'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 AdherenceThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Can Chiropr Assoc. 2017 (Dec); 61 (3): 219–230 ~ FULL TEXT
OPEN ACCESS Peter Stilwell, BKin, DC, MSc, Katherine Harman, PT, PhD
Dalhousie University
5869 University Ave.,
PO Box 15000
Halifax, NS, B3H 4R2AIM: 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 chronic low back pain (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.
KEYWORDS: adherence; chiropractic; exercise; low back pain; qualitative
From the FULL TEXT Article:
Introduction
Clinical practice guidelines now recognize that most patients with acute low back pain (LBP) will improve with time, regardless of the treatment they receive. [1] However, patients often desire immediate symptomatic relief, so passive non-pharmacological treatments (e.g., spinal manipulation) are an option as they can provide modest improvements in pain and function with mild side effects. [1, 2] Yet, the positive effects of passive therapies typically are transient, so providing patients with reassurance combined with active self-management strategies (e.g., exercise) is recommended. [3–5] Further, detecting and managing psychosocial factors for chronicity (e.g., movement fear-avoidance) is recommended in LBP guidelines across the world. [6] For patients who have transitioned to chronic low back pain (CLBP), guidelines place a greater emphasis on a biopsychosocial approach, including education and self-management through exercise. [5, 7]
In Canada, 96.5% of chiropractors have reported using exercise as a part of their treatment plans. [8] Patient exercise adherence is associated with favorable clinical outcomes [9]; yet, available data on patients with CLBP suggests they have poor adherence. [10] Despite chiropractors regularly prescribing exercise and wanting to tackle the inactivity epidemic [11], little research has provided insight as to how chiropractors attempt to facilitate prescribed exercise adherence. [12] In fact, when looking broadly at the non-specific chronic low back pain (NS-CLBP) and exercise adherence literature, few studies have explored the perspectives of exercise-prescribing clinicians (e.g, medical doctors, physiotherapists) or their patients with NS-CLBP. [13–16]
A systematic review by Slade et al. [13] reportedlack of time,
diagnostic uncertainty, and
fear of movement and pain aggravation as some of the most consistently cited patient perceived barriers to prescribed exercise adherence.In contrast, patient perceived facilitators to prescribed exercise adherence included:
good clinician-patient communication,
detailed exercise instruction,
demonstration, and
feedback, as well as follow-up and reassurance provided by the prescribing clinicians. [13]Clearly there is a massive challenge; exercise is a frequently recommended intervention in clinical practice guidelines for CLBP and chiropractors commonly prescribe it; yet, patient adherence is low which impacts outcomes. Rarely do studies incorporate both the patients’ and the exercise-prescribing clinicians’ experiences and beliefs regarding the issue of exercise adherence. [15] To inform research and the development of strategies to improve exercise engagement in the chiropractic context, this study aimed to explore chiropractors’ and chiropractic patients’ experiences and beliefs related to exercise adherence.
Methods
Study design
We used a focused ethnographic design [17, 18] involving individual semi-structured interviews. Focused ethnographies are conducted by researcher(s) who possess background knowledge in the area of interest. They are problem-focused and context-specific, focus on a specific group’s shared experiences, limited to a small number of participants, conducted in a short time frame, conducted to help explain the complex nature of the specific shared experiences and issues within the targeted group(s), and are often used to help enhance healthcare services and practices. [17, 18] Further, focused ethnographies do not require fieldwork/participant observation; a feature that makes a focused ethnography significantly different than a traditional ethnography. [18]
The semi-structured interview guides reflected expectancy theory, as they attempted to unravel how past experiences helped shape current beliefs, preferences, motivation, and ultimately, behavior. [19] In its basic form, expectancy theory suggests that individuals will be motivated to engage in a specific behaviour if they believe that their efforts will result in a positive performance which will result in an outcome that is tied to a desirable reward. [19] In an attempt to obtain unprimed information from the participants, there was a deceptive component to the study design. The participants did not know that the authors were specifically studying prescribed exercise adherence. Instead, participants were advised (in the consent forms and verbally) that the interviews would be broad, exploring chiropractic treatment preferences in adults with CLBP. The initial sample size estimate of six chiropractor participants and six patient participants was predetermined with the anticipation of reaching saturation. [20]
This study was positioned in the post-positivist paradigm that advocates a structured scientific approach. The approach taken by the researchers appreciated that each study participant had their own unique perspective and experiences; however, there were attempts at illuminating/ approximating a single reality20 and to “see the whole picture” [21] p.18. The goal was not to obtain pure objectivity, but to strive towards objectivity by using triangulation as well as rigorous and transparent methods, and therefore this study was conducted and reported considering the consolidated criteria for reporting qualitative research (COREQ). [22] Ethics approval was obtained from the Dalhousie University Health Sciences Research Ethics Board.
