Development of a national pain management competency profile to guide entry-level physiotherapy education in Canada.

BACKGROUND: National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada. AIMS: This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context. METHODS: A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators. RESULTS: Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being "very satisfied" with the process. CONCLUSIONS: This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

Contexte: Contexte: Les stratégies nationales nord-américaines préconisent des améliorations sensibles à la formation de base en matiére de prise en charge de la douleur afin de contribuer à la réduction du fardeau de la douleur chronique. Des travaux antérieurs ont généré un ensemble de compétences interprofessionnelles utile en matiére de prise en charge de la douleur afin de guider la formation des futurs professionnels de la santé. Cependant, trés peu de travaux ont porté sur l'acquisition de telles compétences pour des professions individuelles dans différentes régions. L'uisition de compétences spécifiques à une profession adaptées au contexte local est une première étape nécessaire pour leur intégration dans les systèmes réglementaires locaux. Notre groupe travaille à cet objectif dans le cadre de programmes de formation de base en physiothèrapie partout au Canada.Objectifs: Cette étude visait à créer un profil de compétences consensuel pour la prise en charge de la douleur, propre au contexte canadien de la physiothérapie.Méthodes: Un devis Delphi modifié a étè utilisé pour parvenir à un consensus parmi des formateurs en milieu universitaire et clinique en matière de douleur en milieu universitaire et clinique.Résultats: Des représentants de 14 programmes de formation de base en physiothérapie (93 % des programmes canadiens) et de six formateurs en milieu clinique ont été recrutés. Après deux tours, 15 compétences ont atteint le seuil d'approbation prédéterminé (75 %). La plupart des participants (85 %) ont déclaré être « très satisfaits ¼du processus.Conclusions: Ce processus a permis de dégager un consensus sur un nouveau profil de compétences en matiére de prise en charge de la douleur propre au contexte canadien de la physiothérapie. Ce profil délimite les habiletés requises des physiothérapeutes pour prendre en charge la douleur en début de pratique. Les participants ont été très satisfaits du processus. Cette étude contribue également à la littérature émergente sur la recherche intégrée en matière de prise en charge de la douleur en définissant une méthodologie de recherche qui peut être utilisée pour éclairer des travaux similaires dans d'autres professions de la santé et dans d'autres régions.

A New Way with Words: Bringing Qualitative Research Findings to Action.

The use of arts-based knowledge translation (KT) methods such as video remains underutilized in the research arena, despite the strong influence and reach of technology in society. This paper provides a detailed description of the process involved in producing a video as a novel KT strategy to respond to and address findings from our research on professional socialization experiences of physiotherapy students. Specifically, the video challenged dominant stereotypes regarding the profession by depicting the realities and rewards of modern physiotherapy practice. Using a guiding KT framework, this paper provides insight on how researchers can disseminate their study findings in an impactful way using multimedia. Creative outlets such as video and social media are innovative dissemination tools that enable KT to have a powerful and lasting impact.

A longitudinal, narrative study of professional socialisation among health students.

PURPOSE: Interprofessional collaboration (IPC) among health professionals is well-recognised to enhance care delivery and patient outcomes. Emerging evidence suggests that the early socialisation of students in health professional programmes to teamwork may have a positive impact on their future as collaborative practitioners. With a purpose of contributing to growing evidence on the processes of professional identity construction, and to explore how early expectations and perceptions of IPC develop during professional socialisation and pre-licensure education, our study examined the early professional socialisation experiences among five groups of health professional students. METHOD: A qualitative, narrative approach was used to examine early professional socialisation among five programmes of health professional students (dentistry, medicine, nursing, pharmacy, physiotherapy) at an Atlantic Canadian University. In March and October 2016, students participated in interviews after first term (n = 44) and first year of study (n = 39). Interviews focused on participants' professional identify formation, as well as their perceptions and experiences of IPC. The authors analysed interview transcripts using narrative analysis. RESULTS: Findings identify that despite the espoused importance of IPC within health professional training, students have a limited understanding of their professional roles and are largely focused on developing a uniprofessional, vs. interprofessional identity. Clinical experiences, role models and exposure to teamwork are critical to contextualise collaborative practice and enhance the development of an interprofessional identity. CONCLUSIONS: Findings can be used to guide the development of curricula that promote interprofessional identity development and IPC during early professional socialisation.

