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Implementation of a behavioral medicine approach in physiotherapy: impact and sustainability
Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. (BEME)ORCID iD: 0000-0002-4616-521X
Dalarna university, Sweden.
Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. (BEME)ORCID iD: 0000-0002-4537-030X
Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. (CHIP)ORCID iD: 0000-0001-5904-1390
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2020 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 42, no 24, p. 3467-3474Article in journal (Refereed) Published
Abstract [en]

Purpose: To explore the effects on and sustainability of physiotherapists’ clinical behavior when using facilitation to support the implementation of a behavioral medicine approach in primary health care for patients with persistent musculoskeletal pain. Methods: A quasi-experimental pre-/post-test trial was conducted. Fifteen physiotherapists were included in the experimental group, and nine in the control group. Based on social cognitive theory and the Promoting Action on Research Implementation in Health Services framework, facilitation with multifaceted implementation methods was used during a six-month period. Clinical behaviors were investigated with a study-specific questionnaire, structured observations, self-reports and patient records. Descriptive and non-parametric statistical methods were used for analyzing differences over time and effect size. Results: A sustained increase in self-efficacy for applying the behavioral medicine approach was found. Clinical actions and verbal expressions changed significantly, and the effect size was large; however, changes were not sustained at follow-ups. The behavioral changes were mainly related to the goal setting, self-monitoring and functional behavioral analysis components. No changes in clinical behavior were found in the control group. Conclusion: Tailored multifaceted facilitation can support the implementation of a behavioral medicine approach in physiotherapy in primary health care, but more comprehensive actions targeting sustainability are needed.

Place, publisher, year, edition, pages
Taylor & Francis, 2020. Vol. 42, no 24, p. 3467-3474
Keywords [en]
Physiotherapy; clinical competence; evidencebased practice; musculoskeletal pain; primary health care; self-efficacy
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:mdh:diva-47239DOI: 10.1080/09638288.2019.1596170ISI: 000465891500001PubMedID: 30999779Scopus ID: 2-s2.0-85064690361OAI: oai:DiVA.org:mdh-47239DiVA, id: diva2:1412875
Funder
AFA Insurance, 12169Available from: 2020-03-09 Created: 2020-03-09 Last updated: 2023-03-08Bibliographically approved
In thesis
1. Implementation of a behavioural medicine approach in physiotherapy: Determinants, clinical behaviours, patient outcomes and the implementation process
Open this publication in new window or tab >>Implementation of a behavioural medicine approach in physiotherapy: Determinants, clinical behaviours, patient outcomes and the implementation process
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Current research shows that a behavioural medicine approach in physiotherapy increases the ability to participate in daily activities and decreases sick leave in patients with persistent musculoskeletal pain. A behavioural medicine approach means that the physiotherapist systematically considers biopsychosocial factors of importance for the patient's activity and participation. Active patient involvement is central, and behaviour change techniques are used. One in seven of the patients in primary health care suffers from persistent musculoskeletal pain. Therefore, primary health care needs to implement a behavioural medicine approach in physiotherapy. However, the implementation of new methods is challenging. It is important to increase the knowledge about how to implement a behavioural medicine approach into physiotherapy clinical practice to make recommended treatment available to more patients with persistent musculoskeletal pain. The overall aim of this thesis was therefore to develop and evaluate methods for supporting the implementation of a behavioural medicine approach in physiotherapy for patients with persistent musculoskeletal pain.

In study I, determinants of using a behavioural medicine approach in physiotherapy were identified using a qualitative multiple-case study design. An implementation intervention was developed based on these determinants and on theoretical assumptions regarding behaviour change and learning. The implementation intervention was tested in a quasi-experimental trial for six months and evaluated by focusing on physiotherapists' clinical behaviour changes in study II and the effects on patients' health in study III. In study IV, a process evaluation was conducted with a mixed methods design to explain the impact mechanisms of the implementation intervention. Altogether, 28 physiotherapists, 159 patients and three managers participated in the project.

The determinants identified in study I were associated with the physiotherapist, the patient and the workplace. An implementation intervention was developed based on these determinants and on assumptions in the social cognitive theory, the constructivist learning theory, and the Promoting Action on Research Implementation in Health Services (PARIHS) framework. The implementation intervention consisted of outreach visits, peer coaching, educational materials, individual goalsetting, video feedback, self-monitoring in a diary, the stimulation of manager support and an information leaflet for patients. Immediately after the implementation period, the physiotherapists significantly changed their clinical behaviour, but these changes were not sustained. The patients treated by these physiotherapists achieved no further health improvement compared to a control group. Outreach visits, peer coaching, educational material and individual goalsetting were perceived by the physiotherapists as the most useful methods and supported the implementation through multiple learning methods, action planning, processing experiences, synergy effects with self-efficacy beliefs, and extrinsic motivation.

In conclusion, this thesis contributes to an increased understanding of the complexity regarding what affects the implementation of a behavioural medicine approach in physiotherapy and the promising methods and their impact mechanisms that support this implementation. A distinction between achieving clinical behaviour changes and sustaining these changes is highlighted. This implies that an implementation intervention needs to support both factors in order for the implementation of a behavioural medicine approach to benefit the patients. The thesis also illustrates how combined theoretical perspectives can inform an implementation intervention in physiotherapy in a useful way.