Recruitment and eligibility criteriaPatient participants: Posters were placed on local community bulletin boards and distributed to Nova Scotian chiropractic offices to recruit adults (18–65 years old) with CLBP (greater than three months) currently receiving chiropractic care. Interested participants who emailed the first author were administered a patient participant screening questionnaire that asked details regarding their CLBP and what type of treatments they had received in the last six months. Only those who had received exercise instruction or advice were eligible to participate. In an attempt to recruit patients with NS-CLBP, they were excluded if they had significant pathologies or diagnoses that are known to contribute to LBP. This included pregnancy, infection, tumor, fracture, or significant structural changes with radicular signs/symptoms.
Chiropractor participants: Chiropractors were eligible if they were licensed and practicing in the Halifax metro area, Nova Scotia, Canada. Eligible chiropractors’ email addresses were obtained through the Nova Scotia College of Chiropractors website. If a personal email address could not be obtained, their clinic was contacted via email or phone. Interested participants were administered a chiropractic participant screening questionnaire through email that asked what types of treatments they offer patients with NS-CLBP. Only chiropractors reporting that they very often prescribe home exercise for their patients were included in the study.
Data collectionQuestionnaires and demographics: To contextualize the sample, participant characteristics were gathered. This included the administration of questionnaires to the patient participants; the Keele STarT Back tool that measures risk of a poor outcome/chronicity [23] and the Revised Oswestry Disability Index that measures level of disability/impairment. [24] Patient participants’ age, sex, and duration of CLBP, and chiropractor participants’ sex and years in practice were also collected.
Interviews: Four pilot interviews were conducted with two practicing physiotherapists and two Dalhousie University students who had previously been prescribed exercise for CLBP. The pilot interviews were used to help refine the flow and comprehension of the interview questions, and to confirm the ability to conduct interviews with deception (not knowing that the focus was on exercise). The pilot interviews were not included in the analysis. After the patient and chiropractor participants were recruited and consented to participate, the first author (male chiropractor and graduate student with qualitative research training) led one-to-one audio-recorded semi-structured interviews in a private room at Dalhousie University. The interviews were 50–90 minutes and the second author (female physiotherapist and Associate Professor) attended each interview to contextualize the data and to ask for clarifications as needed. The two years leading up to the study, the first author (interviewer) was involved in various chiropractic-related activities in Nova Scotia. This resulted in him being in contact with most of the chiropractors in Nova Scotia. This provided him with exposure to insider knowledge, specifically the beliefs and practice patterns of Nova Scotian chiropractors. Although this exposure was limited, it appeared to facilitate trust and a candid conversation during the audio-recorded interviews with the chiropractors. He did not have any contact with any of the patient participants prior to conducting the study. The second author did not have any contact/exposure to any of the participants prior to the study.
Appendix A During the interviews, the participants were given the opportunity to provide a rationale regarding their past and current behaviors and to discuss in-depth the issues that they believed were important regarding CLBP management. With this approach, information was obtained in an unrehearsed, non-contrived manner. Although the focus of the study was to understand perspectives regarding prescribed exercise adherence, had the interview questions been strictly on this topic, the participants may have felt judged somehow and might have obscured their true treatment beliefs and priorities. Therefore, the interviewer followed the lead of the participants and molded the interview to elicit significant exercise-related information while also exploring other areas that were important to the participants regarding CLBP care. Sample interview guide questions are found in Appendix A. Each author took field notes during the interviews. The interviews were transcribed verbatim and the participants were provided with a copy of their transcripts through email and given the opportunity to provide clarifications or feedback.
Data analysis
The transcriptions were imported into NVivo™ software for analysis (Version 10 © QSR International Pty Ltd., Victoria, Australia). A systematic approach for analyzing ethnographic data developed by Roper and Shapira was used. [25] The authors independently coded the data, triangulating the patient and chiropractor participant interviews to identify overarching explanations regarding the barriers and facilitators to prescribed exercise adherence. The authors had regular meetings throughout the data analysis steps to discuss field notes, compare coding for each transcript, and to mutually develop themes. The determination of data saturation was an iterative process; the authors regularly discussed recurrent and new themes before conducting further interviews. To increase the validity of the generated themes, study participants were also e-mailed a summary of the preliminary themes and given the option to express disagreement and provide clarifications.
