'I think positivity breeds positivity': a qualitative exploration of the role of family members in supporting those with chronic musculoskeletal pain to stay at work.

BACKGROUND: It is proposed that family members are important sources of support in helping those with chronic musculoskeletal pain to remain at work, but the phenomenon remains largely unexplored. The aim of this study was to examine the extent and nature of support provided by family members in this respect. METHODS: Qualitative data were collected from workers and their 'significant others' (spouses/partners/close family members) in two un-related studies focused on working with pain; one conducted in the United Kingdom (n = 10 dyads) and one in the Netherlands (n = 21 dyads). Thematic analysis techniques were applied to both sets of data independently, and findings were then assimilated to establish common themes. RESULTS: Findings were broadly similar in both studies. Workers acknowledged significant other support in helping them to manage their pain and remain at work, and their descriptions of the type of support provided and required were echoed by their significant others. Three common themes were identified - 'connectivity', 'activity' and 'positivity'. Worker and significant other responses were largely congruent, but significant others provided more in-depth information on the nature of their support, their concerns and the impact on their relationship. CONCLUSIONS: This research presents novel insights about the specific contribution made by significant others in helping their relatives with chronic musculoskeletal pain to stay at work. These findings add to the under-represented 'social' dimension of the biopsychosocial model currently applied to our understanding and treatment of pain, and point to harnessing support from significant others as a potentially effective management strategy.

The Utility of Template Analysis in Qualitative Psychology Research.

Thematic analysis is widely used in qualitative psychology research, and in this article, we present a particular style of thematic analysis known as Template Analysis. We outline the technique and consider its epistemological position, then describe three case studies of research projects which employed Template Analysis to illustrate the diverse ways it can be used. Our first case study illustrates how the technique was employed in data analysis undertaken by a team of researchers in a large-scale qualitative research project. Our second example demonstrates how a qualitative study that set out to build on mainstream theory made use of the a priori themes (themes determined in advance of coding) permitted in Template Analysis. Our final case study shows how Template Analysis can be used from an interpretative phenomenological stance. We highlight the distinctive features of this style of thematic analysis, discuss the kind of research where it may be particularly appropriate, and consider possible limitations of the technique. We conclude that Template Analysis is a flexible form of thematic analysis with real utility in qualitative psychology research.

The reliability of the Leeds Movement Performance Index (LMPI): a new tool for neurological physiotherapy.

BACKGROUND: Measuring movement performance in people with neurological damage requires a tool that reflects physiotherapy assessment and clinical reasoning. The Leeds Movement Performance Index (LMPI) was previously developed by a group of neurological physiotherapists to fulfill these requirements. OBJECTIVE: To assess the reliability of the LMPI for use in neurological physiotherapy practice. METHODS: Twelve senior neurological physiotherapists were trained to use the LMPI and then asked to measure the movement performance of five patients whose movement had been previously video-recorded for this purpose. A retest session was completed after two weeks. Data were analysed to establish internal and external reliability. RESULTS: Internal reliability was assessed using Cronbach's alpha coefficient, applied to the entire scale (0.862) and to each item (range 0.795-0.892). External (inter-rater) reliability was assessed by a calculation of the intraclass correlation coefficient for scores awarded by multiple raters (0.959), with individual item reliability ranging from 0.874 to 0.968. External (test-retest) reliability was assessed by calculating the Spearman's rank correlation coefficient between scores obtained on two testing occasions (0.792) with values of individual items ranging from 0.397 to 0.674. A variance components analysis partitioned variance into components arising from between-patient variability (55.2%) between-therapist variability (7.8%) and between-testing variability (2.8%). CONCLUSIONS: RESULTS indicate that the LMPI is a reliable measurement tool when used by senior neurological physiotherapists.

Are the treatment expectations of 'significant others' psychosocial obstacles to work participation for those with persistent low back pain?

