How do occupational therapists working

CHRONIC BENIGN INTRACTABLE LOW BACK PAIN CBILBP: How do occupational therapists working in primary care facilitatepatients with this condition?... With no concrete evidence torefer to, t

CHRONIC BENIGN INTRACTABLE LOW BACK PAIN (CBILBP): How do occupational therapists working in primary care facilitate

patients with this condition?

The prevalence of chronic low back pain is increasing and is apparent in the number

of patients who continue to be referred to a tertiary pain management service Tenyears ago the Clinical Standards Advisory Group (CSAG) recommended abiopsychosocial assessment of all patients with acute low back pain to identify thepotential risk factors for future chronicity and disability With no concrete evidence torefer to, this study investigated the experiences of occupational therapists in primarycare under the themes of assessment and intervention, knowledge of clinicalstandards, prevention of disability and multi-disciplinary working to measure theprovision of occupational therapy with low back pain patients before referral to atertiary programme An exploratory design, employing a five step phenomenologicalapproach was chosen to elaborate information drawn from a survey questionnaire.Telephone interviews were conducted with five occupational therapists working withchronic low back pain The combined data revealed that there were no specificservices for chronic low back pain and that the primary reason for referral tooccupational therapy, whether in physical or mental health, was not the low backpain Occupational therapists proved well equipped to deal with this client group intheir caseloads due to their focus on occupational performance Assessment andintervention were holistic and demonstrated a full understanding of the effects of lowback pain and the ability to be active with the pain and this facilitated patientempowerment Occupational therapists were not conversant with the CSAGrecommendations but there was evidence to suggest that disability could beminimised Occupational therapists were competent to work independently and in amulti-disciplinary approach with this client group A lack of services for chronic lowback pain was identified

Definitions for study

In areas of rural Wales hospital care is often in generic community facilitiessupported by General Practitioners The establishment of local health boards in April

2003 has revised the politics of care again Some patients have to travel longdistances to access consultant physicians and surgeons, although there is someprovision for outpatient appointments in local day hospitals For the purpose of this

analysis primary care is the period before patients are referred to one of the few

residential pain management programmes in tertiary care The primary care runsfrom the patient’s first appointment with the GP, complaining of low back pain, to thetime when no further pathological intervention is considered useful

Chronic back pain is defined as pain that has persisted for longer than 3 months or

past the time of healing (The College of Anaesthetists and the Pain Society, 2003)and ‘most commonly it is assumed that pain which persists for six monthsprogressively leads to the chronic pain state, resulting in preoccupation with pain,depression, anxiety and disability’ (Wall, Melzack, 1999, p540) This leads to

‘occupational role disruption, psychosocial withdrawal, feelings of helplessness, loss

of self esteem and physical incapacity’ (Strong, 1996, p6)

1999, Croft et al., 1998) of patients who consulted the GP concluded that although

many patients discontinued to visit the GP about back symptoms after the first fewmonths, they reported pain and increased disability at twelve months Thomas et al.,(1999) concluded that persistent low back pain was related to the patients’ pre-morbid state Prevalence appears to be increasing due to cultural changes that haveinfluenced attitudes and beliefs, contributing to psychological distress and long termdisability (Buchbinder et al., 2001, Palmer et al., 2000, Waddell et al., 1999,Bandolier, 1995).

Patients referred to a multi-disciplinary residential pain management centre presentwith acquired bio-psycho-social disabilities resulting from their inability to cope withchronic low back pain Recent studies (Frost et al., 2001, Birkholz & Aylwin, 2000,van Tulder et al., 2000, Gibson, Strong 1998) focus quite emphatically on patients’severe physical, emotional and social impairment, with limited reference to the input

of specific health disciplines or occupational therapy intervention in particular.Personal experience advocates that occupational therapists are well qualified tofacilitate improvement in some patients presenting with the effects of chronic lowback pain and this is supported in the literature (Carruthers 1997, Strong, 1996,McCormack, 1990, Heck, 1987) Occupational therapists assess the impact of pain

on occupational performance in all activities from self-care to family relationships,and work in partnership with patients to develop an optimal programme for living withthe pain (Unruh et al., in Strong et al., 2002) They are holistic in approach,acknowledging emotional and social, as well as physical distress However, it seemsthat occupational therapists have not recorded their personal experiences ofassessment and treatment of patients with chronic low back pain, whether workingindividually, or in a multi-disciplinary team It is unclear what, if any, occupationaltherapy is available in the pre-tertiary pain management programme period, orwhether in fact it has any significant effect on patients, before admission or inpreventing admission It is not unusual to become insular in our own field of work,

losing sight of the approaches or treatments of fellow therapists working in othersections of medicine As an Occupational Therapist working in a tertiary painmanagement programme, it is important to be informed about the pre-treatmenthistory of the patients that are referred to, and treated at, the centre A colleagueinvestigated iatrogenic factors contributing to patients’ consequent disability with lowback pain and discovered that poor information from clinicians, influencing patientbeliefs about their condition, was a contributing factor (Hafner, 1999) The author

considered that occupational therapists may be contributing to patient disability.

This study sets out to:

 Record the experiences of occupational therapists working with chronic low backpain in primary care

 Evaluate the knowledge of occupational therapists in primary care working withchronic low back pain patients

 Assess the potential of occupational therapy in primary care preventing disability

in patients with chronic low back pain

 Discover whether occupational therapists in primary care can contribute to themanagement of chronic low back pain more effectively alone, or in a multi-disciplinary team

Aims of Study

Patients presenting at a chronic pain management programme with chronic benign,intractable low back pain are not always reliable witnesses about occupationaltherapy input in previous interventions Many have been subjected to severaltreatments with no success or long lasting effect and they are frequently onlyable to identify the doctor or consultant involved The report about otherclinicians is often vague and identities confused However it is apparent thatpatients are often more disabled than they need to be due to poor or unhelpfuladvice (Hafner, 1999) It is possible that occupational therapists are equallyresponsible for contributing to this disability following the assessment andtreatment they offer patients in primary care, or that in fact there is nooccupational therapy input available or provided This study asks:

How does Occupational Therapy assessment and intervention, in primary care, affectpatients with chronic, benign, intractable, low back pain?

