How physiotherapists attend to the human aspects of care when working with people with low back pain: a thematic analysis.

Pain is a multidimensional experience. Physiotherapy has attempted to enhance earlier biomedical approaches to patient care through approaches like the 'biopsychosocial' model. Nevertheless, physiotherapy continues to focus on biomedical and/or behavioural aspects of care. We critically investigated how physiotherapists attend to human (psychosocial, emotional, existential, and moral) aspects of low back pain care. We co-analysed ethnographic data with researchers, patients, and physiotherapists using concepts of conforming, tinkering and abandoning 'scripts'. Data included observations of 28 physiotherapy interactions between 26 patients and 10 physiotherapists and 7 researcher-clinician dialogues. Analysis suggests when conforming to scripts, clinicians have difficulty recognising and responding to emotions; time pressure limited clinicians focus, and a biological focus often distracted from psychosocial aspects of people's back pain experiences. In contrast, tinkering with or abandoning scripts allowed space to broaden the focus. Drawing from theorists such as Butler (1999) and Gibson et al. (2020) our analysis contributes to health sociology, arguing that 'tinkering' with or 'abandoning' scripts can foster more humanistic, flexible and reflexive approaches to care. Although health sociologists have explored tinkering, abandoning is new; within physiotherapy, it encapsulates being able to respond with agility to non-physical elements of care without constraint from traditional ways of thinking and doing.

Uncertainty in low back pain care - insights from an ethnographic study.

PURPOSE: To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions. MATERIALS AND METHODS: We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions). RESULTS: We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks. CONCLUSIONS: Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

A socio-emotional analysis of technology use by people with intellectual disabilities.

BACKGROUND: Access to information and communication technologies (ICTs) is often thought to enhance the lives of people with intellectual disabilities (ID) and is considered an important aspect of digital inclusion. However, inclusion practices often fail to address societal inequalities that lead to and sustain exclusion. The aim of this research was to enhance understandings of the relationships people with ID form with technology by critically analysing the underlying assumptions of inclusion practices. METHOD: We employed a post-qualitative approach to reanalyse previously collected data from face-to-face interviews with 10 Australian adults with ID who attended a community literacy programme about their technology use in their daily lives. Two of social theorist Sara Ahmed's key concepts were used to analyse these data: (1) 'stickiness' of emotions, where certain (socially dominant) emotions are considered to attach to objects over time (e.g. mobile phone use is normal/good) and (2) 'fit' between people and objects, where there is a sense of comfort when objects are designed for people like you - those outside the 'norm' experience discomfort and a sense of being 'othered' in their interactions with such objects which do not fit them. RESULTS: Our analysis identified how people with ID often attributed positive feelings to technology even when they had seemingly negative interactions with their devices (e.g. they could not use certain features, caregivers acted as gatekeepers to access). The positive associations were likely the outcome of implicitly held understandings that society highly values technology (Ahmed's stickiness of emotions). Although some participants accessed technology without difficulty, others experienced discomfort due to difficulties using devices that were not designed for them (Ahmed's fit between people and objects). Importantly, some participants had access to technology and the technical skill to use ICTs, but other factors, such as not having many friends, impacted their ability to use their devices in meaningful ways. CONCLUSION: Our analysis suggests that digital inclusion practices focused on providing access to technology may unintentionally harm in ways that are not immediately apparent when working with people with ID. Harms might include further marginalisation or 'othering' of people with ID. It is important to recognise that well-meaning attempts to encourage use of ICTs may be counterproductive if they lead to experiences of marginalisation. To avoid this, inclusion practices could focus beyond access to devices, and the ability to use them, to include considerations of the multiple socio-emotional effects. What is a good fit is not entirely predeterminable, exploration of the possibilities for what will work well for any individual requires experimentation and creativity, and a careful attention to unintended effects. Beyond this, the development of new technology should consider how to diversify devices that often fail to fit people with disabilities.

Enhancing human aspects of care with young people with muscular dystrophy: Results from a participatory qualitative study with clinicians.