Results
Participant characteristics
Figure 1 Three female patients (Revised Oswestry: moderate disability) and three male patients (Revised Oswestry: minimal disability) participated in the study. The six patient participants had a mean age of 34.5 years (SD 14.4) and a mean duration of low back pain of 10.0 years (SD 8.3). All were categorized as low risk for poor outcome/ chronicity based on the STarT Back tool. Further, most of the participants stated that they had seen several different practitioners for their LBP; some had consulted with multiple chiropractors that had prescribed exercise. The six chiropractor participants had a mean of 8.3 years in practice (SD 7.3); one was female and five were males. Figure 1 illustrates the flow of the participants into the study.
Themes
Table 1
Table 2A
Table 2B Of the twelve participants, no one requested transcript alterations or expressed disagreement after receiving an email revealing the deceptive component of the study and a summary of the preliminary themes. The projected sample size was not altered and saturation was deemed to be reached as consistent codes and themes continued to emerge from the patient and chiropractor participants’ narratives. After the twelve interviews, it was decided that further interviews would not likely generate any new significant themes and there were no areas requiring further probing or exploration based on the aim of the study. Four main themes were generated from the data:
1. diagnostic and treatment beliefs motivating behavior,
2. passive-active treatment balance,
3. the therapeutic alliance and patient-centered care, and
4. exercise delivery.There was significant conceptual overlap among the themes, with many quotes fitting into several themes. Each theme contains dimensions along a continuum, ranging from barriers to facilitators to prescribed exercise adherence. Further interviews may have revealed deviating experiences and beliefs, or sub-themes. However, it was anticipated that these findings would have fit within the themes already identified or expanded beyond the aim of the study. Table 1 summarizes the themes with corresponding barriers and facilitators identified. Table 2 provides supporting quotes for each theme.
Discussion
The results of this study suggest that in this sample, exercise adherence is not simply the patients lacking motivation or not having enough time in the day. Instead, the results suggest that adherence to prescribed exercise is the product of chiropractors’ and patients’ experiences and beliefs, the development of their clinical relationship, and the way exercise is prescribed and monitored in parallel with other treatment modalities. Most of the findings are congruent with existing qualitative literature exploring the barriers and facilitators to exercise adherence in patients with NS-CLBP, despite the majority of these studies being non-chiropractic focused and conducted outside North America. [13–16] This includes the findings that exercise adherence may be facilitated with easy exercise delivery changes made by exercise-prescribing clinicians, including: prescribing simple exercises, limiting the number of exercises prescribed, demonstrating the exercises, providing feedback, and scheduling follow-up appointments to review the exercises and monitor progress. While most of the barriers and facilitators to prescribed exercise adherence reported in this study appear to be modifiable, effectively explaining pain and the longterm benefits of exercise appears to be quite challenging, as will now be discussed.
Our most complex theme, diagnostic and treatment beliefs motivating behaviors, has also been clearly described in the literature outside the chiropractic context. Slade et al. [26] explored how Australian physiotherapists prescribe exercise for patients with NS-CLBP. The authors described how the physiotherapists sought out diagnostic certainty as a means to improve their credibility and to get patients to adhere to an exercise plan. When outcomes were not what they or the patient expected, frustration and blaming occurred and some physiotherapists defaulted to inaccurate nocebo-laden structural explanations of pain or feigned a certain diagnosis.26 Further, another study by Slade et al. [27] found that patients with NS-CLBP wanted their healthcare providers to explain their pathology and management (exercise) to reduce uncertainty. While these findings are congruent with our results, the patient participants in our study were less focused on finding the cause of their LBP than was expected based on existing literature from the patient perspective. [13, 16] There are many possible explanations for this. One possibility is that the patient participants’ chiropractors had explained NS-CLBP in a way that reduced diagnostic uncertainty. There is some evidence that chiropractors have even more of a biomedical focus than physiotherapists. [28] It is possible that chiropractors’ patho-anatomical explanations (regardless of their accuracy) reduced diagnostic uncertainty. If so, this creates a dilemma as providing detailed and specific patho-anatomical explanations for most cases of LBP is not consistent with best practice. [29] Interestingly, our patient participants were all categorized as low risk on the STarT Back tool, yet many described debilitating flare-ups and various psychosocial risk factors for chronicity (e.g., fear-avoidance, belief that pain equals damage). Further, most of the patient participants seemed to welcome and embrace patho-anatomical explanations for their pain.
