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Att leva med en kropp som värker: samtal med fysioterapeuten
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
2014 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and aim: Physiotherapists in primary care meet, assess and treat patients with long-standing benign musculoskeletal pain. As a clinical condition, long-standing pain is common but nonetheless it is quite complex. The aim of this thesis has been, from a bodily existential perspective, to investigate and conceptualise the experience of living with longstanding benign musculoskeletal pain, and from there, to work out a method for conversation and assessment within non-specialised physiotherapy.

Methods: Our first study was an interview study where we applied a phenomenological approach and investigated the ways individuals suffering from long-standing pain experienced their body and their illness. Four aspects of body experience were described, and based on these aspects, four typologies of attitudes to pain were distinguished. In the second study, we made two group interviews with six physiotherapists about their experiences of using, in their clinical work, questions from the interview guide in study I that had given particularly rich responses. Transcripts were analysed using phenomenography. In the third study, patients’ verbal responses to the key questions, directed to them by physiotherapists in clinical situations, were investigated, and the four aspects of body experience from study I formed the concepts of a deductive analysis. In study IV, finally, the key questions and typologies were tried by a larger group (31), and their experiences and the possible applicability of the method were studied by qualitative content analysis combined with the counting of codes.

Results: We created four typologies of attitudes to long-standing pain: “Surrendering to one’s fate”, “Accepting by an active process of change”, “Balancing between hope and resignation” and “Rejecting the body”. These typologies, in turn, were based on four aspects of body experience: “The body as an aspect of identity”. “Body reliance”, “Body awareness”, and “Ways of understanding pain”. In study II, by the aid of key questions,  patient and physiotherapist managed to have a conversation on bodily existential matters. The physiotherapist learnt to know the patient as a person, a process appeared to be initiated in the patient, and their relation changed. The patient was willing to talk about her body in pain, and had the words to do this. In study III, the key questions opened ways to reflections on body, existence, and biography. The four aspects of body experience were central to the patients’ descriptions. In study IV, the participating physiotherapists reported by large positive experiences from applying key questions and typologies. The patients reflected, emotions were evoked, and the relation and the communication often improved. The typologies helped in giving a comprehensive perspective of the patient’s problem, and to grasp where in the process of rehabilitation the patient was to be found.

Conclusions: The method, seven key questions combined with the tentative frame of interpretation of the answers, seemed to be easily applied by interested physiotherapists in non-specialised practice. The application of the method addresses the need of developing the professional role of the physiotherapist. The challenge is to face the whole person, who is her lived body as well as her identity crisis, carried by emotions such as grief and anger. This may inspire the use of the full potential of the physiotherapist’s professional role in the clinical encounter.

Abstract [sv]

Bakgrund och syfte: Fysioterapeuter i primärvården möter, bedömer och behandlar patienter med långvarig benign muskuloskeletal smärta. Tillståndet är vanligt och men likafullt komplext. Syftet med detta avhandlingsarbete har varit att i ett kroppsligt existentiellt perspektiv utforska och begreppsliggöra upplevelsen av att leva med långvarig benign muskuloskeletal smärta samt att utifrån detta utveckla en metod för samtal och bedömning inom icke specialiserad fysioterapi.

Metoder: Arbete I var en intervjustudie med fenomenologisk ansats där vi undersökte hur individer med långvarig smärta upplevde sin kropp och sina besvär. Fyra aspekter av kroppsupplevelsen beskrevs och ur dessa urskildes fyra klart åtskilda typologier av förhållningssätt. I arbete II gjorde vi två gruppintervjuer med sex fysioterapeuter om deras erfarenheter av att i kliniskt arbete använda frågor – nyckelfrågor - ur frågeguiden i arbete I som givit särskilt rika svar. Utskrifterna av gruppintervjuerna analyserades med fenomenografisk ansats. I arbete III undersöktes patienters svar på nyckelfrågorna, ställda av fysioterapeuter under kliniskt arbete, och de fyra aspekterna av kroppsupplevelse från arbete I utgjorde begrepp för en deduktiv analys. I arbete IV slutligen prövades nyckelfrågorna och  typologierna av en större grupp (31) fysioterapeuter i primärvården och deras erfarenheter och den möjliga användbarheten av metoden studerades. En kvalitativ innehållsanalys med beräkning av koder användes.