Physiotherapy: an active, transformational, and authentic career choice.

Background: This paper arises from a larger study exploring early professional socialization across five professions: physiotherapy, nursing; dentistry; pharmacy; and medicine. Purpose: To explore the process of physiotherapy student professional identity development and the evolution of expectations and views of interprofessional practice in the first year of their program. Methods: One-on-one interviews at three time points: after being accepted into the physiotherapy program and before classes began (T1; n = 12); after term one (T2; n=9) and on completion of year one (T3; n = 7). Analyses employed narrative methodology, guided by anticipatory socialization and professional identity theories. Results: At T1, participants described their path towards physiotherapy, indicating career satisfaction as the core of their choice. Expectations of practice aligned with the normative social positioning of the profession. T2 and T3 interviews revealed that their pre-entry conceptualization of practice was both challenged and positively reinforced, leading them either to being satisfied with, or questioning their choice. Clinical placements created the most meaningful opportunities to understand their roles both as individual professionals and members of a collaborative team. Conclusion: Findings revealed the complex process of professional socialization in physiotherapy students with implications for admissions and formal and IPE curricula.

Pre-entry perceptions of students entering five health professions: implications for interprofessional education and collaboration.

Dysfunctional interprofessional teams are a threat to health system performance and the delivery of quality patient outcomes. Implementing strategies that prepare future health professionals to be effective collaborators requires a comprehensive understanding of how early professional socialization and professional identity formation occur. We present findings from a qualitative study, grounded in narrative methodology, examining early professional socialization among students across five health professional programs (dentistry, medicine, nursing, pharmacy, physiotherapy) in the first year of health professional training. Between April and September 2015, students (n = 49) entering programs at an Atlantic Canadian University participated in one-on-one, audiotaped interviews starting before formal program orientation. Pre-entry interviews focused on factors influencing students' career choice and expectations of future profession and interprofessional collaboration (IPC). Findings revealed that many different experiences influenced participants' career choice and framed the social positioning of their future career (e.g., leadership, prestige, autonomy). Participant narratives revealed the existence of stereotypes pertaining to their chosen and other health professions. Study findings provided insights that may help strengthen initiatives to promote positive professional identity formation within the context of IPC. Implications of this research highlight the need for the early introduction of IPC including pre-entry recruitment messaging for prospective health professionals.

Painful metaphors: enactivism and art in qualitative research.

Enactivism is an emerging theory for sense-making (cognition) with increasing applications to research and medicine. Enactivists reject the idea that sense-making is simply in the head or can be reduced to neural processes. Instead, enactivists argue that cognisers (people) are embodied and action-oriented, and that sense-making emerges from relational processes distributed across the brain-body-environment. We start this paper with an overview of a recently proposed enactive approach to pain. With rich theoretical and empirical roots in phenomenology and cognitive science, conceptualising pain as an enactive process is appealing as it overcomes the problematic dualist and reductionist nature of current pain theories and healthcare practices. Second, we discuss metaphor in the context of pain and enactivism, including a pain-related metaphor classification system. Third, we present and discuss five paintings created alongside an enactive study of clinical communication and the co-construction of pain-related meanings. Each painting represents pain-related metaphors delivered by clinicians during audio-recorded clinical appointments or discussed by clinicians and patients during interviews. We classify these metaphors, connecting them to enactive theory and relevant literature. The art, metaphors and associated narratives draw attention to the intertwined nature of language, meaning and pain. Of clinical relevance to primary and allied healthcare, we explore how clinicians' taken-for-granted pain-related metaphors can act as scaffolding for patients' pain and agency, for better or worse. We visually depict and give examples of clinical situations where metaphors became enactive, in that they were clinically reinforced and embodied through assessment and treatment. We conclude with research and clinical considerations, suggesting that enactive metaphor is a widely overlooked learning mechanism that clinicians could consider employing and intentionally shape.