BACKGROUND: Most research into clinical care of Duchenne or Becker dystrophinopathies (MD) has focused on slowing progressive muscular weakness and extending lifespan. Scarce attention has been paid to the "human" aspects of care such as psychosocial health, living a fulfilling life, or dealing with disability stigma. This study partnered with clinicians to identify and address local and systemic barriers to these human aspects of care. METHODS: We employed a participatory qualitative design at a multidisciplinary MD clinic using 2 methods: (a) ethnographic observations over a 6-month period of clinic visits of children with MD and families, involving 12 clinicians, and (b) 3 "dialogues" (2-way discussions) with these clinicians to collaboratively analyze practices and co-produce recommendations for change. RESULTS: Our methods produced rich data that, when coanalyzed with clinicians and in consultation with a family advisor, provided deep insights into the practices and underlying assumptions of a neuromuscular clinic. Staff recognized the importance of the human aspects of care but, in reviewing the observational data, identified that it was given insufficient attention in (a) routine clinical processes, (b) clinician-family patterns of interaction, and (c) staffing allocations. CONCLUSION: Although the human aspects of care were important to clinicians in the MD clinic, the routines and nature of the clinic meant these were frequently sidelined for biomedical objectives. We present collaboratively produced practical recommendations toward addressing this disjunction between ideals and practice including developing flexibility to tailor appointment frequency, composition, and length; providing time and physical space for psychosocial aspects of care; and clinician skill building to support child/family expression of "negative" emotions; and discussion of sociopolitical aspects of MD such as living with disability stigma. The study offers a set of considerations that, taking into account individual differences, offer insights for similar clinics elsewhere.

Addressing weight stigma in physiotherapy: Development of a theory-driven approach to (re)thinking weight-related interactions.

In this article, we propose a theory-driven approach to developing interventions for reducing weight stigma in physiotherapy and discuss the design and exploratory trial of such an intervention. Weight stigma has been identified in physiotherapists in empirical investigations. However, there has been little consideration of how this stigma might be addressed. We highlight Goffman's work on stigma that provides social and embodied understandings of stigma. Goffman's approach, however, is notably apolitical, ahistorical and lacks mechanisms for understanding power. We suggest that post-structuralist perspectives can provide insight into these areas. Drawing on these theories, we critically examine the literature on weight stigma reduction, finding that trials have largely been unsuccessful. We argue that this may be due to overly passive and simplistic intervention designs. As context-specific understandings are desirable, we examine the nature of physiotherapy to determine what might be relevant to (re)thinking weight in this profession. We then discuss the development of a multifactorial, active weight stigma intervention we trialed with eight physiotherapists. Supported by theory, the outcomes of the exploratory study suggest that physiotherapy-specific factors such as fostering professional reflexivity and improving understandings of stigma need to be incorporated into an active intervention that considers the complex determinants of weight stigma.

Opposites attract: MHC-associated mate choice in a polygynous primate.

We investigated reproduction in a semi-free-ranging population of a polygynous primate, the mandrill, in relation to genetic relatedness and male genetic characteristics, using neutral microsatellite and major histocompatibility complex (MHC) genotyping. We compared genetic dissimilarity to the mother and genetic characteristics of the sire with all other potential sires present at the conception of each offspring (193 offspring for microsatellite genetics, 180 for MHC). The probability that a given male sired increased as pedigree relatedness with the mother decreased, and overall genetic dissimilarity and MHC dissimilarity with the mother increased. Reproductive success also increased with male microsatellite heterozygosity and MHC diversity. These effects were apparent despite the strong influence of dominance rank on male reproductive success. The closed nature of our study population is comparable to human populations for which MHC-associated mate choice has been reported, suggesting that such mate choice may be especially important in relatively isolated populations with little migration to introduce genetic variation.

Philopatry and reproductive success in Bornean orang-utans (Pongo pygmaeus).

Behavioural observations suggest that orang-utans are semi-solitary animals with females being philopatric and males roaming more widely in search of receptive partners, leading to the prediction that females are more closely related than males at any given site. In contrast, our study presents evidence for male and female philopatry in the orang-utan. We examined patterns of relatedness and parentage in a wild orang-utan population in Borneo using noninvasively collected DNA samples from animals observed to defecate, and microsatellite markers to assess dispersal and mating strategies. Surprisingly, resident females were equally as related to other resident females (mean r(xy) = 0.303) as resident males were to other resident males (mean r(xy) = 0.305). Moreover, resident females were more related to each other and to the resident males than they were to nonresident females, and resident males were more related to each other (and resident females) than they were to nonresident males. We assigned genetic mothers to 12 individuals in the population, while sires could be identified for eight. Both flanged males and unflanged males achieved paternity, similar to findings reported for Sumatran orang-utans.

