interviews were completed, audio recorded, and transcribed. Data was analyzed using thematic analysis. FINDINGS: Three themes arose from the data: (1) Fulfilling professional responsibilities; (2) Changing organizational landscape; and (3) Professional reality of rationalizing and accommodating austerity. The clinical implications of austerity included increased length of hospital stay, insufficient community services, constrained resources, and understaffing. Participants demonstrated attempts to preserve their professional status and services through restratification throughout the intra-professional hierarchy, changing division of labor, and re-professionalization. CONCLUSIONS: Despite claims that austerity is coming to an end, it remained a reality for these clinicians in the NHS. Physiotherapists in this study used similar methods to preserve practice when faced with exogenous constraints as seen in medicine, such as re-professionalization and restratification. However, this attempt to defend professionalism by a non-medical healthcare profession was met with both successes and losses and has implications for the wider healthcare profession ecology, identifying an area for future research.

Understanding how patients' pain beliefs influence chronic low back pain management in Ghana: a grounded theory approach.

INTRODUCTION: Chronic low back pain (CLBP) is associated with negative consequences in high and low/middle-income countries. Pain beliefs are important psychosocial factors that affect the occurrence and progression of CLBP and may be influenced by the sociocultural context and interactions with healthcare professionals (HCPs). The pain beliefs of Ghanaian patients with CLBP are unknown and the factors influencing pain beliefs in African contexts are unclear. OBJECTIVES: To explore the pain beliefs of Ghanaian patients with CLBP, how they influence CLBP management/coping and to identify the mechanisms influencing them. DESIGN: Qualitative study using individual semistructured face-to-face interviews, situated within Straussian grounded theory principles and critical realist philosophy. PARTICIPANTS: Thirty patients with CLBP accessing physiotherapy at two teaching hospitals in Ghana. RESULTS: Participants suggested dominant biomedical/mechanical beliefs (related to CLBP causes, posture and activity, and the belief of an endpoint/cure for CLBP). Maladaptive beliefs and practices, in particular fear-avoidance beliefs, and dependence on passive management and coping, were common among participants. These beliefs and practices were mostly influenced by HCPs and sociocultural expectations/norms. Although spirituality, pacing activity and prescribed exercises were commonly mentioned by participants, other active strategies and positive beliefs were expressed by a few participants and influenced by patients' themselves. Limited physiotherapy involvement, knowledge and awareness were also reported by participants, and this appeared to be influenced by the limited physiotherapy visibility in Ghana. CONCLUSION: Participants' narratives suggested the dominant influence of HCPs and the sociocultural environment on their biomedical/mechanical beliefs. These facilitated maladaptive beliefs and adoption of passive coping and management practices. Therefore, incorporation of more positive beliefs and holistic/active strategies by Ghanaian patients and HCPs may be beneficial. Furthermore, patient empowerment and health literacy opportunities to address unhelpful CLBP/sociocultural beliefs and equip patients with management options for CLBP could be beneficial.

Q Methodology in the COVID-19 Era.

All face-to-face studies were affected by the COVID-19 pandemic, as they could not be run in person due to rules and guidance linked to social distancing which were in force during the outbreak. Finding and testing an available COVID-secure approach for both participants and researchers was important as was the need to continue conducting such studies during this critical time. At present, the extant literature indicates a clear gap in research that elucidates how to carry out a Q methodology study online, step by step. This paper describes an option for online Q methodology using an approach that simulates all of the steps performed in a face-to-face setting using an open-source software known as Easy-HtmlQ. Using a case study in telemedicine adoption as illustration, this paper also considers the perspective of both research participants and Q methodology researchers via semi-structured interviews. Using Easy-HtmlQ V1.1 in online Q methodology studies appears to be an affordable, practical and user-friendly solution. Some of the benefits associated with running Q methodology studies online were the decreased costs, enabling the recruitment of wider number of participants, providing a COVID-19-secure environment and offering convenience to both participants and researchers during the research process. The findings of this study may contribute to increasing the number of online Q methodology studies in the future, as it has succeeded in offering a feasible approach for Q methodology researchers.

Operationalisation of a biopsychosocial approach for the non-pharmacological management of patients with chronic musculoskeletal pain in low- and middle-income countries: A systematic review.

BACKGROUND: Chronic musculoskeletal pain is a major health concern. The biopsychosocial approach is an evidence-based approach recommended for managing chronic musculoskeletal pain. However, the evidence for this approach is largely reported from high-income countries; therefore, it is important to ascertain how biopsychosocial approaches are operationalised in low- and middle-income countries to inform practice. AIM: To examine the evidence for the operationalization of biopsychosocial interventions in managing patients with chronic musculoskeletal pain in low-and middle-income countries. METHODS: The search included studies published in English from 2008 to September 2019 in: Cochrane library, OVID, CINAHL, Scopus, PUBMED, Web of Science, and SportDiscus. Randomised and non-randomised trials using a biopsychosocial intervention were considered. The review team developed a search strategy; two independent reviewers screened and assessed results for quality. RESULTS: Sixteen studies were included (n = 996) with mainly low back pain populations (n = 11 studies). Others were osteoarthritis (n = 1) and other musculoskeletal pain (n = 4). The majority (n = 12) of studies attained fair to poor quality, three had good quality, one scored excellent quality. Interventions applied biopsychosocial principles such as cognitive functional therapy, and graded activity, delivered by healthcare professionals such as physiotherapists and doctors. However, most results provided insufficient information regarding healthcare professionals' capacity to deliver interventions, lack of information regarding intervention delivery and training of healthcare professionals. CONCLUSIONS: The results highlight the potential for delivering biopsychosocial interventions in low- and middle-income countries; however, future research should consider robust methodological approaches with clear details to achieve high-quality trials.