How are we doing? The psychosocial history-taking practices of physical therapists when evaluating adults with chronic pain
Chronic musculoskeletal pain is the most frequently treated disorder by physical therapists (PTs). The biopsychosocial model (BPS) model, a holistic, integrative model is one of four constructs that informs physical therapy practice, recognizes the impact that the biological, psychological, and social factors have on the pain experience. It is the framework that the World Health Organization, American Physical Therapy Association, and clinical practice guidelines recommend that PTs use in the evaluation and treatment of persons with chronic pain (CP). In order to effectively manage all aspects of the pain experience, a thorough assessment of psychosocial factors during the history-taking portion of the initial evaluation is required. Little is known about the psychosocial history-taking practices of PTs when evaluating adults with CP in the United States. The aims of the three dissertation studies were: 1) to investigate the reliability and validity of a survey designed to measure psychosocial history-taking practices, 2) to explore the relationship between PTs’ demographic characteristics (years of clinical practice, evaluation time allowed, gender, American Board of Physical Therapy Specialty certification (ABPTS), and work setting), and their psychosocial scores on the survey 3) to explore the decision-making processes that PTs use when they decide whether and to what depth psychological cognitive factors should be explored at the first visit, and to understand the factors and cues that influence the process. Prior to studies One and Two, expert review of the survey supported that the survey
had strong face and content validity. The survey was emailed to 30,000 PTs licensed in eight states whose licensing boards provided email addresses; to be eligible, PTs had to be licensed in the United States and treating, at least occasionally, adults with CP. The first 49 respondents to complete the survey twice were used to assess test-retest reliability. The average time between surveys was 7.8 days. Strong test-retest reliability was demonstrated in each of the psychological and social subdomains and the overall psychosocial score using the Pearson’s correlation coefficient and the Bland-Altmann plot. Item analysis revealed strong internal consistency of all factors within the psychological subdomains/domain. Criterion validity, using the Pain Attitude and Belief Scale- Physical Therapist, was not demonstrated. In Study Two, evaluation time allowed and years of clinical experience were found to be significant independent predictors of the psychosocial score and explained 12.2% of the variance in the psychosocial score when entered into the regression model with gender and ABPTS certification. When respondents were grouped by years of clinical experience, the largest significant between group differences in the mean psychosocial score existed between the less than 5 years group and the 5-10, 11-15, 16+ years of experience groups. Finally, no significant interaction was found between work setting and the psychological factors (cognitive, emotional, and behavioral factors); however, the main effects of work setting, and psychological factor were both significant. PTs who practiced in outpatient therapy clinics asked more questions about psychological stressors than did PTs in acute care and inpatient rehabilitation; there was not a significant difference between respondents from acute care and inpatient rehabilitation. Lastly, PTs, regardless of work setting, assessed behavioral psychological factors to a greater extent than cognitive and emotional factors, and they assessed emotional factors least of all. Study Three, revealed that PT-related factors and external cues and factors influenced PTs’ decision-making when they considered whether and to what depth pain cognitions in adults with CP should be explored at the first visit. PT-related factors included evaluation practices that were predominately biomedical, prioritized the development of a therapeutic alliance over the assessment of psychological factors, and, when exploring psychological stressors, were iterative (over multiple sessions) in nature. Additionally, the values, beliefs, and judgements of PTs influenced the decision-making process. External factors included: 1) healthcare system issues such as documentation and reimbursement issues, and 2) patient cues to which PTs attended. The patient cue that PTs most frequently cited as an indicator that pain cognitions required attention was an inconsistency between biomechanical/biomedical factors and the patient’s overall presentation. Additional cues included: 1) the manner in which patients characterized past healthcare encounters with providers, 2) heightened concerns about their pain condition relative to the injury and/or “hyper-focus” on pain (also demonstrated through increased focus on past diagnostic testing results and/or medication use), and 3) and the chronicity of the patient’s pain condition. PTs used fast and slow thinking strategies to decide how to progress at the first visit. While there were indications of pattern recognition, hypothetic-deductive, mechanisms-based and, to a lesser degree, narrative reasoning, there was insufficient evidence to identify specific reasoning methods used. The results of the three studies supported the use of the author-developed survey to measure the psychosocial history-taking practice of PTs when evaluating adults with CP. Increased evaluation time and more years of clinical experience resulted in higher coverage of psychosocial stressors. PTs with less than five years of clinical experience assessed significantly fewer psychosocial factors than PTs with five or more years of experience. Work setting influenced the questions PTs asked; PTs from outpatient practices asked more questions about psychosocial factors than did PTs from acute care or inpatient rehabilitation. Overall, PTs asked more questions about behavioral and cognitive factors than emotional factors. Finally, the decision-making process of PTs was influenced by PT-related and external factors and cues. PTs displayed fast and slow thinking strategies when deciding how to explore pain cognitions.