BACKGROUND: Treatment expectations form a fundamental component of the self-regulatory model of health behavior, which defines such cognitions as illness perceptions. Unrealistic and/or unhelpful treatment expectations have been linked to detrimental clinical and work outcomes in those with persistent low back pain. However, research of this nature has rarely focused on the influence of 'significant others' (spouse/partner/close family member). OBJECTIVE: To provide an in-depth examination of the treatment expectations of the 'significant others' of individuals who have become unable to work due to persistent low back pain, highlighting how significant others may influence recovery and work participation outcomes for such individuals. PARTICIPANTS: A convenience sample (n=18) of work disability benefit claimants and their significant others were recruited from two settings in the North of England. METHOD: A qualitative research design was employed, and semi-structured interviews based on the chronic pain version of the Illness Perceptions Questionnaire-Revised were conducted with claimants and their significant others. Interview data were analysed using template analysis. RESULTS: It was found that significant others expected a substantial reduction or complete removal of pain in order for treatment to be considered successful. The pursuit of diagnostic tests was important in validating such expectations, and there was continued scepticism of treatments already undertaken or offered as an alternative. Like the individuals affected, significant others believed that a correct diagnosis had not yet been received, which led to a continued delay in return to work. CONCLUSIONS: This study demonstrates that significant others have similar unrealistic and/or unhelpful treatment expectations to those widely reported by individuals with persistent low back pain, and could further reinforce such illness perceptions and serve as wider psychosocial obstacles to recovery and continued work participation.

Illness perceptions in the context of differing work participation outcomes: exploring the influence of significant others in persistent back pain.

BACKGROUND: Previous research has demonstrated that the significant others of individuals with persistent back pain may have important influences on work participation outcomes. The aim of this study was to extend previous research by including individuals who have remained in work despite persistent back pain in addition to those who had become incapacitated for work, along with their significant others. The purpose of this research was to explore whether the illness beliefs of significant others differed depending on their relative's working status, and to make some preliminary identification of how significant others may facilitate or hinder work participation for those with persistent back pain. METHODS: Interviews structured around the Illness Perception Questionnaire (chronic pain version) were conducted with back pain patients recruited from a hospital pain management clinic along with their significant others. Some patients had remained in work despite their back pain; others had ceased employment. Data were analysed using template analysis. RESULTS: There were clear differences between beliefs about, and reported responses to, back pain symptoms amongst the significant others of individuals who had remained in employment compared with the significant others of those who had ceased work. Three overarching themes emerged: perceived consequences of back pain, specific nature of employment and the impact of back pain on patient identity. CONCLUSIONS: Significant others of employed individuals with back pain focused on the extent to which activity could still be undertaken despite back pain symptoms. Individuals out of work due to persistent back pain apparently self-limited their activity and were supported in their beliefs and behaviours by their significant others. To justify incapacity due to back pain, this group had seemingly become entrenched in a position whereby it was crucial that the individual with back pain was perceived as completely disabled. We suggest that significant others are clearly important, and potentially detrimental, sources of support to individuals with back pain. The inclusion of significant others in vocational rehabilitation programmes could potentially be a valuable way of mobilising readily accessible resources in a way that supports optimal functioning.

How do doctors refer to patient-reported outcome measures (PROMS) in oncology consultations?

PURPOSE: We conducted a secondary qualitative analysis of consultations between oncologists and their patients to explore how patient-reported outcome measures (PROMs) data were referred to in the process of (1) eliciting and exploring patients' concerns; (2) making decisions about supportive treatment and (3) making decisions about chemotherapy and other systemic treatments. METHODS: We purposively sampled audio recordings of 18 consultations from the intervention arm and 4 from the attention control arm of a previous UK randomised controlled trial of the feedback of PROMs data to doctors (Velikova et al. in J Clin Oncol 22(4):714-724 [1]). We used a combination of content and conversation analysis to examine how opportunities for discussion of health-related quality of life issues are opened up or closed down within the consultation and explore why this may or may not lead to changes in patient management. FINDINGS: Explicit reference to the PROMs data provided an opportunity for the patient to clarify and further elaborate on the side effects of chemotherapy. High scores on the PROMs data were not explored further if the patient indicated they were not a problem or were not related to the cancer or chemotherapy. Symptomatic treatment was more often offered for problems like nausea, constipation, pain and depression but much less so for fatigue. Doctors discussed fatigue by providing a cause for the fatigue (e.g. the chemotherapy), presenting this as 'something to be expected', minimising its impact or moving on to another topic. Chemotherapy regimens were not changed on the basis of the PROMs data alone, but PROMs data were sometimes used to legitimise changes. CONCLUSIONS: Explicit mention of PROMs data in the consultation may strengthen opportunities for patients to elaborate on their problems, but doctors may not always know how to do this. Our findings have informed the development of a training package to enable doctors to optimise their use of PROMs data within the consultation.

