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Implementation of a behavioural medicine approach in physiotherapy: Determinants, clinical behaviours, patient outcomes and the implementation process
Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. (BeMe Health)ORCID iD: 0000-0002-4616-521X
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 [en]
behaviour change; behaviour medicine; determinants; implementation; musculoskeletal pain; physiotherapy; primary health care; process evaluation; sustainability
Keywords [sv]
beteendeförändring: beteendemedicin; determinanter; fysioterapi; implementering; muskuloskeletal smärta; primärvård; processutvärdering; vidmakthållande
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:mdh:diva-47243ISBN: 978-91-7485-460-2 (print)OAI: oai:DiVA.org:mdh-47243DiVA, id: diva2:1412923
Public defence
2020-05-15, Beta, Mälardalens högskola, Västerås, 13:15 (Swedish)
Opponent
Supervisors
Funder
AFA Insurance, 12169Available from: 2020-03-09 Created: 2020-03-09 Last updated: 2020-03-30Bibliographically approved
List of papers
1. The complexity of integrating a behavioral medicine approach into physiotherapy clinical practice
Open this publication in new window or tab >>The complexity of integrating a behavioral medicine approach into physiotherapy clinical practice
2019 (English)In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 35, no 12, p. 1182-1193Article in journal (Refereed) Published
Abstract [en]

Introduction and Aim: The implementation of a behavioral medicine (BM) approach in physiotherapy is challenging, and studies regarding the determinants are sparse. Thus, the aim of this study was to explore determinants of applying a BM approach in physiotherapy for patients with persistent pain across the micro-, meso-, and macro-levels. Methods: A qualitative multiple-case study design was used. Data were collected from four cases through semi-structured interviews with physiotherapists (PTs), patients, and managers; observations of video-recorded treatment sessions; and reviews of local directives and regulations. Data were analyzed with inductive content analysis and cross-case analysis, followed by mapping to the domains of determinants at the micro-, meso-, and macro-levels within the Implementation of Change Model. Results: Similar determinants were found across the cases. At the micro-level, these determinants concerned the PTs’ ambivalence toward a BM approach, a biomedical focus, embarrassment asking about psychosocial factors, BM knowledge, skills for applying the approach, and self-awareness. Others concerned the patients’ role expectations of the PT, patients as active or passive agents in the treatment process, patients’ focus on biomedical aspects, and confidence in the PT. At the meso-level, support from managers and peers, allocation of time, and expectations from the organization were identified as determinants. No determinants were identified at the macro-level. Conclusion: The complexity of integrating a BM approach into physiotherapy clinical practice arises from multiple determinants functioning as both facilitators and barriers. By selecting strategies to address these determinants, the implementation of a BM approach could be supported.

Keywords
Behavioral medicine,  physiotherapy,  clinical practice,  determinant,  facilitator,  barrier
National Category
Medical and Health Sciences Health Sciences
Research subject
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-41172 (URN)10.1080/09593985.2018.1476996 (DOI)000510124300005 ()29847287 (PubMedID)2-s2.0-85047962277 (Scopus ID)
Funder
AFA Insurance, 12169
Available from: 2018-10-15 Created: 2018-10-15 Last updated: 2020-03-19Bibliographically approved
2. Implementation of a behavioral medicine approach in physiotherapy: impact and sustainability
Open this publication in new window or tab >>Implementation of a behavioral medicine approach in physiotherapy: impact and sustainability
Show others...
(English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165Article in journal (Refereed) Epub ahead of print
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.

Keywords
Physiotherapy; clinical competence; evidencebased practice; musculoskeletal pain; primary health care; self-efficacy
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-47239 (URN)10.1080/09638288.2019.1596170 (DOI)30999779 (PubMedID)
Funder
AFA Insurance, 12169
Available from: 2020-03-09 Created: 2020-03-09 Last updated: 2020-03-12Bibliographically approved
3. Implementation of a behavioral medicine approach in physiotherapy: A process evaluation of facilitation methods
Open this publication in new window or tab >>Implementation of a behavioral medicine approach in physiotherapy: A process evaluation of facilitation methods
Show others...
2019 (English)In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, no 1, article id 94Article in journal (Refereed) Published
Abstract [en]

Background: In a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences. Methods: An explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used. Results: The physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking. Conclusions: The findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time. 

Place, publisher, year, edition, pages
BioMed Central Ltd., 2019
National Category
Physiotherapy
Identifiers
urn:nbn:se:mdh:diva-46027 (URN)10.1186/s13012-019-0942-y (DOI)000494477200001 ()31684977 (PubMedID)2-s2.0-85074548087 (Scopus ID)
Available from: 2019-11-14 Created: 2019-11-14 Last updated: 2020-03-19Bibliographically approved

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