While in-depth patho-anatomic explanations may facilitate passive care buy-in, this type of education may create rather than reduce psychosocial factors for chronicity. Darlow and colleagues reported that clinicians’ biomedical- rooted explanations can have a lasting negative impact, with patients often viewing their backs as fragile and needing to be protected. [30] These beliefs might result in hyper-vigilance and guilt surrounding poor exercise adherence. [30] Further, we suspect that this may drive a quest for a fix and passive care dependence. While some clinical practice guidelines explicitly state education that increases the perceived threat or fear associated with LBP should be avoided [29], little guidance is provided beyond this. The concept of unintentional negative effects (nocebo effects) is rarely discussed in the context of exercise prescription or chiropractic in general. [31] Therefore, it was not surprising when many of the chiropractors in our study (and chiropractors described by patient participants) wanted to fix the patient with tissue-based approaches and defaulted to patho-anatomical explanations of persistent pain. In many cases, this appeared to contribute to a poor passive-active treatment balance – negatively impacting exercise priority and adherence. Further, it appeared that some clinicians’ fear-avoidant beliefs might have transferred to their patients.
Helping clinicians and patients better understand the science of pain, such as the hurt versus harm concept, may improve outcomes. Pain neuroscience education (PNE) [32, 33] is being adopted by professions outside of chiropractic as it can reduce diagnostic uncertainty, reduce perceived threat, and open the door to exercise prescription with greater adherence. [34] Further, PNE requires the building of a strong therapeutic alliance as various evidence-based explanations and techniques are used to change a patient’s beliefs and behaviors. [35] Similar to other clinicians using PNE, chiropractors may be able to better help their patients by integrating PNE into their CLBP management, including exercise prescription. Further, behavior change theory has been evolving [36] and a taxonomy of behavior change techniques (BCTs) has recently been put forward, with each technique having varying levels of supporting evidence in different contexts. [37] The use and description of exercise-based BCTs has also become the focus of clinical research [38, 39] Interestingly, most of the chiropractors in our study, unknowingly, described the use of specific exercise-based BCTs to help patients adhere to prescribed exercise.
Referring to a recently published BCT checklist used in the context of exercise prescription [38], the chiropractor participants in this study clearly described the use of: cognitive restructuring, graded exposure, providing information on consequences, setting graded exercises, booster sessions, prompting review of behavior exercise goals, and providing feedback on exercise performance. This suggests that chiropractors who prescribe exercise may benefit from behavior change training for non-psychologists – where they are taught how to intentionally and appropriately use evidence-based BCTs. PNE inherently involves BCTs, so they can be used in conjunction. Training in these areas could help chiropractors better understand pain, explore their own beliefs about pain, and ultimately deliver more accurate pain information alongside exercise prescription informed by behavior change theory. Still, more research on exercise adherence is needed that applies appropriate use of theory in the study design. [40] This will provide further evidence as to what BCTs may or may not be optimal in given contexts.
Limitations
One limitation of this study was the little variability in patient participants’ levels of disability and risk for chronicity/ poor outcome based on the administered questionnaires. All of the patient participants were low risk based on the STarT Back and were categorized as having minimal to moderate disability based on the Revised Oswestry. This limits the generalizability and transferability of the finding to patients scoring higher on the STarT Back and Revised Oswestry.
Another limitation is that the study only included chiropractors that frequently prescribe exercise. This may have produced a selection bias, unintentionally targeting those who are more rehabilitation focused, refining their exercise delivery. Therefore, the study may have included chiropractors that were more likely to identify positive exercise prescription experiences and facilitators rather than barriers. Additionally, this study only included one female chiropractor, potentially limiting the transferability of the findings. However, the interviews did provide a window to explore the practices of other chiropractors through patient and chiropractor participants’ second-hand reports. Still, the generalizability and transferability of the finding must be considered with caution.
Conclusion
Identified barriers and facilitators to prescribed exercise adherence in chiropractic patients with NS-CLBP revolved around four primary themes:1. diagnostic and treatment beliefs motivating behavior,
2. passive-active treatment balance,
3. the therapeutic alliance and patient-centered care, and
4. exercise delivery.Most of the barriers and facilitators to prescribed exercise adherence appeared to be modifiable, highlighting the possibility to strengthen facilitators and break down barriers. Exercise adherence may be facilitated in patients with CLBP with simple exercise delivery changes made by chiropractors. This includes making exercise simple, limiting the number of exercises prescribed, demonstrating the exercises, providing feedback, and scheduling follow-up appointments to review the exercises and monitor progress.
However, changing chiropractors’ and patients’ diagnostic and treatment beliefs that are barriers to exercise adherence appears challenging. Further, addressing patients’ fears while balancing passive and active care is not an easy task. In addition to BCT training, chiropractors may benefit from pain education training, such as PNE. Research is needed testing the use of PNE and BCTs in the context of chiropractic and exercise prescription. Combined PNE and BCT training may help chiropractors keep up to date with the current understanding of pain, explore their own beliefs about pain, and ultimately deliver more accurate pain information alongside more effective exercise prescription.
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