Answers to the following queries will help to verify a satisfactory conclusion

1 What occupational therapy assessment and intervention is offered to patientswith low back pain?

2 Are occupational therapists in primary care conversant with clinical guidelinesand recommendations for low back pain?

3 Can occupational therapy in primary care prevent disability in low back painpatients?

4 Can occupational therapy assessment and intervention for low back pain standalone in primary care or contribute more effectively within a multi-disciplinaryapproach?

on improving performance and occupational roles through the use of graded activity,stress management and counselling Towards the end of the decade chronic painwas being recognised as an illness rather than a disease (Waddell, 1987) andmedical approaches to treatment were evolving

A more structured approach to pain management was observed in the 1990s.Carruthers (1997) identified an increasing interest of occupational therapists in painmanagement in the ten years leading up to her study Strong (1996) had no doubtthat occupational therapists are well equipped to enhance patients’ performanceskills in the assessment (Gibson, Strong, 1998), and treatment of chronic low backpain and O’Hara (1996) advocated their role as facilitators and advisers to enableindependent functioning The authors favoured a cognitive behavioural approach tothe overall management of chronic pain Occupational therapists are certainlyrecognised as an integral member of the residential pain management multi-disciplinary team (Birkholz, Aylwin, 2000), and are recommended by the Pain Society

as team members in the treatment of chronic pain (1997b) The potential of

occupational therapy is not in doubt but there is sparse evidence of implementation

or practice experiences

Knowledge of occupational therapists working in primary care working with CBILBP

An initial report (CSAG, 1994) and subsequent clinical guidelines (Waddell et al.,

1999, Newton et al., 1999, Royal College of General Practitioners, 1999) recommendthe bio-psycho-social assessment and treatment of patients with acute low back pain.The intention is to minimise future chronicity and disability by the identification ofpsychosocial risk factors and to recommend multi-disciplinary treatment andmanagement Occupational therapists are well qualified to offer biopsychosocialassessment and treatment programmes for patients, to encourage problem solvingskills and to prevent the onset of a chronic lifestyle (O’Hara, 1996) Their focus onoccupational performance makes them essential personnel for the patient withreduced physical and emotional strategies consequent to the pain (Unruh et al., inStrong et al., 2002) Little et al., (1996) and Newton et al., (1999) were not reassuringabout the implementation of the CSAG recommendations overall and occupationaltherapy was not categorised: neither was occupational therapy included in theadvisory group (Waddell et al., 1999)

Koes et al (2001) compared international clinical guidelines for the management oflow back pain in primary care and commented that guidelines for the United Kingdomincluded acute pain, rather than chronic pain, assessment and treatment Howeverfour main groups of psychosocial risk factors for the development for chronicdisability are listed The United Kingdom guidelines are commended, as they arecommon for all primary care health professions although the list does not includeoccupational therapists Further commendations are cited for a compilation of theirrecommendations and for upgrading the recommendations as new evidence has

become available (Newton et al., 1999) Specific recommendation for chronic pain is

to refer for exercise therapy No literature was found on occupational therapists’contribution, knowledge of, or adherence to clinical guidelines for assessment andtreatment of acute or chronic low back pain

The National Occupational Therapy Pain Association (NOTPA, 2004, Appendix G)recommends that therapists have a certain level of knowledge about pain and itsmanagement The joint publication of the College of Anaesthetists & the Pain Society(2003) reinforces that all personnel involved in the management of chronic pain, notspecifically low back pain, should be trained ‘adequately to ensure a safe andeffective service’ NOTPA (2004) and Birkholz & Aylwin (2000) stipulate occupationaltherapy remit as goal setting and graded activity pacing, to reduce flare-ups andsetbacks, to improve occupation, as part of the interdisciplinary pain managementteam It is unclear if they relate this to primary care, as well as the establishedresidential pain management programmes in tertiary care, for patients with prevalentsymptoms

There is concern that lack of training for occupational therapists in chronic pain mayaccount for the lack of input (Strong et al., 1999, Carruthers, 1997) A study by Jones

et al (2000) concluded that education about chronic pain had a significant effect onthe beliefs of occupational therapists working with this client group, but a study hasyet to emerge about the evidence of the impact on practice as a consequence.Brown (2002) and Steuart-Corry et al., (1997), discerned that occupational therapistsworking with chronic pain patients were unable to reach a consensus on treatmentapproaches, although they did not define low back pain or refer to primary carespecifically In their letter to Carruthers & Madeley, Steuart-Corry et al (1997) statethat although there is basic training for occupational therapists in pain management

at undergraduate level, there is every need for further training to extendunderstanding and techniques in pain management.

Potential of occupational therapy in primary care preventing disability in CBILBP patient

Gaynord (1996) presented a case study of a patient with fibromyalgia andosteoarthritis in an endeavour to clarify the role of the occupational therapist inprimary care She wanted to demonstrate that primary care therapists were wellsuited to long term rehabilitation support by reporting clinical details The co-operation of the patient, family and occupational therapist lead to improvements inthe patient’s coping strategies The patient enhanced functional levels throughimproved sleep, relaxation practice, goal setting and pacing and the provision ofappropriate household aids