The influence of 'significant others' on persistent back pain and work participation: a qualitative exploration of illness perceptions.

BACKGROUND: Individual illness perceptions have been highlighted as important influences on clinical outcomes for back pain. However, the illness perceptions of 'significant others' (spouse/partner/close family member) are rarely explored, particularly in relation to persistent back pain and work participation. The aim of this study was to initiate qualitative research in this area in order to further understand these wider influences on outcome. METHODS: Semi-structured interviews based on the chronic pain version of the Illness Perceptions Questionnaire-Revised were conducted with a convenience sample of UK disability benefit claimants, along with their significant others (n = 5 dyads). Data were analysed using template analysis. RESULTS: Significant others shared, and perhaps further reinforced, claimants' unhelpful illness beliefs including fear of pain/re-injury associated with certain types of work and activity, and pessimism about the likelihood of return to work. In some cases, significant others appeared more resigned to the permanence and negative inevitable consequences of the claimant's back pain condition on work participation, and were more sceptical about the availability of suitable work and sympathy from employers. In their pursuit of authenticity, claimants were keen to stress their desire to work whilst emphasising how the severity and physical limitations of their condition prevented them from doing so. In this vein, and seemingly based on their perceptions of what makes a 'good' significant other, significant others acted as a 'witness to pain', supporting claimants' self-limiting behaviour and statements of incapacity, often responding with empathy and assistance. The beliefs and responses of significant others may also have been influenced by their own experience of chronic illness, thus participants lives were often intertwined and defined by illness. CONCLUSIONS: The findings from this exploratory study reveal how others and wider social circumstances might contribute both to the propensity of persistent back pain and to its consequences. This is an area that has received little attention to date, and wider support of these findings may usefully inform the design of future intervention programmes aimed at restoring work participation.

The implementation of occupational health guidelines principles for reducing sickness absence due to musculoskeletal disorders.

BACKGROUND: Occupational health guidelines recommend a biopsychosocial approach to manage sickness absence due to musculoskeletal disorders (MSDs), with a primary focus on early intervention through provision of a supportive network. AIMS: To investigate the implementation of a guidelines-based intervention (early contact of absentees; addressing psychosocial obstacles; offering temporary modified work; communicating among the players), and to determine whether this is effective for reducing return-to-work times and duration of future absence. METHODS: A non-randomized controlled trial was conducted within a UK company. Occupational health nurses at two experimental sites (1,435 workers) were trained to deliver the intervention to workers taking absence due to MSDs (low back and upper limb disorders), while usual care was delivered at three control sites (1,483 workers). Company-recorded absence data were collected over a 12-month follow-up period. RESULTS: The implementation of the experimental intervention was impeded by unforeseen organizational obstacles at one site (policies, procedures and individual approaches) which had a detrimental effect on uptake and delivery. At the site where the intervention was delivered per protocol, absence was significantly less compared with controls; 6.5 and 10.8 days, respectively. However, the duration of future absence was not significantly different (13.0 and 25.1 days, respectively). CONCLUSIONS: An early intervention addressing psychosocial obstacles to recovery can be effective for reducing absence due to MSDs. Successful implementation, where the key players are onside and organizational obstacles are overcome, is difficult to achieve.