Objective: To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy. Methods: We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized. Results: Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient’s understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls. Conclusion: Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain. Study registration: Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Depression frequently co-exists with chronic pain. Contemporary models suggest that these conditions share pathobiological mechanisms, prompting a need to investigate their temporal association. This investigation aimed to explore two distinctly different chronic pain conditions, and their cross-sectional and prospective associations with depression. Self-reported information was available on chronic widespread pain (CWP), chronic low back pain (CLBP) (45y), and depression symptoms (45y and 50y) from up to 9377 participants in the 1958 British cohort. Depression symptom outcomes were derived by ‘Clinical Interview Schedule-Revised’ (45y) and ‘Short Form-36’ (50y). Relationships between both chronic pain conditions and depression symptoms were investigated by fitting four separate logistic regression models, each with varying levels of covariate adjustment, including depression at baseline. CWP was associated with depression symptoms cross-sectionally (OR = 2.04, 95% CI 1.65; 2.52, p <0.001, n = 7629), and prospectively when fully-adjusted for baseline, sociodemographic, lifestyle, and health covariates (OR = 1.45, 95% CI 1.17; 1.80, p = <0.001, n = 6275). CLBP was associated with depression symptoms prospectively (full model: OR = 1.28, 95% CI 1.01; 1.61, p = 0.04, n = 6288). In fully-adjusted models the prospective association of CWP with depression symptoms was more heavily influenced by our covariates than CLBP with depression. Pain may be a stressor from which depression can arise. Development of depression is differentially associated upon the type of pain experienced. Screening for depression symptoms amongst individuals with both chronic pain conditions is indicated and should be repeated over time.

From Where We've Come to Where We Need to Go: Physiotherapy Management of Chronic Whiplash-Associated Disorder

Chronic pain (CP) is a leading global health burden. While high-value physiotherapy (HVP) such as exercise can be effective for rehabilitation, low-value treatments such as manual therapy, remain common. We identified barriers and enablers to HVP for persons with CP, and established their alignment with the Theoretical Domains Framework (TDF) of behaviour change. Six databases were systematically searched for studies reporting quantitative and/or qualitative data on barriers and enablers experienced by physiotherapists to the delivery of HVP for individuals with CP. Data were tabulated and narratively synthesised. Thirty-seven studies were included, relating to chronic low back pain [17], osteoarthritis [15], various musculoskeletal conditions [3], rotator cuff tendinopathy [1], and patellofemoral pain [1]. Barriers to HVP for chronic low back pain and osteoarthritis mapped to eight common TDF domains: knowledge, skills, social/professional role and identity, beliefs about consequences, environmental context and resources, beliefs about capabilities, intentions, and social influences. Key barrier and enabler themes included: system-level resources, knowledge/training, and professional factors. Physiotherapists face barriers to implementing HVP for the rehabilitation of individuals with CP, spanning multiple TDF domains. Findings suggest the need for multi-faceted interventions, including changes in resourcing and capacity building within healthcare systems.