It has been recognised that occupational therapists are well qualified to manage painfrom a holistic perspective (McCormack, 1990) with their focus on increasing thepatients level of functioning (Shannon, 2002, Chesney, Brorsen, 2000, Moran &Strong, 1995) There is no indication in the literature that pure occupational therapyintervention in primary care prevents disability in long term chronic back pain, rather

it decreases disability Taylor’s (2001) examination of undergraduates over their threeyear training established that patient independence is only empowered when theyhave some choice in their treatment O’Hara (1996) opined that specialist equipment,for patients with chronic pain, is provided when its use will help the patient to regaincontrol over the practical aspects of their lives If the equipment enables the familymember to care more easily for the patient, then the invalid role is reinforced Thetherapist’s role can be to provide information relating to equipment so that the patient

is able to make informed choices about purchasing equipment

Davis (1996) in her paper on primary care management of chronic musculoskeletalpain identified chronic pain as a common problem and that treatment wasinconsistent Having acknowledged the ongoing effects of chronic pain she madesuggestions for the assessment and treatment in primary care Several theories wererecommended including pharmacological intervention, physical therapy andrelaxation, with no suggestion of appropriate therapists or of low back painspecifically Turner (1996) undertook a meta-analysis of educational and behaviouralapproaches for back pain in primary care based on randomised trials She concludedthat a cognitive behavioural approach to treatment may be appropriate, particularly

as a means of preventing the progression of acute back pain to chronic disablingback pain However more studies are recommended A physical therapist ismentioned as a contributor to treatment, but it is unclear if this is a physiotherapist or

an occupational therapist as the article is of American origin Apparently occupationaltherapists have the skills and approach for clients with low back pain but there is noaccount of the outcomes of the intervention

Can occupational therapy in primary care stand alone for CLBP or is a disciplinary approach more effective?

multi-Desirable Criteria for Pain Management Programmes (The Pain Society, 1997a)stipulates that no single profession can possess all the skills required to effectivelyaddress patient needs in pain management programmes Fixed sessions forhealthcare personnel including occupational therapists (Royal College ofAnaesthetists & the Pain Society, 2003) should be available O’Hara (1996) supportsthe multi-disciplinary approach to chronic pain as it provides mutual support for thepatients and a forum within which they have shared experiences, symptoms andfears She sees it as an extension of what she calls the uni-disciplinary model, which

is an interaction between the patient and one clinician only Emulating much of the

literature she interprets, rather than researches, the role of occupational therapistsopining that the aim of intervention in pain management is educative andparticipative, so that the patients play an active role in their own treatment Clinicianssuggested include an occupational therapist, physiotherapist, clinical psychologistand nurse and she maintains that the range of core skills available in thiscombination support the patient in learning to manage pain

Birkholz & Aylwin (2000) reinforce the premise that occupational therapy is aspecialist area within a specialised multi-disciplinary team and that pain management

is successful because of the mixed input of the specific skills Criteria for painmanagement programmes as prepared by the Pain Society (1997a) recommended

an occupational therapist trained in pain management as a key clinical member Oneshort report was found relating to an occupational therapy treatment programme forchronic pain (Carruthers, 1997), but this was not specific to low back pain Thepaucity of exercise was identified, and physiotherapy input as part of the programmewas recommended as essential to address this limitation Patients attended for twohours weekly, learning to take responsibility and control through task performanceand education Interactive group work was a positive approach, repetition ofinformation facilitated learning, and the format of the programme was continuing toevolve despite the lack of resources

Several years ago Strong (1987) suggested that patients with chronic benign painincluding low back pain, needed to be treated by a team of variously skilledpractitioners including occupational therapists The consensus between her (Strong,Unruh in Strong et al., 2002) and O’Hara (1996) is that occupational therapists arecore members of a multi-disciplinary team Both authors favoured a multi-disciplinaryapproach to all chronic pain management and discussed occupational therapy as

part of that formula In a separate article Strong (1998) did suggest incorporatingcognitive behavioural therapy with occupational therapy as a psycho-educationaltreatment for low back pain Patients in the treatment group showed greaterimprovement over time than the control group in terms of increased patient controland reduced helplessness, disability and pain intensity The occupational therapyprogramme complemented the input of the psychologist.

Phenomenology as an approach to occupational therapists experiences with CBILBP.

That phenomenology is well suited to occupational therapy study has beenacknowledged by Kelly (1996), and demonstrated and debated at length by Finlay(2000, 1999, 1998, 1997) Finlay’s (1999) evidence was based on her study ofclinical reasoning strategies, which lead her to conclude that occupational therapistsactually use a phenomenological process of multi-dimensional thinking anyway tounderstand individual’s meaning

Tryssenaar’s (1999) study enabled understanding of the phenomenon or experience

of what it was actually like becoming an occupational therapist in practice The casestudy approach generated elaborate and extensive data to identify the emergentthemes of the experience, while encouraging the researcher to reflect on her ownexperience and practice in an empathic fashion Very recent studies (Reynolds &Prior, 2003, Reynolds, 2003) questioned patients about the value of artisticintervention Reynold’s (2003) own study favoured in depth interview rather than thetemplate approach to gather clues of the patients’ experiences Henare et al (2003)employed patients’ paintings, and their explanations of these paintings, to gain anunderstanding of the reality and experience of patients’ chronic pain Thephenomenological methodology of exposing emergent themes in that study enabled

one practising occupational therapist, one occupational therapy lecturer and onenurse lecturer to gain a greater understanding of the common losses and lives ofchronic pain patients, while encouraging patients to share their experiences

When questioning parents of children with Juvenile Idiopathic Arthritis, Schroder et al(2003) were able to gain greater perception of parents’ perceptions through semi-structured, flexible interviews, which extracted information on the struggles andconcerns of parents The information would be utilised when working with otherparents with arthritic children In similar vein, Finlay (1998) was able to gain insightand make sense of what occupational therapists felt about their patients Whileacknowledging certain limitations of their study, Helm & Dickerson (1995) gaineduseful feedback on the effect of hand therapy to modify intervention in occupationaltherapy using video taped interviews Udell & Chandler (2000) confirmed that theirphenomenological study was well suited to the topic and yielded rich data on theopinions of three Christian Occupational Therapists addressing the spiritual needs ofclients, using an interview format