Resultat: Vi skapade fyra typologier av förhållningssätt till långvarig smärta: Acceptera sitt öde, acceptera genom aktiv förändring, befinna sig mellan acceptans och avståndstagande eller ta avstånd från sin värkande kropp. Dessa typologier byggdes upp av fyra aspekter av kroppsupplevelse: Kroppen som en aspekt av identiteten, kroppstillit, kroppsmedvetenhet samt förståelse av sin smärta. I arbete II visade det sig möjligt att tillsamman patient och fysioterapeut, med hjälp av nyckelfrågorna, föra ett kroppsligt existentiellt samtal. I samtalen lärde fysioterapeuten känna patienten som person, det föreföll som att en process inom patienten satte igång, samt att deras relation förändrades. Patienten var villig att samtala om sin värkande kropp och hade ord för detta. I studie III banade nyckelfrågorna väg för reflektioner om kropp, existens och biografi. De fyra aspekterna av kroppsupplevelse hade en central plats i patienternas beskrivningar. I arbete IV beskrev de deltagande sjukgymnasterna överlag positiva erfarenheter av att använda nyckelfrågor och typologier. Patienterna reflekterade, känslor väcktes och relationen och kommunikationen förbättrades ofta. Typologierna hjälpte till att få ett helhetsperspektiv på patientens problematik och att förstå var patienten befann sig i rehabiliteringsprocessen, vilket kunde vara värdefull vid bedömning och val av behandling.

Konklusion: Metoden, sju nyckelfrågor tillsammans med den erbjudna möjliga referensramen för tolkning av svaren (de fyra typologierna), förefaller lätt att ta till sig för intresserade fysioterapeuter i icke specialiserad verksamhet.Användandet av metoden belyser vikten av en utvidgning av fysioterapeutrollen. Utmaningen är att möta hela människan, som är sin levda kropp såväl som sin identitetskris buren av känslor som sorg och ilska. Detta kan sporra till att fullt ut utnyttja de möjligheter i mötet med patienten som den fysioterapeutiska yrkesrollen omfattar.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. , 93 plus en bilaga p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1401
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-106748DOI: 10.3384/diss.diva-106748ISBN: 978-91-7519-363-2 (print)OAI: oai:DiVA.org:liu-106748DiVA: diva2:718409
Public defence
2014-06-02, Aulan, Hälsans Hus (ingång 16), Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-05-21 Created: 2014-05-21 Last updated: 2014-06-16Bibliographically approved
List of papers
1. Living with a body in pain – between acceptance and denial
Open this publication in new window or tab >>Living with a body in pain – between acceptance and denial
2007 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 21, no 3, 291-296 p.Article in journal (Refereed) Published
Abstract [en]

The aetiology of nonspecific musculoskeletal pain is considered to be multi-factorial. Long-standing pain not only has a negative impact on the individual's general health but also changes the individual's experience of him/her self and his/her world. The aim of this study was to describe how individuals with long-standing musculoskeletal pain, in a bodily existential perspective, relate to their aching body. Semi-structured interviews with 20 patients were analysed using mainly a phenomenological-hermeneutic method. From the analysis, four main categories reflect the meaning contents of the interviews: the body as an aspect of identity; body reliance; body awareness; ways of understanding pain. From these categories, four distinct typologies were inferred: surrendering to ones fate; accepting by an active process of change; balancing between hope and resignation; rejecting the body. The result indicates that patients with long-standing pain are to be found along a spectrum from accepting to rejecting the aching body. Body awareness and body reliance seem to have importance in the process of acceptance of the body as well as life situation as a whole, which we regard as interesting hypotheses for further inquiry.

Place, publisher, year, edition, pages
John Wiley & Sons, 2007
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-106745 (URN)10.1111/j.1471-6712.2007.00475.x (DOI)17727540 (PubMedID)
Available from: 2014-05-21 Created: 2014-05-21 Last updated: 2017-12-05Bibliographically approved
2. We got the whole story all at once: physiotherapists use of key questions when meeting patients with long-standing pain
Open this publication in new window or tab >>We got the whole story all at once: physiotherapists use of key questions when meeting patients with long-standing pain
2010 (English)In: SCANDINAVIAN JOURNAL OF CARING SCIENCES, ISSN 0283-9318, Vol. 24, no 2, 281-289 p.Article in journal (Refereed) Published
Abstract [en]