Athletes Play Through Pain-What Does That Mean for Rehabilitation Specialists?

CONTEXT: Pain in sport has been normalized to the point where athletes are expected to ignore pain and remain in the game despite the possible detrimental consequences associated with playing through pain. While rehabilitation specialists may not have an influence on an athlete's competitive nature or the culture of risk they operate in, understanding the consequences of those factors on an athlete's physical well-being is definitely in their area of responsibility. OBJECTIVE: To explore the factors associated with the experiences of subelite athletes who play through pain in gymnastics, rowing, and speed skating. DESIGN: The authors conducted semistructured interviews with subelite athletes, coaches, and rehabilitation specialists. They recruited coach participants through their provincial sport organization. Athletes of the recruited coaches who were recovering from a musculoskeletal injury and training for a major competition were then recruited. They also recruited rehabilitation specialists who were known to treat subelite athletes independently by e-mail. SETTING: An observation session was conducted at the athlete's training facility. Interviews were then conducted either in a room at the university or at a preferred sound-attenuated location suggested by the participant. PARTICIPANTS: The authors studied 5 coaches, 4 subelite athletes, and 3 rehabilitation specialists. INTERVENTIONS: The authors photographed athletes during a practice shortly before an important competition, and we interviewed all the participants after that competition. Our photographs were used during the interview to stimulate discussion. RESULTS: The participant interviews revealed 3 main themes related to playing through pain. They are: Listening to your body, Decision making, and Who decides. CONCLUSION: When subelite athletes, striving to be the best in their sport continue to train with the pain of an injury, performance is affected in the short-term and long-term consequences are also possible. Our study provides some insight into the contrasting forces that athletes balance as they decide to continue or to stop.

Assessing ventilatory control stability in children with and without an elevated central apnoea index.

BACKGROUND AND OBJECTIVE: Frequent central apnoeas are sometimes observed in healthy children; however; the pathophysiology of an elevated central apnoea index (CAI) is poorly understood. A raised CAI may indicate underlying ventilatory control instability (i.e. elevated loop gain, LG) or a depressed ventilatory drive. This pilot study aimed to compare LG in otherwise healthy children with an elevated CAI to healthy controls. METHODS: Polysomnographic recordings from children (age > 6 months) without obstructive sleep apnoea and with a CAI > 5 events/h (n = 13) were compared with age and gender-matched controls with a CAI < 5 events/h (n = 13). Spontaneous sighs were identified during non-rapid eye movement (NREM) sleep, and breath-breath measurements of ventilation were derived from the nasal pressure signal. A standard model of ventilatory control (gain, time constant and delay) was used to calculate LG by transforming ventilatory fluctuations seen in response to a sigh into a ventilatory-drive signal that best matches observed ventilation. RESULTS: The high CAI group had an elevated LG (median = 0.36 (interquartile range, IQR = 0.35-0.53) vs 0.28 (0.23-0.36); P ≤ 0.01). There was no difference in either the time constant (P = 0.63) or delay (P = 0.29) between groups. Elevated LG observed in the high CAI group remained after accounting for degree of hypoxia (average oxygen saturation (SpO2 ) during each analysable window) experienced (0.40 (0.30-0.53) vs 0.25 (0.23-0.37); P = 0.04). CONCLUSION: An elevated CAI in otherwise healthy children is associated with a raised LG compared to matched controls with a low CAI, irrespective of level of hypoxia. This relative ventilatory instability helps explain the high CAI and may ultimately be able to help guide diagnosis and management in patients with high CAI.

Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non-First Nations children and youth.

BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non-First Nations children. METHODS: Data from a study population of age- and sex-matched First Nations and non-First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health). RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non-First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non-First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non-First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.0, and OR 1.7, 95% CI 1.2-2.3, respectively). INTERPRETATION: First Nations children were diagnosed with more pain than non-First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non-First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

Creating a safe space for First Nations youth to share their pain.

INTRODUCTION: Indigenous children and youth may be quiet about the way they express their pain and hurt which is in contrast to how health professionals are trained to assess it. OBJECTIVES: The aim was to understand how youth from 4 First Nation communities express pain using narratives and art-based methods to inform culturally appropriate assessment and treatment. METHODS: This qualitative investigation used a community-based participatory action methodology to recruit 42 youth between 8 and 17 years of age to share their perspectives of pain using ethnographic techniques including a Talking Circle followed by a painting workshop. Physical pain perspectives were prominent in circle conversations, but emotional pain, overlapping with physical, mental, and spiritual pain perspectives, was more evident through paintings. Art themes include causes of pain and coping strategies, providing a view into the pain and hurt youth may experience. Youth were more comfortable expressing emotional and mental pain through their artwork, not sharing verbally in conversation. RESULTS: Circle sessions and artwork data were themed using the Indigenous Medicine Wheel. Content of the circle conversations centered on physical pain, whereas paintings depicted mainly emotional pain (eg, crying or loneliness; 74% n = 31) with some overlap with physical pain (eg, injuries; 54%), mental pain (eg, coping strategies; 31%), and spiritual pain (eg, cultural symbols; 30%). Common threads included hiding pain, resilience, tribal consciousness, persistent pain, and loneliness. CONCLUSION: Once a safe space was created for First Nation youth, they provided a complex, culturally based understanding of the pain and coping experience from both an individual and community perspective. These engaging, culturally sensitive research methods provide direction for health providers regarding the importance of creating a safe space for young people to share their perspectives.

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.

OBJECTIVES: This study aimed to assess chiropractors' awareness of clinical practice guidelines for low back pain and to identify barriers and facilitators to the screening and management of psychosocial factors in patients with low back pain. METHODS: This qualitative study used semi-structured interviews informed by the Theoretical Domains Framework with 10 Nova Scotian chiropractors who were members of a practice-based research network. RESULTS: The participants correctly identified what the guidelines generally recommend and described the value of psychosocial factors; however, none of the participants could name specific clinical practice guidelines for low back pain. We identified 6 themes related to barriers and facilitators for chiropractors screening and managing psychosocial factors. The themes revolved around the participants' desire to fulfill patients' anatomy-focused treatment expectations and a perceived lack of training for managing psychosocial factors. Participants had concerns about going beyond the chiropractic scope of practice, and they perceived a lack of practical psychosocial screening and management resources. Social factors, such as the influence of other health care practitioners, were reported as both barriers and facilitators to screening and managing psychosocial factors. CONCLUSIONS: The participants in this study reported that they mostly treated with an anatomical and biomechanical focus and that they did not always address psychosocial factors identified in their patients with low back pain. Although these findings are limited to Nova Scotian chiropractors, the barriers identified appeared to be potentially modifiable and could be considered in other groups. Low-cost interventions, such as continuing education using evidence-informed behavior change techniques, could be considered to address these barriers.

Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core stability programs and considering context.

This commentary explores the importance of considering the biopsychosocial model and contextual factors when prescribing exercise. Diverse exercise programs for patients with chronic low back pain (CLBP) produce similar outcomes, without one specific exercise protocol demonstrating clear superiority. One clear barrier to positive outcomes is poor exercise adherence. We suggest that there are certain common contextual factors present in all exercise prescription scenarios that may impact adherence and health-related outcomes. While challenging common core stability exercise prescription, we present an argument for enhancing and intentionally shaping the following contextual factors: the therapeutic alliance, patient education, expectations and attributions of therapeutic success or failure, and mastery or cognitive control over a problem. Overall, this commentary argues that to improve exercise adherence and outcomes in the CLBP population, the context in which exercise is delivered and the meaning patients embody need to be considered and shaped by clinicians.