The phenomenological methodology in the quoted studies was receptive to theexperiences and expressions of the therapists and patient interviewed Theinformation was gathered at face value, and the emergent themes of the studieswere collated as evidence-based practice for future interventions A more formalquantitative approach may have been stilted and failed to allow the data to evolvethrough the descriptions of those studied (Schroder et al., 2003, Finlay, 1998) Aclose biographical account of the experiences of higher degree graduates (Dawkins

& May, 2002), could never have been explained in quantitative terms

Vigilance about trustworthiness reinforced the researchers’ desire to elaborate thetrue facts (Schroder et al., 2003, Udell & Chandler, 2000, Finlay, 1998) Crotty (1996,

p19) reasons that nurse researchers require a ‘method of enquiry that will notprejudice the subjectivity of the experience under study’ Reflexivity is theresponsibility of the researcher and bracketing presuppositions and preconceptions(Henare et al., 2003, Schroder, 2003, Udell & Chandler, 2000, Finlay, 1999, Crotty,1996) during data collection and analysis recorded as true an account of thesubjects’ viewpoint as possible Common themes in the data were identified andrecorded, with minimum bias.

The literature review has identified the current state of research, located theoreticalframeworks and drawn implications for the research to explore (Grbich, 1999) Thepaucity of evidence of occupational therapists’ experiences suggested potential toelaborate Much of the more recent research on chronic low back pain is based onthe outcomes of multi-disciplinary pain management programmes working in acognitive behavioural approach (Williams et al., 1996, Gough & Frost, 1996, Moran &Strong, 1995) The responsibilities of each team member are not isolated, even if theteam members are identified A systematic review (van Tulder et al., 2000) ofbehavioural treatment makes no reference to clinicians involved, or occupationaltherapists’ experiences

The literature established that the knowledge and input of occupational therapistswith this client group is unclear Shannon (2002) confirmed the dearth ofdocumentation on the efficacy of occupational therapy treatment in multi-disciplinarypain management programmes While opinion suggested there was no shortage ofconfidence in the ability of occupational therapists to work with this client group, therewas little evidence of their experiences or effectiveness Particularly difficult todecipher is the occupational therapy contribution in the preferred multi-disciplinarycare approach to pain management or the occupational therapists providingindividual treatment Phenomenology has been rationalised as a suitable

methodological approach for research founded in occupational therapy particularly as

a rich source for evidence based practice (Henare, et al., 2003, Taylor, 2000, Helm &Dickerson, 1994)

The concurrence is that phenomenological research is underpinned by the writings ofEdmund Husserl (1859 -1938), (Racher, 2003, Grbich, 1999, Corben, 1999, Finlay,

1999, Seymour & Clark, 1998) Husserl posited phenomenology as the only rigorousscience that was not tainted by subjectivity and this is measured by the researcher‘sability to suspend previous knowledge while gathering new knowledge (Racher,

2003, Lowes, Prowse, 2001, Seymour & Clarke, 1998) Suspension is achieved bybracketing out or putting to one side preconceptions and beliefs followingexamination and acknowledgement, while remaining open to the participant’s point ofview in the experiences reported (Finlay, 2000) This openness is termed intuiting(Grbich, 1999, Polit & Hungler, 1997) The focus of the theory is the interpretation ofpeople’s experiences with a certain phenomena or concept and to describe livedexperience and perceptions (Finlay, 1997, Polit & Hungler, 1997) by returning to the

phenomenon (Sim, Wright, 2000, Grbich, 1999) This makes the key elementsdescription and interpretation of the gathered information (Seymour & Clark, 1998)

Traditionally the philosophy considers that humans exist quite independently (Grbich,1999) and their unique experience of the world is a result of that existence (Dawkins

& May, 2002) Phenomenologists attempt to understand phenomena or humanactivity from the viewpoint of the person being studied, in the belief that individualsneed to be understood within their everyday environment (Dawkins & May, 2003,Shepherd et al., 1993) The phenomenon here is the therapeutic strategies used byoccupational therapists working with patients with low back pain (Guidetti, Tham,2002)

Phenomenology has been proposed as an exercise in critique (Crotty, 1998,Seymour & Clark, 1998, Koch, 1995), which encourages some evaluation of all that

is taken for granted (Grbich, 1999, Kelly, 1996) The main source of data inphenomenological research is the co-participation of researcher and participant indeep conversation The participant takes the lead and the researcher strives to enterthe individual participant’s world or experience (Lowes, Prowse, 2001, Polit &Hungler, 1997) Everything is examined at first hand with an open mind, and ‘the datamust be allowed to emerge in their own form and speak for themselves’ (Crotty,

1996, p20) as common themes relating to the phenomenon under discussion Theresearch interview is a purposeful, data-generating activity and a good interviewgenerates quality data (Lowes, Prowse, 2001)

Due to the debate surrounding the phenomenological approach (Lowes, Prowse,

2001, Annels, 1999, Finlay, 1999, Koch, 1995), this study chose to adopt Crotty’s(1996) theory He posited that phenomenology today is about ‘people’s subjective,everyday experiences’: that is ‘ experience as people understand it in everyday

terms,’ where the term ‘phenomenon’ is interchanged with the term ‘experience’(1998, p83) In his book (1996) he debated the use, and interpretation of,phenomenology in nursing research, referring to thirty studies apparently employingthe phenomenological approach As a result of his study he devised a ‘step by stepmethodological research process’ (Crotty, 1996, p158-159) based on the coreprinciples (Grbich, 1999) of phenomenology philosophy

The research question and the evolution of the data often dictate the framework ofqualitative research, and Crotty’s theory lent itself to the flow of the topic underinvestigation The aim of this study was to determine how occupational therapistsfacilitate patients in primary care with chronic benign intractable low back pain Oneway to determine the outcome was to question occupational therapists about theirwork, to record, analyse and understand their experiences, while suspending andbracketing any personal preconceptions and beliefs of the author in production of thefindings

The stepwise process runs through five stages

1 The focus on the point of interest, that is the phenomenon

2 The phenomenon is as it really is This is established by listening and layingaside all previous ideas judgements, feelings, assumptions, connotations andassociations that the researcher would think about in a general situation

3 The documentation of the description of the experience is based on specificresponses

4 The description comes from the sample and it does not include any interpretation

on the part of the researcher

5 The information is true and characteristic

(Adapted from Crotty, 1996, p158-159)

This process will be demonstrated by this study.

