‘A challenge to my professional identity’- resisting the shift from over-management to self-management for back pain within an implementation trial: a qualitative study

Abstract

Objective: the Enhanced Transtheoretical Model Intervention (ETMI) is based on behavioral models and focuses on guiding Chronic Low Back Pain (CLBP) patients to self-manage symptoms and engage in recreational physical activity. While there is promising evidence that ETMI benefits patients, it is unclear how challenging it might be to implement widely. This investigation focused on the perceptions of physiotherapists trained to deliver ETMI for CLBP. 

Design: a Qualitative study comprised of semi-structured interviews (July to November 2023). Interviews were audio-recorded, transcribed, coded, and analyzed thematically by two independent researchers. 

Setting: data were obtained as part of a large implementation study evaluating the uptake and impact of ETMI amongst physiotherapists in a large public healthcare setting. 

Participants: 22 physiotherapists trained to deliver the ETMI approach and chose to use it with at least one patient. 

Results: while physiotherapists acknowledged the evidence base behind ETMI and the clarity of the approach, they struggled to adapt it to routine delivery. Exploration of the reasons for this identified an overarching meta-theme, ‘A challenge to my professional identity’, and three main themes consisting of 1) interventions such as ETMI contradicted my training. 2) I am ambivalent/ do not accept evidence that contradicts my habitual practice, and 3) I am under-skilled in psychological and communication skills. 

Conclusion: this study highlights the reluctance of physiotherapists to implement evidence-based interventions such as ETMI, which fundamentally challenge their traditional practice and therapeutic identity. The shift from over-management by experts seeking cures to supporting self-management was not palatable to physiotherapists. The challenge of embracing a new professional identity must be addressed to enable a successful implementation of the approach. 

Contribution of the Paper: 

• This study highlights the reluctance of physiotherapists to implement evidence-based interventions such as ETMI, which fundamentally challenge their traditional practice and therapeutic identity. 

• The shift from overdiagnosis (weak cores, bad postures, unstable back, or disc sliding) and over-management (specific exercises, modalities, or special techniques) by experts seeking cures to support self-management was not palatable to physiotherapists. 

• The findings could lead to a reevaluation of professional development programs for physiotherapists, with an emphasis on updating skills and knowledge to align with evidence-based practices, ultimately aiming to enhance the quality of care provided to patients.

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