Cet article explore l'importance de considérer le modèle biopsychosocial et les facteurs contextuels avant de prescrire des exercices. Divers programmes d'exercices pour les patients qui souffrent de lombalgie chronique produisent des résultats semblables, sans qu'un protocole d'exercices particulier démontre une supériorité claire. Un obstacle évident à l'atteinte de résultats positifs est le fait de ne pas persister à faire les exercices. Nous laissons entendre qu'il existe certains facteurs contextuels communs dans tous les scénarios de prescription d'exercices pouvant avoir des répercussions sur la persistance et les résultats axés sur la santé. Tout en contestant la prescription d'exercices communs de stabilisation du tronc, nous présentons un argument en faveur de l'accroissement et l'élaboration intentionnelle des facteurs contextuels suivants : l'alliance thérapeutique, la sensibilisation du patient, les attentes et les attributions du succès ou de l'échec thérapeutique, ainsi que la maîtrise ou le contrôle cognitif d'un problème. Dans l'ensemble, cet article soutient qu'afin d'améliorer la persistance à effectuer les exercices et les résultats au sein de la population atteinte de lombalgie chronique, le contexte dans lequel l'exercice est fourni et la signification exprimée par le patient doivent être pris en considération par les cliniciens.

'I didn't pay her to teach me how to fix my back': a focused ethnographic study exploring chiropractors' and chiropractic patients' experiences and beliefs regarding exercise adherence.

AIM: To inform future research and exercise prescription for patients with chronic low back pain (CLBP), this study explored chiropractors' and chiropractic patients' experiences and beliefs regarding the barriers and facilitators to prescribed exercise adherence. METHODS: A focused ethnographic approach was used involving 16 semi-structured interviews, including pilot interviews (n = 4) followed by interviews with chiropractors (n = 6) and chiropractic patients with CLBP (n = 6). RESULTS: Barriers and facilitators to prescribed exercise adherence revolved around four themes: diagnostic and treatment beliefs motivating behavior, passive-active treatment balance, the therapeutic alliance and patient-centered care, and exercise delivery. CONCLUSION: Exercise adherence may be facilitated in patients with CLBP with simple exercise prescription changes made by chiropractors. However, changing chiropractors' and patients' diagnostic and treatment beliefs that are barriers to exercise adherence appears challenging. Training chiropractors in pain neuroscience education and the intentional use of behavior change techniques warrants future investigation.

OBJECTIF: Pour fournir de l'information sur les recherches futures et les exercices prescrits aux patients souffrant de lombalgies (LC), cette étude consistait à examiner les expériences et les croyances de chiropraticiens et de patients qui constituent des obstacles à la fidélité ou des facteurs qui la favorisent. MÉTHODOLOGIE: Étude ethnographique comportant 16 entrevues semi-structurées et des entrevues pilotes (n = 4) suivies d'entrevues avec des chiropraticiens (n = 6) et des patients souffrant de LC (n = 6). RÉSULTATS: Les obstacles à la fidélité aux exercices prescrits et les éléments qui la favorisent sont liés aux quatre points suivants: croyances sur le diagnostic et le traitement motivant le comportement, équilibre entre traitement passif et traitement actif, alliance thérapeutique et soins centrés sur le patient et fourniture d'exercices. CONCLUSION: Chez les patients souffrant de LC, de simples changements d'exercices apportés par le chiropraticien pourraient favoriser la fidélité aux exercices. Cependant, il semble difficile de changer des croyances sur le diagnostic et le traitement qui s'opposent à l'observance. Un examen plus approfondi de la pertinence d'une formation en neurosciences de la douleur et du recours intentionnel à des techniques servant à changer le comportement serait justifié.

Multiple seizure-induced thoracic vertebral compression fractures: a case report.