Ethics

Ethical approval for this study was granted by the local Research and DevelopmentCommittee, the University Ethics Board and the local Research Ethics Committee.Ethics committees may be the gatekeepers but ultimately it was the researcher whowas responsible for ensuring that the project was ethical throughout the study (Sim,Wright, 2000, Seale, Barnard, 1999)

The fundamental ethical principles for research (Butler, 2003, College ofOccupational Therapists, 2003, Sim, Wright, 2000, Seale & Barnard, 1999, Polit &Hungler, 1997) required that the researcher:

• protect the autonomy of others (autonomy),

• respect the dignity of others (respect),

• promote others wellbeing (beneficence),

• refrain from causing harm (non-maleficence),

• deal with others fairly (justice)

The design of this study involved the use of a survey questionnaire and telephoneinterview Each approach had some ethical implications for the researcher Bothapproaches required participant consent: one was implied by the return of thequestionnaire and the other written, to take part in a telephone interview Informedconsent is sometimes problematic in a qualitative approach to research as theexploratory nature makes it difficult to introduce and explain (Polit & Hungler, 1997).The introductory letter (Appendix C) to occupational therapists contained a fullexplanation of the process and nobody was approached for telephone interviewwithout the opportunity to acquire sufficient information (Sim, Wright, 2000), or to askfor further explanation Written consent was obtained for all telephone interviews and

all parties were offered the right to withdraw from the study at any time (Seale,Barnard, 1999, Parahoo, 1997) Telephone interviews were offered as a pacedexperience to minimise any discomfort, at the therapists’ convenience Ongoing orprocess consent (Polit & Hungler, 1997) was recognised by member checking whenparticipants collaborated in the ongoing decision making within the study.

Confidentiality of data was protected as transcripts and data were coded andidentities were secured elsewhere (Taylor, 2001, Seale, Barnard, 1999, Grbich,1999) All information was respected as valid, and consent to formal member checkwas agreed at the conclusion of the telephone interview to ensure that participantsfelt fairly represented in the analysis of the data (Tryssenaar, 1999, Polit & Hungler,1997) Moral or legal obligation about exposing confidential information was notchallenged (Butler, 2003, Polit & Hungler, 1997) The tape-recorded interviews wereerased at the conclusion of the study

Continued contact with the sample can be an issue if participants are known to theresearcher, or if they work in the same environment, as it can blur the specific role asresearcher or practitioner (Butler, 2003, Conneeley, 2002) Co-opting clinicians fromother Health Boards and Trusts gave the parity of sample but guarded against theperils of direct daily contact It precluded potential bias or flawing of data byresearcher or the participants (Butler, 2003), due to familiarity or misguided loyalty

The author is satisfied that she has adhered to the research standards of the College

of Occupational therapists (2003)

Design

Since the literature review revealed a lack of research in the experiences ofoccupational therapists working with patients with chronic low back pain, anexploratory approach to this study was elected

Pilot Study

A pilot study was carried out to improve and assess the feasibility of the projectedstudy (Sim, Wright, 2000, Polit & Hungler, 1997, Ballinger & Davey, 1998, Walker,1996), particularly to establish clarity of the questions, to obtain constructive criticism

on the format, content, and the length of the questionnaire Questionnaires wereposted to three occupational therapists not included in the main study with anexplanatory letter, a comments sheet (Ballinger & Davey, 1998), and stamped

addressed envelope (Appendix B) The study resulted in minor adjustments to the

questionnaire to encourage completion of the questionnaire

• Please complete ALL the questions whether this is your remit or not

• Please answer the following questions even if you have answered ‘No’ toquestions 12 and 13

A question was added to clarify respondents’ definition of chronic pain to ensure

parity of understanding of the condition for discussion, and a larger box was provided

to elaborate on multi-disciplinary preferences Due to the constraints of time thestudy ran with these adjustments In terms of face validity, the respondents were able

to relate the content of the questionnaire to the study under review Content validitywas assured by requesting information on various facets of the occupationaltherapists’ experiences of patients with low back pain (Sim, Wright, 2000, Foulder-Hughes, 1998 Parahoo, 1997) The answers to the pilot study confirmed reliability asthe participants interpreted the instructions in the same way (Foulder-Hughes, 1998,Parahoo, 1997)

It was decided to use the original telephone interview format, as it was designed toencourage participant lead with only prompts or reflection from the interviewer,allowing flexibility to encourage the richness of data The same ethical considerationsapplied as for the main study.

METHOD

Sample

Permission and names of practising occupational therapists were obtained from eightHead Occupational Therapists (Appendix A), from four areas of Mid-Wales The list ofnames made it easier to follow up those who did not return the initial survey (Curtin &Jaramazovic, 2001) Only one Head declined due to shortage of clinicians and anemphasis on hospital discharge Forty occupational therapists were selected atrandom by an independent clerk A postal survey questionnaire (Appendix C) wasdistributed to ascertain that there was occupational therapy available for patientsprior to attending the tertiary in-patient programme This was to record a profile aboutthe respondents (Foulder-Hughes, 1998), and included open questions to gaindetailed views and perceptions of the sample (Curtin & Jaramazovic, 2001) Aquestionnaire was chosen to encourage respondents to comply because they werenot faced directly with an interview (Foulder-Hughes, 1998, Ballinger & Davey, 1998),and to gain a smaller sample for telephone interview Returned questionnairesimplied consent to use the data Inclusion criteria for telephone interview were,occupational therapists working with low back pain patients in primary care Apurposive, that is a typical (Sim, Wright, 2000, Polit & Hungler, 1997), criterionsample of five occupational therapists working with chronic low back pain wasselected All volunteered (Dawkins & May, 2002) to take part in the telephone

interview at a time convenient to them for which individual informed consent wasobtained.