Life history correlates of inbreeding depression in mandrills (Mandrillus sphinx).

Inbreeding depression reflects the negative consequences of increased homozygosity at genes that affect fitness. We investigate inbreeding depression in a semi-free-ranging colony of mandrills (Mandrillus sphinx), using high-quality pedigree data, comprising five maternal generations and 20 years of morphological and demographic data. We examine the relationship between inbreeding coefficients and four fitness correlates: two growth parameters (mass and height for age) and longevity in both sexes, and age at first conception in females. Inbreeding was correlated with both growth parameters, but only in females, with inbred females being smaller than noninbred females. Inbreeding was also correlated significantly with age at first conception, with inbred females giving birth earlier in life than noninbred females. We suggest that sex-biased maternal investment may explain this sex-differential response to inbreeding, although the lack of a significant association between inbreeding and growth in males may also be due to the provisioned nature of the colony. The surprising relationship between age at first conception and inbreeding may be related to smaller adult size in inbred females, or to their being less able to escape from male sexual coercion.

Genetic diversity and reproductive success in mandrills (Mandrillus sphinx).

Recent studies of wild animal populations have shown that estimators of neutral genetic diversity, such as mean heterozygosity, are often correlated with various fitness traits, such as survival, disease susceptibility, or reproductive success. We used two estimators of genetic diversity to explore the relationship between heterozygosity and reproductive success in male and female mandrills (Mandrillus sphinx) living in a semifree ranging setting in Gabon. Because social rank is known to influence reproductive success in both sexes, we also examined the correlation between genetic diversity and social rank in females, and acquisition of alpha status in males, as well as length of alpha male tenure. We found that heterozygous individuals showed greater reproductive success, with both females and males producing more offspring. However, heterozygosity influenced reproductive success only in dominant males, not in subordinates. Neither the acquisition of alpha status in males, nor social rank in females, was significantly correlated with heterozygosity, although more heterozygous alpha males showed longer tenure than homozygous ones. We also tested whether the benefits of greater genetic diversity were due mainly to a genome-wide effect of inbreeding depression or to heterosis at one or a few loci. Multilocus effects best explained the correlation between heterozygosity and reproductive success and tenure, indicating the occurrence of inbreeding depression in this mandrill colony.

Growth and ontogeny of sexual size dimorphism in the mandrill (Mandrillus sphinx).

We present body mass (N = 419) and crown-rump length (CRL, N = 210) measurements from 38 male and 49 female mandrills born into a semifree-ranging colony in order to describe growth from birth to adulthood, and to investigate maternal influences upon growth. Adult male mandrills are 3.4 times the body mass, and 1.3 times the CRL, of adult females. Body mass dimorphism arises from a combination of sex differences in length of the growth period (females attain adult body mass at 7 years, males at 10 years) and growth rate. Both sexes undergo a subadult growth spurt in body mass, and this is much more dramatic in males (peak velocity 551 g/months +/- 89 SEM at 84-96 months). CRL dimorphism arises from bimaturism (females attain adult CRL at 6 years, males after 10 years), and neither sex shows a particular subadult growth spurt in CRL. Sexual size dimorphism thus represents important time and metabolic costs to males, who mature physically approximately 3-4 years after females. Considerable interindividual variation occurs in the size-for-age of both sexes, which is related to maternal variables. Older mothers have heavier offspring than do younger mothers, and higher-ranking mothers have heavier offspring than do lower ranking mothers. Mass advantages conferred upon offspring during lactation by older and higher-ranking mothers tend to persist postweaning in both sexes. Thus maternal factors affect reproductive success in both sexes, influencing the age at which offspring mature and begin their reproductive career.

Arrested development of secondary sexual adornments in subordinate adult male mandrills (Mandrillus sphinx).