BACKGROUND: Musculoskeletal injuries stemming from forceful muscular contractions during seizures have been documented in the literature. Reports of multiple seizure-induced spinal fractures, in the absence of external trauma and without risk factors for fracture, are rare. CASE PRESENTATION: A 28-year-old male, newly diagnosed with epilepsy, presented to a chiropractic clinic with the complaint of mid-thoracic pain beginning after a tonic-clonic seizure with no associated external trauma. Radiographs revealed the impression of five new vertebral compression fractures from T4 to T8. DISCUSSION: This report highlights the importance of a complete history and examination of patients with a history of tonic-clonic seizures and back pain, especially when considering spinal adjustments. SUMMARY: This case report presents an argument that a tonic-clonic seizure, in the absence of external trauma or significant risk factors for fracture, resulted in multiple vertebral compression fractures.

CONTEXTE: Des études sur les blessures musculosquelettiques résultant de contractions musculaires forcées pendant les crises épileptiques ont déjà été publiées dans les revues scientifiques. Les rapports de fractures vertébrales multiples causées par des crises épileptiques, en l'absence de traumatismes externes et sans facteurs de risque de fracture, sont rares. EXPOSÉ DE CAS: Un homme de 28 ans, qui a reçu un diagnostic récent d'épilepsie, s'est présenté à une clinique de chiropratique se plaignant d'une douleur mi-dorsale débutant après une crise de grand mal sans traumatisme externe associé. Les radiographies révèlent l'impression de cinq nouvelles fractures vertébrales par compression de T4 à T8. DISCUSSION: Ce rapport souligne l'importance d'un historique complet et de l'examen des patients ayant des antécédents d'une crise de grand mal et de douleurs dorsales, en particulier si l'on envisage des ajustements vertébraux. RÉSUMÉ: Ce rapport de cas présente l'argument qu'une crise de grand mal, en l'absence de traumatismes externes ou de facteurs de risque significatifs pour fracture, a donné lieu à de multiples fractures vertébrales par compression.

Coping Styles, Pain Expressiveness, and Implicit Theories of Chronic Pain.

Whereas some individuals use active coping strategies and are able to adaptively cope with their pain, others use passive strategies and catastrophic appraisals, which are often associated with increased displays of pain behavior and negative pain-related outcomes. To investigate attribution-based implicit theories as a potential underlying mechanism that might affect coping success, we hypothesized that pain patients with an incremental implicit theory of pain (i.e., view pain as malleable) would have more active coping strategies, lower levels of pain expressiveness, and better pain-related outcomes than those with an entity implicit theory of pain (i.e., view pain as nonmalleable). Patients with chronic back pain undergoing a functional assessment completed a variety of self-report measures and participated in a pain-inducing physiotherapy procedure. The results revealed those with an incremental theory of pain used more active coping strategies, displayed less pain behavior, and reported better pain-related outcomes (e.g., lower levels of depression) than individuals with an entity theory of pain. The findings suggest implicit theories of pain may represent an underlying social-cognitive mechanism linked to important coping, emotional, and expressive reactions to chronic pain. Identifying such a mechanism may provide valuable information for the assessment and treatment of chronic pain.

The Development and Testing of a Checklist to Study Behaviour Change Techniques used in a Treatment Programme for Canadian Armed Forces Members with Chronic Non-specific Low Back Pain.

PURPOSE: There are reports of increased use of a variety of behaviour change techniques (BCT) by physiotherapists and findings of beneficial effects of use. However, there is a lack of physiotherapy-specific definitions of these techniques, as well as a sense of how physiotherapists use them in practice. Through this study, the authors created and field tested a preliminary nomenclature and description for BCT in patients with chronic non-specific low back pain (CNSLBP). METHODS: Items for the Physiotherapy Behaviour Change Technique (PT-BCT) checklist were derived from a nomenclature created for use in psychology and also from publications of studies using cognitive behaviour therapy-based approaches in physiotherapy. Content validity was tested via survey of clinical and research experts. Videotapes of a 6-week patient self-management rehabilitation programme were used for training, reliability testing, and field testing of the PT-BCT checklist. RESULTS: Checklist items were endorsed by the majority of experts surveyed; intra- and inter-rater reliability were moderate to high. In the field study, a broad range of BCT types (behavioural, cognitive, and motivational) were observed in both classroom and gym settings. CONCLUSIONS: The BCT nomenclature arising from this study and the PT-BCT checklist will be useful to further explore behaviour change in physiotherapy practice. The observation in this study that BCT were integrated into physiotherapists' practice illustrates how physiotherapists can play a role in changing behaviour, specifically in the presence of CNSLBP.