Data Collection

Data collection tools were:

1 A survey questionnaire (Appendix C) to identify occupational therapists workingwith chronic low back pain, requesting demographic background and openquestions designed to elicit the broader context of the occupational therapists’experiences with patients with chronic low back pain

2 A tape-recorded telephone interview with a prepared interview schedule(Appendix D) to elucidate the verbal account of occupational therapists’experiences with chronic low back pain

Triangulation which is the implementation of more than one collection technique inone study increases the probability of revealing richer data (Hammell, 2002, Sim,Wright, 2000, Polit & Hungler, 1997, Silverman, 1993), leading to richer informationfor analysis

Survey

So that non-respondents could be sent another questionnaire to maximise theresponse rate (Curtin & Jaramazovic, 2001), postal questionnaires were coded andlogged (Ballinger & Davey, 1998) and sent to forty occupational therapists in theLocal Health Boards and Trusts Information on the study, consent forms fortelephone interviews and stamped addressed envelopes were included (AppendixC) Non respondents received the questionnaire twice over a two-month period.Returned questionnaires were logged and the data recorded under question numbersand topics Demographic data was tabulated and numbered under the headings of

1 age, gender, years worked, title, type of work, client group, qualifications

2 training in pain, additional training in pain, work with pain now, ever worked withpain

3 reason for referral, origin of referral, multi-disciplinary working and requirementsfor additional training about pain

and confirmed the background of the respondents

Open responses were recorded as question numbers and headings under definition

of chronic pain, clinical guidelines for low back pain, effects of chronic low back pain,strengths and weaknesses of patients with low back pain, interventions offered,progress observed and the effects of occupational therapy intervention Thesequestions elaborated the therapists’ observations and understandings of the patientwith chronic low back pain

Interviews

Unstructured interviews were designed to elucidate the participants experiencewithout imposing any of the researchers personal views, particularly when theresearcher had no concrete views (Polit & Hungler, 1997), and took place over a fourweek period Interviews were preferred as potentially they yielded deeper data(Parahoo, 1997) The integrity of the interviewee was respected at all times (Sim,Wright, 2000), and the primary data collection instrument was the researcher whointerviewed and listened to the recorded data (Conneely, 2002, Beck, 1994, Sheperd

et al., 1993) The resulting data was a creation between the researcher and theresearched (Polit & Hungler, 1997, Koch, 1995) with an emphasis on the opinion ofthe participant (Seymour & Clarke, 1998)

Telephone interviews were chosen to limit the amount of travelling involved for face

to face interviews in a large rural area, and were arranged following receipt of

consent forms from volunteer therapists Background information was discussed andtimes were set to cause least disruption in the busy schedules of participants andresearcher Interviewees were advised to ask for breaks at the outset of the interview

to avoid fatigue Interviews lasted from 15 minutes to 45 minutes and were numberedone to five

The interviews were guided, semi-structured and circular to yield conversation (Sim,Wright, 2000, Crotty, 1996) The interviewer prepared broad, open ended questions

on the interview schedule, to avoid bias (Pearce & Richardson, 1996), initially invitingthe therapist to ‘tell’, as an icebreaker to talk (Hand, 2003) about the assessmentsand interventions they offered patients with low back pain The researcherdemonstrated active listening (Sim, Wright, 2000, Crotty, 1996) and encouragement

by prompting, probing, reflecting, paraphrasing and discussing with the interviewee.The interview did not follow an exact order, as some flexibility was desirable to allowthe researcher to follow up issues raised The interview schedule was prepared toensure that all participants reported on the same topics to aid reflection, but was notdesigned to inhibit the intuiting of the researcher or the flow of the participant Theinterviews explored the experience of working with chronic low back pain to generatedata based on the respondents’ personal experiences (Dawkins & May, 2002,Parahoo, 1997) Permission to member check was requested at the conclusion ofeach interview All participants agreed to read the interview hard copy to authenticatethe content

The researcher jotted phrases in a reflective diary as the interview allowed and thenrecorded related reflections (Taylor, 2001, Sim, Wright, 2000, Grbich, 1999, Finlay,1998), within two hours of the completed dialogue There were also opportunities todebrief with colleagues, none of whom are occupational therapists, but who areexperts in the area of pain management and one who is an experienced researcher

The tape-recorded interviews were scribed individually by an independent cleric andthe hard copies distributed to the participants for authentication (Appendix E)

Data Analysis

Analysis and results were based on the aptitude of the analyst (Lowes, Prowse,

2001, Holloway, Wheeler, 1998), and the individuals’ representation of theirexperiences (Seymour, Clark, 1998) Initially the accuracy and quality of the datadepended on what the respondent wanted to disclose and the integrity of the sample

to contribute accurately (Pope et al., 2000, Parahoo, 1997, Silverman, 1993) Theanalysis of survey and interview texts was performed manually (Sim, Wright, 2000)with the aid of a word processor The researcher devised her own method ofanalysing the data, which on later reading compared to the editing analysis orcategorisation scheme described by other writers (Taylor, 2001, Polit & Hungler 1997,Bowman, 1994) This involved comprehending, synthesising, theorising andrecontextualising, moving backwards and forwards from the raw data to emergentthemes This approach worked best for the researcher (Sim & Wright, 2000, Polit &Hungler, 1997) Data provided a description, but not an explanation, and the role ofthe researcher was to sift and interpret to make sense of what had been reported(Pope et al., 2000) Although critiqued as a rather laborious process it enhanced thedata rather than reduced it to numerical coding

Survey

The demographic material had been coded and sectioned under headings atcollection and the categories were then totalled, collated, recorded and reported.Individual open questions were analysed independently on separate sheets andcategorised into common topics By reading and rereading the responses new

categories emanated from the text until no new categories were realised Theresponses to these open questions reported broader data on therapist experiencethan anticipated It was decided to store these findings before the interview processbegan (Polit & Hungler, 1997) This was to reduce bias and to bracket the informationbefore collecting data yet to be revealed by the telephone interview.