Previous studies of semifree-ranging mandrills identified two morphological and social variants of the adult male, based on behavioral and secondary sexual characteristics. "Fatted" males are social, with highly developed sex skin coloration, large testes, high plasma testosterone levels, and fat rumps; while "nonfatted" males are peripheral or solitary, with paler sex skin, smaller testes, lower plasma testosterone, and slimmer rumps. We present a detailed study of morphology and group association for 10 adult male mandrills, living in two semifree-ranging groups in Gabon, in order to relate differences between males to dominance rank. The results show that rather than existing as two distinct morphotypes, male mandrills represent a continuous spectrum of possibilities between social males with fully developed secondary sexual characteristics, and solitary males with muted secondary sexual characteristics. Alpha males (N = 2) had the highest testosterone levels, the most colorful sex skin, and the most active sternal glands, and were the only males to spend 100% of their time with the social group. Rank relationships between nonalpha males (N = 8) were not always clear, but all subordinate males had lower testosterone levels and less development of the secondary sexual adornments, and were less group-associated than alpha males. These findings suggest that only alpha males have sufficient testosterone to develop full secondary sexual characteristics, and we propose possible socioendocrine mechanisms underlying the suppression of testosterone and secondary sexual development in subordinate adults. We discuss differences in secondary sexual development in relation to reproductive strategies, and discuss the evolution of alternative reproductive morphs in primates.

Changes in the secondary sexual adornments of male mandrills (Mandrillus sphinx) are associated with gain and loss of alpha status.

Two semifree-ranging mandrill groups, inhabiting large, naturally rainforested enclosures in Gabon, were studied to measure morphological, endocrine, and behavioral changes that occurred when adult males rose, or fell, in dominance rank. Gaining alpha rank (N = 4 males) resulted in increased testicular size and circulating testosterone, reddening of the sexual skin on the face and genitalia, and heightened secretion from the sternal cutaneous gland. Blue sexual skin coloration was unaffected. New alpha males increased in rump "fattedness," but not in body mass, and spent more time associated with other group members, rather than ranging alone. Loss of alpha position (N = 4 males) resulted in less pronounced effects than those that occurred after males had risen to alpha positions. Deposed alpha males showed decreased testicular volume, decreased body mass, a reduction in the extent of red (but not blue) sexual skin coloration, and decreased sternal gland activity. Deposed males did not decrease in the brightness of sex skin coloration. These results demonstrate that male-male competition and rank reversals have remarkable effects upon testicular function, secondary sexual traits, and behavior in the adult male mandrill. Secondary sexual traits respond to changes in male social status and therefore may be important as intrasexual signals of dominance rank.

Circannual changes in the secondary sexual adornments of semifree-ranging male and female mandrills (Mandrillus sphinx).

Male mandrills (Mandrillus sphinx) have spectacular secondary sexual adornments. These include red and blue sexual skin on the face, rump, and genitalia; a sternal scent-marking gland; and a "fatted" rump. Mandrills are seasonal breeders, and in other seasonally-breeding primate species members of both sexes may show increased expression of secondary sexual characteristics during the mating season. We examined changes in male secondary sexual adornments and testosterone levels, in relation to seasonal changes in the female reproductive cycle and sexual skin morphology, in two semifree-ranging mandrill groups. Females showed circannual changes in sexual skin tumescence, and periods of tumescence peaked from May-July in a long-established group. However, formation of a second, smaller group, two years previous to commencement of the study, disrupted the seasonal pattern of sexual skin tumescence and births. As the groups occupied adjacent enclosures, it appears that social factors, as well as physical environment, affected the seasonal patterning of reproduction in females. Male mandrills, by contrast, did not exhibit marked circannual changes in secondary sexual traits. Although adult male testicular volume and circulating testosterone levels increased significantly during the mating season, sexual skin coloration and rump "fattedness" showed no consistent changes with season. There was some evidence to suggest that maturing males (ages 5-8 yr) showed increased development of red sexual skin during mating periods, but once males had fully developed secondary sexual adornments, they remained stable throughout the year. The possible reasons for this are discussed in relation to intermale competition and social organization in mandrills.

Management of alcohol abusing patients in accident and emergency departments.

A pilot study was undertaken in the Accident & Emergency (A & E) departments of two central London teaching hospitals to determine if patients who were abusing alcohol and had not received any prior medical treatment or counselling for their drinking problem were amenable to offers of help. During the 24-month study period 104 patients were identified as having a previously untreated alcohol problem, and of these 46% attended an appointment to discuss their drinking habits. The group identified was much smaller than would be expected from the number attending the A & E departments during the study period and the reasons for this are discussed. However, the important observation from the study is that almost half the patients identified as having an alcohol problem returned to the department the following day to seek advice. This suggests that A & E departments are an appropriate place to offer patients initial help about their drinking habits.