Objectif : On signale une utilisation accrue, par les physiothérapeutes, de tout un éventail de techniques de modification du comportement (TMC) et l'on constate des effets bénéfiques. Il manque toutefois des définitions de ces techniques qui sont spécifiques à la physiothérapie et l'on ne sait pas trop comment nous les avons utilisées dans la pratique. Cette étude a créé une nomenclature et une description préliminaires de TMC chez les patients souffrant de lombalgie chronique non spécifique (LCNS) et l'on en a fait l'essai pratique. Méthodes : Les questions figurant sur la liste de contrôle des techniques de modification des comportements en physiothérapie (TMC-PT) ont été tirées d'une nomenclature créée pour la psychologie et aussi d'études publiées au cours desquelles on a utilisé des démarches basées sur la thérapie comportementale cognitive en physiothérapie. La validité du contenu a été vérifiée au moyen de sondages d'experts cliniques et de recherches. On a utilisé des enregistrements vidéo d'un programme de réadaptation de l'autoprise en charge d'un patient d'une durée de six semaines pour la formation, l'essai de fiabilité et l'essai pratique de la liste de contrôle TMC-PT. Résultats : La majorité des experts sondés a approuvé les éléments de la liste. La fiabilité intra et interévaluateurs a varié de modérée à élevée. Au cours de l'étude pratique, on a observé un vaste éventail de types de TMC (comportementales, cognitives et motivationnelles) à la fois en classe et au gymnase. Conclusions : La nomenclature des TMC découlant de cette étude et la liste de contrôle TMC-PT aideront à explorer plus à fond le changement de comportement à la pratique de la physiothérapie. L'observation selon laquelle les TMC ont été intégrées dans la pratique de la physiothérapie dans le cadre de cette étude démontre comment les physiothérapeutes peuvent jouer un rôle en modifiant le comportement, surtout en présence d'une LCNS.

Working with people to make changes: a behavioural change approach used in chronic low back pain rehabilitation.

PURPOSE: To describe the approach used by a physiotherapist who led a rehabilitation programme for injured members of the military with chronic low back pain designed to enhance self-efficacy and self-management skills. METHOD: This in-depth qualitative study used audio- and video-recorded data from interviews and field observations. Using an inductive analysis process, discussion of emerging themes led to a description of the physiotherapist's approach. RESULTS: The approach has three elements: developing a trusting relationship through building rapport, establishing a need in patients' minds to be actively engaged in their rehabilitation, and finding workable rehabilitation solutions that are most likely to be adopted by individual patients. This approach fits into current theories about health behaviour change (e.g., Transtheoretical Model of Change, Motivational Interviewing, Motivational Model of Patient Self-Management and Patient Self-Management) and elements of the therapeutic alliance. Using the therapeutic alliance (rapport) and behaviour change techniques, the physiotherapist focused on the perceived importance of a behaviour change (need) and then shifted to the patient's self-efficacy in the solutions phase. CONCLUSIONS: If we recognize that rehabilitation requires patients to adopt new behaviours, becoming aware of psychological techniques that enhance behaviour change could improve treatment outcomes.