Interview

After verification of the text by the sample therapists, the researcher read the textsseveral times to get a feel of the interview and the experiences of the intervieweesand the interviewer Themes emerged after repeated reading and were drawn fromcommon words, phrases, sentences and themes that highlighted any commonality(Dawkins & May, 2002, Taylor, 2001, Corben, 1999) The highlighted text was thencategorised in accordance with the aims of the study, and recorded on separatesheets under the headings of Assessment and Intervention, Clinical Guidelines,Disability Prevention, and Multi-disciplinary/Individual Therapy During the readingadditional themes emerged which were tabulated under the headings of Reasons forReferral, Holistic Approach, Concerns of Occupational Therapists and Independenceand Empowerment All quotations were numbered according to coding of participantsand page numbers from the text Each category was reread and re-evaluated severaltimes to compare and synthesise the comments of each section Therapistquotations were reported to support the outcomes presented

The open question response and interview response themes were compared forfurther commonality (Henare et al., 2003, Bowman, 1994) using the same technique,and the findings were presented in the Discussion (p 40)

Results

SURVEY QUESTIONNAIRE

Demographic Background: (Questions 1 to 9, 11 to 13, 15 to 17, 23, 24, 26)

Twenty six occupational therapists responded to the postal survey Eight were unable

to complete the exercise either because there was no service in their area or they didnot feel qualified to answer One therapist was actually taking a career break Somequestions were omitted by respondents, and the figures for individual questionresponse are included in each question result

• The majority of participants were aged 30 to 50 years with one under 30 andthree over 50 years

• Sixteen females and two males responded

• Twelve therapists had qualified by Diploma in Occupational Therapy, Five BSc

OT and one had a post graduate MSc OT

• Therapist years of service were recorded as:

1 to 5 years 5 to 10 years 11 to 15 years > 15 years

4 Therapists 3 Therapists 3 Therapists 8 Therapists

• The majority ranked themselves Senior Occupational Therapists, five were Heads

of Departments and two Basic Grade therapists

• Many therapists were employed in more than one area of work in hospital andcommunity settings, Acute Psychiatry, Elderly Mentally Ill, Out Patients andCommunity No one worked purely with chronic low back pain patients althougheleven clinicians reported some input with low back pain patients now

• Patients were not referred for low back pain alone, but rather for depression orphysical assessment in mental health services and general functionalassessment and rehabilitation at home or work for non specific physicalconditions in physical health

• Referrals were taken mainly from GPs with fewer from other professionals andConsultants Therapists reported seeing patients for assessment and treatmentwho had experienced low back pain for:

3 months 6 months 1 year 18 months 2 years >2 years

1 therapist 4 therapists 4 therapists 1 therapists 2 therapists 6 therapists

• Only one therapist reported definite training for chronic low back pain, althoughtwo had actually spent a short time at a back school, and two had done shortplacements Therapists had not attended additional training and were generallyself-taught through reading of journals or talking to physiotherapists Tentherapists said they would like more training

• All therapists preferred multi-disciplinary team work to give the maximum input topatients, utilising the breadth of combined expertise Quotations included ‘eachdiscipline would have unique perspective and advice’, ‘so that the person isworked with holistically’

The initial sample experiences then were broad, working in physical and mentalhealth, generally at a senior level Low back pain was not a primary cause for referraland back pain assessed was chronic (had lasted longer that six months) Training inchronic pain was sparse and multi-disciplinary working was the favoured option

Clinical Guidelines for Low Back Pain (Questions 18, 19)

Acute low back pain Chronic low back pain

Not one of the seventeen responding

therapists was aware of any formal

clinical assessments

Not one of the fifteen respondingtherapists was aware of any formalclinical assessments

In Practice

Reported approaches and suggestions

for assessment of acute low back pain

Reported approaches and suggestions for the assessment of chronic low back pain

• Read medical history, noting previous

interventions, take history from

patient’s view,

• full medical history as would expectpatient probably already alteredlifestyle to accommodate problem

• Observation

• Occupational therapy functional

assessment / ADL

• Review of exacerbating pain features,

patients perception of level of pain,

posture, transfers seating/bed,

driving, work, leisure

• Concentrate on patient goals

• Would pass on to physio

• observation

• occupational therapy functional /lifestyle assessment / ADL tomeasure the effects of the pain ratherthan causes

• patient’s perception of pain andexacerbating features, posture,transfers, seating/bed, driving, work,leisure

Although there was no knowledge of the CSAG guidelines (1999, 1996, 1994),particularly acute guidelines and the prevention of disability, the consensus report inapproach to assessment in both clinical areas focussed mainly on the physicalpresenting symptoms and the patients’ ability to cope with their everyday demands.One therapist wrote that she would look at the triggers for both and focus on how tominimise them

CATEGORIES FROM OPEN QUESTIONS

The results not directly answering the aims are presented in Appendix F

Physical interventions recommended:

• functional, environmental, workplace, home, driving, ergonomics of home andwork environment assessments

• graded exercise

• fatigue management, relaxation, energy conservation and joint protection

• physical coping strategies and lifestyle advice such as transfers from chair,posture and manual handling,

• providing equipment for example a wheelchair, and compensatory techniques toenable maximum performance