Abstract [sv]

Forskning visar att ett beteendemedicinskt arbetssätt i fysioterapi ökar aktivitetsförmåga och minskar sjukskrivning hos patienter med långvarig smärta ifrån muskler och leder. Ett beteendemedicinskt arbetssätt innebär att fysioterapeuten systematiskt beaktar biopsykosociala faktorer av betydelse för patientens aktivitets- och delaktighetsförmåga. Aktiv patientmedverkan är centralt och beteendeförändringstekniker används för att stödja patientens beteendeförändring. Var sjunde patient på en vårdcentral söker för långvarig smärta ifrån muskler och leder. Primärvården behöver därför implementera det beteendemedicinska arbetssättet i fysioterapi. Dock är implementering av nya arbetssätt utmanande och det finns idag sparsamt med studier som handlar om effektiv implementering av ett beteendemedicinskt arbetssätt i fysioterapi. Det är därmed viktigt att öka kunskapen om hur man kan implementera ett beteendemedicinskt arbetssätt i fysioterapi, för att den rekommenderade behandlingen ska komma fler patienter tillgodo. Det övergripande syftet med avhandlingen var därför att utveckla och utvärdera metoder för att stödja implementering av ett beteendemedicinskt arbetssätt i fysioterapi för patienter med långvarig smärta ifrån muskler och leder.

I studie I användes en kvalitativ flerfalldesign för att identifiera determinanter för användandet av ett beteendemedicinskt arbetssätt i fysioterapi. Ett implementeringsstöd utvecklades baserat på dessa determinanter, men också baserat på teoretiska antaganden för beteendeförändring och lärande. Implementeringsstödet testades i en kvasi-experimentell studie under sex månader och utvärderades med fokus på fysioterapeuters kliniska arbetssätt i studie II och effekter på patienters hälsa i studie III. I studie IV användes en mixad metod för processutvärdering av implementeringsstödet i syfte att förklara verkningsmekanismer. Sammanlagt deltog 28 fysioterapeuter, 159 patienter och tre chefer i projektet.

Resultatet identifierade determinanter kopplade till fysioterapeuten, patienten och arbetsplatsen. Ett implementeringsstöd utvecklades baserat på dessa determinanter och antaganden från social kognitiv teori, konstruktivistiskt lärande och the Promoting Action on Research Implementation in Health Services (PARIHS)-ramverket. Implementeringsstödet bestod av handledning i klinik, kollegialt stöd, utbildningsmaterial, individuell målsättning, återkoppling på videoinspelade patientmöten, självmonitorering i dagbok, stimulering av chefsstöd och informationsblad för patienter. Fysioterapeuterna förändrade sitt arbetssätt omedelbart efter implementeringsperioden, men förändringarna vidmakthölls inte över tid. Patienterna som behandlades av dessa fysioterapeuter fick ingen ytterligare förbättring av sin hälsa jämfört med en kontrollgrupp. Fysioterapeuterna upplevde att handledningen i klinik, det kollegiala lärande, utbildningsmaterialet och den individuella målsättningen gav det mest betydelsefulla implementeringsstödet. En blandning av lärmetoder, en handlingsplan, bearbetning av erfarenheter, synergieffekter med tilltron till att använda det beteendemedicinska arbetssättet och yttre motivation identifierades som verkningsmekanismer för fysioterapeuternas förändrade arbetssätt.

Denna avhandling bidrar till ökad förståelse för komplexiteten i vad som påverkar implementering av ett beteendemedicinskt arbetssätt i fysioterapi, samt identifiering av lovande metoder och dess verkningsmekanismer för att stödja implementeringen. Vidare belyses att olika mekanismer styr initiering och vidmakthållande av beteendeförändring vid implementering. Det är därför viktigt att implementeringsstödet fokuserar på båda faktorer för att det beteendemedicinska arbetssättet ska komma patienten tillgodo. Avhandlingen illustrerar också hur teoretiska perspektiv kan kombineras för att gynna implementering i fysioterapi.

Place, publisher, year, edition, pages
Västerås: Mälardalen University, 2020
Series
Mälardalen University Press Dissertations, ISSN 1651-4238 ; 310
Keywords
behaviour change; behaviour medicine; determinants; implementation; musculoskeletal pain; physiotherapy; primary health care; process evaluation; sustainability, beteendeförändring: beteendemedicin; determinanter; fysioterapi; implementering; muskuloskeletal smärta; primärvård; processutvärdering; vidmakthållande
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-47243 (URN)978-91-7485-460-2 (ISBN)
Public defence
2020-05-15, Delta/Digitalt, Mälardalens högskola, Västerås, 13:15 (Swedish)
Opponent
Supervisors
Funder
AFA Insurance, 12169
Available from: 2020-03-09 Created: 2020-03-09 Last updated: 2020-04-08Bibliographically approved

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Fritz, JohannaSöderlund, AnneAlmqvist, LenaSandborgh, Maria

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