Objet : Décrire l'approche suivie par un physiothérapeute qui a dirigé un programme de réadaptation pour militaires blessés atteints de lombalgie chronique. Le programme visait à améliorer les techniques d'autoefficacité et d'autoprise en charge. Méthode : Cette étude qualitative en profondeur a utilisé des données audio et vidéo enregistrées à la suite d'entrevues et des observations sur le terrain. Basée sur un processus d'analyse inductive, la discussion sur les thèmes émergents a abouti à une description de la démarche du physiothérapeute. Résultats : L'approche comporte trois éléments: établissement d'une relation de confiance par la création d'une complicité, établissement, dans l'esprit des patients, d'un besoin de participer activement à la réadaptation et découverte de solutions de réadaptation pratiques que chaque patient en particulier est le plus susceptible d'adopter. Cette approche correspond aux théories actuelles sur les changements de comportement en santé (p. ex., modèle transthéorique du changement, entrevues de motivation, modèle de motivation de l'autoprise en charge par les patients et autoprise en charge par les patients) et les éléments de l'alliance thérapeutique. En se basant sur l'alliance thérapeutique (complicité) et des techniques de modification du comportement, le physiothérapeute s'est concentré sur l'importance perçue d'un changement de comportement (besoin) et est passé ensuite à l'autoefficacité du patient au cours de la phase des solutions. Conclusions : Si nous reconnaissons que la réadaptation oblige les patients à adopter de nouveaux comportements, une sensibilisation aux techniques qui appuient les changements de comportement pourrait améliorer les résultats du traitement.

Insomnia in clients with chronic, work-related musculoskeletal pain in a work recovery rehabilitation program.

BACKGROUND: There is a high prevalence of sleep disturbance with people experiencing chronic pain. Although multi-disciplinary rehabilitation programs address many contributing factors for chronic pain, the impact of insomnia on clients is not often measured. OBJECTIVE: Two studies were used to: first explore the experience of insomnia in a group of clients with chronic pain and then, in a group enrolled in a six-week work recovery rehabilitation program, compare measures of sleep disturbance at entry and upon its completion. PARTICIPANTS: Sixteen clients participated in focus groups and 29 completed questionnaires; 46% were women and the average age was 43 years. They had a wide range of work-related musculoskeletal injuries and all had chronic pain. METHODS: First two, semi-structured focus group interviews explored sleep disturbance. Then a different set of participants completed three sleep questionnaires before and after completing a rehabilitation program. RESULTS: Focus group participants described sleep disturbance consistent with clinical insomnia and how it had a considerable impact on their lives. Completed questionnaires confirmed the presence of sleep disturbance at admission into a six-week rehabilitation program and at discharge, most measures were unchanged. CONCLUSIONS: Although chronic pain rehabilitation generally includes interdisciplinary approaches, specific attention to insomnia is not part of this chronic pain rehabilitation program and therefore it is not surprising that there was no appreciable change by the end of the program. However, because sleep disturbance is prevalent in the chronic pain population and in this sample, and has such a strong impact on the individual's daytime functioning, effective interventions directed at sleep restriction and stimulus control should complement chronic pain rehabilitation programs.

Client Education: Communicative Interaction between Physiotherapists and Clients with Subacute Low Back Pain in Private Practice.

PURPOSE: To explore, through focus-group interviews, client education provided by physiotherapists in private practice who treat injured workers with subacute low back pain (SA-LBP). METHODS: Six focus-group interviews were held in the fall of 2006 to explore treatment practices of physiotherapists for this population. Each of the 44 physiotherapists who volunteered attended one of six regional sessions. RESULTS: Three overarching themes emerged: the critical importance of education; education: a multidimensional concept; and the physiotherapist-client relationship. In this study, we found that education provides continuity by tying together the separate tasks occurring during one treatment session. Our participants said that time is of the essence in private practice and described how they provide education seamlessly, making this type of delivery efficient. CONCLUSIONS: Education is a highly valued aspect of practice for physiotherapists. Verbal, tactile, and visual information obtained from the client as assessment and treatment progress is explored, expanded, and contextualized in conversation with the client. In a communicative, interactive process, client fears, other contextual information, and physiotherapist information about procedures and techniques, exercises, and anatomy are collaboratively interrelated.