One therapist working in mental health recorded referral to colleagues in physicalservice for specialist input and another, immediate referral to a Consultant, GP orgeneral hospital for specialist input Neither defined the nature of specialist input

Interventions for emotional issues recommended

 anxiety management

 assertiveness training

 talking therapies mainly

The enhancement of problem solving skills, were suggested as well as patient education to enable self-sufficiency and independence Specific approaches were

• Solution Focussed Therapy

• goal setting, planning and pacing

• alternatives, enabling techniques for carrying out ADL, work and leisure

• balancing work, rest and play and evaluation

• education about the back and potential damage

• education re-good posture, exercise programme and back strengthening

One therapist noted working in conjunction with the patient to identify ADL/occupationthe individual is having difficulty with, and to provide interventions to address theseareas Overall the interventions recorded, emulated the holistic approach gatheredfrom other open questions

Assessment and Intervention

Assessment

Therapists reported the use of a holistic and general occupational therapyassessment, not specifically geared to low back pain but which highlighted the effects

of back pain

Primary assessment would be from a mental health perspective and

obviously we take into account then if people are having problems

No specific assessments ……….general occupational therapy

assessment…… I would find out exactly how it’s affecting their everyday life

to make sure we can gear the intervention part for them

(Therapist 1)Most problems….are sort of multi-complicated………….I tend to look

at them as what are the problems and what can I do to help

(Therapist 2)One therapist favoured a common sense approach to find the patient’s perspective

on what they wanted and what they felt would help, as well as a home visit to checkout the environment for potential adaptations She used a talking solution focusedapproach to enable patients to identify the immediate functional difficulties impedingtheir lifestyle Another used a broad multi-disciplinary physical and cognitiveassessment, also used by nurses and physiotherapists, to identify all the problemsthe patients were having They looked at patients’ lifestyle, perception and beliefs

about increased pain The patients with low back pain were very chaotic and soprevious interventions and present coping strategies were reviewed One therapist inmental health suggested that she would refer the patient to an occupational therapyphysical service if available Another identified the appropriate referrals herself fromthe weekly referral meeting

Intervention

The patients with back pain were fairly entrenched and required longer-termintervention Common approaches to intervention were improving function byemploying activity scheduling, goal planning, and pacing, while problem solvingthrough talking

Showing them how to do things in a different way rather than the way

they did things before ……their back pain………….perhaps they used

to cut the whole hedge……….to do half an hour today and half

an hour tomorrow……….looking at how they manage their anxiety…

things like confidence building (Therapist 3)

A variable approach to the supply of aids and adaptations was apparent and

therapists:-…….would deal with the practical side of things….….there is a fair

bit of chair raising, and toilet raising, grab rails and that kind of thing

(Therapist 2)

………do look at equipment in the short term……we try not to use

equipment at all………….unless we feel we cannot work with the

client……… if they’re not ready to accept that the pain can be

One therapist found that moving and adapting the home with equipment reducedphysical dysfunction and emotional distress and improved patient control It was ajoint problem solving process between the patient and therapist to find a way of doingthings She was not the only therapist to offer relaxation exercises Three therapistsfocused on talking therapy, and detailed pacing and cognitive plans to manage the

over activity cycle She was the only clinician to address the unthreatening nature ofchronic pain with the patients.

The data revealed a limited range of specific intervention for chronic back pain whichfocused mainly on enabling patients to work with their pain One therapist identifiedthe need for education about chronic pain and no therapists mentioned pain relief Itwas a management of ongoing pain, allowing the patients to live more easily with it.The general approach to intervention demonstrated practical coping strategies withsome cognitive input to increase the patients’ overall self-management The supply ofaids and adaptations was seen as a facilitator by two therapists, while oneconsidered them unnecessary All therapists were competent to offer some painmanagement strategies using occupational therapy principles

Clinical Guidelines

No interviewees had knowledge of any clinical guidelines for the assessment andtreatment of chronic low back pain

I don’t follow any particular guidelines (Therapist 1)

I haven’t got access to any specific to low back pain (Therapist 4)

However one therapist admitted that she would like some and another assumed thatthey existed but she did not know

Things have become really entrenched and we often wonder if they’d

been seen earlier or if psychological problems had been tackled

earlier, whether or not the outcomes of people would be different

(Therapist 3)

I feel that what we can offer is just a glimpse really of the fact that

there is a way forward……….I feel that it is fine when

we can provide the intervention but I don’t think it’s enough, it’s

not intensive enough for them……….There is a perception that nothing can

be done…….it’s the time factor… it’s so much easier to be handing out aprescription than to work with the client (Therapist 5)

However one therapist reported timely intervention by astute colleagues

Nursing staff are very good - if they think there is a functional

problem, that I can help with they do actually refer straight on to me

(Therapist 4)Prevention depended on the attitude and motivation of the patient concerned and thewillingness to take things on board, and was not necessarily related directly to theinput of the therapist, but that did not exempt or limit input

…… there are interventions that can be done, but mostly I get people in this area who accept that they’ve got aches and pains and get on with it

(Therapist 2)

… we find that people look after their pain and are unwilling to view

There was conflict of interest and potential impediment if patients were over cared for

by family or external agencies A vicious circle evolved because patients wereinactive due to somebody else doing it for them There was a difference of opinionabout the supply of aids and adaptations This concerned what the patient was ready

to accept and what the therapist felt was suitable

Often I find that people don’t really want things [aids] ……unless theyabsolutely have to have them because they don’t want people seeing

them in a wheelchair as much as anything (Therapist 2)

… look at maybe equipment and adaptations to people’s property

and their home…….to see if there is anything we can do to change

(Therapist 4)There was an awareness of therapist responsibility to enable the patient to visualiseintervention, to achieve the potential while being cognisant of what the patientwanted and was prepared to accept Alternative approaches were sought to reducestress on painful joints and looking at what patients can do within their living patterns,rather than focussing on the pain