Long-standing musculoskeletal pain has many dimensions. Physiotherapy lacks a tested method of dialogue with which physiotherapists and patients can together explore pain in all its complexity. The present aim was to find out how physiotherapists experienced the influence of systematically prepared key questioning on their relation to, and understanding of, patients with long-standing pain. A group of six physiotherapists with long experience of pain rehabilitation used such questions in their encounters with their patients. Two periods of work with the questions were followed by discussions in which the physiotherapists shared their experience in a joint focus group. Verbatim transcripts of the discussions constitute the data of the study. A phenomenographic method was used for the analysis. The responses to the key questions gave the physiotherapists an insight into the patient as a person. The questions started a process of change in the patient, and changed the physiotherapists relation to her or him. The patient expressed feelings and experience, and this also seemed to encourage a change in chosen coping strategies. This new content of the interaction challenged the physiotherapists role, thus raising questions about her professional mandate.

Place, publisher, year, edition, pages
Blackwell Publishing Ltd, 2010
Keyword
qualitative method, phenomenography, dialogue method, key questions, biopsychosocial, pain management, physiotherapy, professional mandate
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-56678 (URN)10.1111/j.1471-6712.2009.00718.x (DOI)000277713500011 ()
Available from: 2010-05-31 Created: 2010-05-31 Last updated: 2014-05-21
3. Telling about long-lasting pain – the role of key questions in physiotherapy encounters
Open this publication in new window or tab >>Telling about long-lasting pain – the role of key questions in physiotherapy encounters
2014 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Aim: For a physiotherapist in primary care wishing to meet her/his patient in the entirety of possible causes of long-lasting pain, the ability to perceive its nuances and context is indispensable.

The aim was to investigate the verbal responses of patients with long-lasting pain to key questions addressing their biography, identity and lived body.

Methodology: Three Swedish physiotherapists asked eight patients with long-lasting pain seven questions regarding body experience at the introductory and concluding, tape-recorded, treatment sessions. A deductive, qualitative analysis was made through four concepts naming aspects of body experience: body reliance, body awareness, models for explaining pain and the body’s integration in the identity.

Major findings: The key questions opened ways to bodily-existential reflections. The aspects of body experience were central to the patients’ descriptions. Appreciable differences emerged between the patients in how they described the experience of living with pain, and in some cases differences were seen between the conversations of the first and the last treatment session with the same patient.

Conclusions: The questions addressed crucial issues of living with pain and seem to have a potential to capture changes in body experience. Physiotherapists may recognize their patients’ biographical disruptions, reconstruction and adapt their treatment accordingly.

Keyword
Pain management, Clinical dialogue, Physiotherapy, Bodily existential perspective, Body awareness, Body reliance, Key questions, Deductive qualitative analysis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-106746 (URN)
Available from: 2014-05-21 Created: 2014-05-21 Last updated: 2014-05-21Bibliographically approved
4. Improving the interaction between the physiotherapist and the patient with long-lasting pain
Open this publication in new window or tab >>Improving the interaction between the physiotherapist and the patient with long-lasting pain
2014 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Purpose: To investigate whether it would be possible to improve the understanding and communication between physiotherapists and patients with long-lasting pain by, in a systematic way, approaching their condition from a bodily existential perspective.

Method: 31 physiotherapists answered written open questions about what happened when they in 90 encounters used key questions about living with pain together with a tentative frame for interpreting the answers - typologies of approaches to living with long-lasting pain. In the analysis, we combined qualitative content analysis with the counting of the numbers of codes.

Results: According to the physiotherapists, patients were positive to answering the key questions, which also evoked emotional responses and reflection. The relation between the physiotherapists and their patients improved. The typologies helped the physiotherapists understand their patients better, as well as in assessing the patients’ problems and choosing treatment. In all, positive experience clearly dominated. Conclusion: When used by physiotherapists with an interest in patients with longlasting pain, the key questions and typologies seem to enrich the clinical interaction in many cases. To try the generalisability of our findings, we regard it an interesting possibility to conduct a larger, quantitative questionnaire study based on the experiences and results of the present one.

Keyword
Qualitative method, pain management, pain assessment, clinical dialogue, communication, bodily existential, physiotherapy
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-106747 (URN)
Available from: 2014-05-21 Created: 2014-05-21 Last updated: 2014-05-21Bibliographically approved

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