Evaluative language in physiotherapy practice: How does it contribute to the therapeutic relationship?

In physiotherapy, the therapeutic relationship--in which a therapist and patient work together to achieve treatment goals--is increasingly seen as the foundation of patient care. How the therapeutic relationship is established and enacted, however, is not well understood. One way to better understand the nature of the relationship is to examine how therapists and patients evaluate and inform each other about the patient's physical capacity, sensation, and emotions. As the patient and therapist's talk is the primary means to realise and exchange such evaluations, our focus is on evaluative language used by the therapist and patient in their interactions. The aim of this paper is to examine the language and function of evaluation in physiotherapy consultations. The study is a discourse analytic one using Appraisal Theory. In Appraisal Theory, language resources that speakers use to construe evaluations such as emotions, judgments of behaviour and aesthetics are expressed as a system. The sub-systems are Affect (expressing emotion), Judgment (assessing behaviour) and Appreciation (evaluating processes and objects). The data are a convenience sample of 18 consultations from two cultural and therapeutic settings: primary healthcare (Sweden, Australia); and hospital rehabilitation (Australia). The findings show that both patient and therapist utilise all sub-systems of Appraisal; however, use of the sub-systems by the therapist and patient differs functionally. Judgment and Appreciation play a central role in therapists' co-construction of patients' physical history and presenting problem. In contrast, patient Affect evaluations, mainly to do with emotions about loss of capacity and pain, are generally not followed up by the therapist. The findings suggest that while patients engage with the therapeutic relationship from a clinical and interpersonal perspective, therapists are more narrowly focused on their own clinical tasks. The study findings have implications for understandings of the therapeutic relationship in physiotherapy and can inform teaching.

In Hospital We Trust: Experiences of older peoples' decision to seek hospital care.

The purpose of this study was to explore how older people experience and perceive decisions to seek hospital care while receiving home health care. Twenty-two Swedish older persons were interviewed about their experiences of decision to seek hospital while receiving home health care. The interviews were analyzed using qualitative content analysis. The findings consist of one interpretative theme describing an overall confidence in hospital staff to deliver both medical and psychosocial health care, In Hospital We Trust, with three underlying categories: Superior Health Care, People's Worries, and Biomedical Needs. Findings indicate a need for establishing confidence and ensuring sufficient qualifications, both medical and psychological, in home health care staff to meet the needs of older people. Understanding older peoples' arguments for seeking hospital care may have implications for how home care staff address individuals' perceived needs. Fulfillment of perceived health needs may reduce avoidable hospitalizations and consequently improve quality of life.

Utilization of patient resources in physiotherapy interventions: Analysis of the interaction concerning non-specific low back pain.

This paper reports on an empirical study in Sweden of how patient resources come into play in physiotherapy interventions. A qualitative analysis was conducted of five video-recorded first encounters between patients with non-specific low back pain (NSLBP) and physiotherapists in primary care, using Conservation of Resource Theory (COR) to identify and focus on how physiotherapists made use of patients' resources (objects, conditions, personal characteristics and energies). The findings reveal variations in how these resources are utilized during the intervention. Resources with implications for what happens in the examination room during the ongoing encounter and resources characterized by professional familiarity were both employed in the intervention. However, underutilized resources were featured in the broader lifeworld perspective of laypeople and of other professional frames. The findings raise questions about professional challenges that go beyond professional skills. This implies that professionals need to improve skills in understanding and integrating patient resources into interventions.

Problem-solving in physiotherapy--physiotherapists' talk about encounters with patients with non-specific low back pain.

PURPOSE: To investigate how physiotherapists talk about the choice of intervention for patients with NSLBP, particularly how professionals manage clinical encounters that may be experienced as challenging. METHOD: Discourse analysis was performed of four focus groups' talk. Twenty-one experienced physiotherapists working in primary health care in southern Sweden participated. RESULTS: Four focal themes appeared: Responsibility for health and health-related problems; Normalization - what counts as a normal back pain problem in relation to living an ordinary life; Change process - how to lead one's life; and Individualization of the intervention in relation to the individual patient but also from the physiotherapists' point of view. The themes shape an over-arching pattern of Problem-solving - which concerned both the professional task and the back pain problem, and was related to varying case complexity. This may have implications for the intervention the individual patient will be offered and on outcome. CONCLUSIONS: Physiotherapists' attitudes and approaches seem to entail components of professional and personal values which may influence patients' access to health care, with a risk for unequal assessment and intervention as a consequence. We argue that enhanced physiotherapist-patient collaboration, including patient-led problem-investigation, is a prerequisite for improved outcome in terms of patient satisfaction, and for physiotherapy development. Future investigations of patients' roles in specific face-to-face encounters are needed.

Physiotherapists' clinical reasoning about patients with non-specific low back pain, as described by the International Classification of Functioning, Disability and Health.

PURPOSE: To explore and describe what physiotherapists experience they need to know about patients with non-specific low back pain (NSLBP) to make decisions about intervention. METHOD: Four focus groups containing a total of 21 physiotherapists were carried out in Sweden. Interviews were transcribed and qualitative content analysis performed. The manifest content was coded and categorised, and a theme emerged. Extracted symptoms and signs were linked to ICF codes. RESULT: Physiotherapists' clinical reasoning represented a broad view on low back pain (LBP) including codes from all ICF components. The participants argued for individualisation of intervention to a specific patient's problems. A theme of case complexity emerged, involving three levels: easy case, characterised by impairment in body function with close relation to specific body structures; complex case, characterised by impairments in body function, particular mental functions, activity limitations and participation restrictions, particular management of activity level and very complex case, characterised by impairments in body function, activity limitations and participation restrictions, and contextual factors, with help-seeking behaviour as a particular feature. CONCLUSION: The physiotherapists' clinical reasoning reflected a broad view on patients with NSLBP, with variations related to case complexity. The use of ICF codes contributed to understanding that the physiotherapists applied a broad perspective on NSLBP as a health condition as well as to knowledge about how physiotherapists' understand patients with NSLBP. Physiotherapists' use of the ICF in clinical practice might facilitate identification and assessment of specific patient's back pain problem as they occur in daily life and therefore be helpful in rehabilitation planning. Findings might also have an educational value.