ABSTRACT
The aim of this study was to explore and describe the physiotherapy treatment experiences of persons with persistent musculoskeletal pain. Eleven participants with persistent musculoskeletal pain in the back, neck, or shoulders were included in the study. Data was collected via semi-structured interviews and were analysed with qualitative content analysis. The analysis resulted in the theme “Towards acceptance and management of pain”, comprising four sub-themes: 1) Establishing and maintaining a therapeutic alliance; 2) Being active, taking initiative and facing challenges; 3) Appreciating guidance, incentive and having a sounding board; and 4) Acquired knowledge and new body awareness change behaviours. The theme and sub-themes describe how the participants used increased knowledge, awareness, movements and exercises learned from the physiotherapy treatment to develop strategies for managing pain and the process of acceptance. A trusting relationship and continual dialogue with the physiotherapist was considered to be important. The participants were actively involved in the process as exercises, activities and other treatment modalities were individualized. This was rewarding but also challenging and required effort on their part. The physiotherapist’s initiatives and actions were an important incentive and means of support.
Introduction
Musculoskeletal pain is one of the most common reasons in primary health care for consulting a physiotherapist (Jordan et al., Citation2010; Speerin et al., Citation2014). Having persistent musculoskeletal pain is a complex experience, unique to each individual, and can lead to disability and reduced health (Loeser, Citation1991). Physiotherapy aims to help these persons achieve healthy levels of activity and self-management, at its best addressing both their physical limitations and their beliefs about and understanding of their condition (Chartered Society of Physiotherapy CSP, Citation2014). In that sense, physiotherapy treatment can be seen as a process wherein both physiotherapist and patient are actively involved. In helping persons with persistent pain to enhance pain management, Semmons (Citation2016) proposed three key elements for physiotherapy treatment and clinical practice: 1) patient education; 2) empowerment; and 3) exercise. These suggested strategies are meant for the physiotherapist. We believe that it also is important to understand patient expectations and experiences of the physiotherapy treatment process.
Some previous studies of patients’ expectations of physiotherapy treatment confirm that persons with persistent pain expect to receive explanations for their pain (Bernhardsson, Larsson, Johansson, and Öberg, Citation2017; Calner, Isaksson, and Michaelson, Citation2017; Stenberg, Fjellman-Wiklund, and Ahlgren, Citation2012). Exercises and training are common expectations (Bernhardsson, Larsson, Johansson, and Öberg, Citation2017; Calner, Isaksson, and Michaelson, Citation2017), which is in line with the recommendations of Semmons (Citation2016). Earlier findings also elucidate how patients expect a trusting relationship and good communication with the physiotherapist (Bunzli et al., Citation2016; Slade, Patel, Underwood, and Keating, Citation2014; Stenberg, Fjellman-Wiklund, and Ahlgren, Citation2012); and to be actively engaged in the treatment (Bernhardsson, Larsson, Johansson, and Öberg, Citation2017; Stenberg, Fjellman-Wiklund, and Ahlgren, Citation2012). In addition to the treatment process, expectations of treatment outcomes are also described, encompassing several aspects. Hoping for the best possible results, having realistic or even resigned attitudes (Calner, Isaksson, and Michaelson, Citation2017), getting pain relief, improving function and physical fitness and well-being (Hsu et al., Citation2014) have all been expressed as expected outcomes.
Considering the limited knowledge of patients’ expectations of physiotherapy, exploring and describing the physiotherapy experiences of those with persistent pain seems worthy. Several other studies have explored physiotherapy experiences of patients with persistent pain (Cooper, Smith, and Hancock, Citation2008; May, Citation2007; Sokunbi, Cross, Watt, and Moore, Citation2010; Stenberg, Fjellman-Wiklund, and Ahlgren, Citation2012; Wilson, Chaloner, Osborn, and Gauntlett-Gilbert, Citation2017). Some of these studies focused on the patients’ perspective rather than the physiotherapy treatment process (May, Citation2007; Sokunbi, Cross, Watt, and Moore, Citation2010). The study by Wilson, Chaloner, Osborn, and Gauntlett-Gilbert (Citation2017) examined treatment in a specialized pain clinic, while Stenberg, Fjellman-Wiklund, and Ahlgren (Citation2012) had a gender perspective and Cooper, Smith, and Hancock (Citation2008) aimed to define patient centeredness from the patients’ perspective. At the time of the study, we found a lack of explorative studies of persons with persistent musculoskeletal pain and their personal experiences in relation to the physiotherapy treatment process in primary care. When evaluating the physiotherapy treatment for persistent pain, we believe that it is important to take these persons’ experiences into account. Gaining further knowledge about this could contribute to determining how the treatment process could be improved. This would be important knowledge for a physiotherapist to understand how to support and help individuals with pain management. The aim of this study was to explore and describe the physiotherapy treatment experiences of persons with persistent musculoskeletal pain.
Method
An explorative qualitative research design was used in order to develop an understanding of physiotherapy treatment experiences according to the aim of the study. Qualitative content analysis was chosen to identify, describe and categorize patterns within the data, as it focuses on subject and context and emphasizes variation (e.g. similarities within and differences between parts of the text) (Graneheim and Lundman, Citation2004; Graneheim, Lindgren, and Lundman, Citation2017). The regional ethics review board in Umea, Sweden approved the study (DNR 2013–11-31 M).
Participants and procedure
Participants were primarily recruited from a previous study concerning persons’ expectations of physiotherapy treatment (Calner, Isaksson, and Michaelson, Citation2017) and were contacted again by the first author after completion of their physiotherapy treatment. Six of the ten participants agreed to participate in the current study. Four participants did not participate for reasons unknown. Additional recruitment was conducted among persons who had recently completed physiotherapy treatment at two primary health care services. Permission to identify and contact the persons registered at the primary health care services was obtained from the chief manager of each unit. In order to be included in the study, participants had to be over 18 years of age, speak fluent Swedish, and report persistent musculoskeletal pain from the neck, back, or shoulders. Exclusion criteria were persons with dementia, other instances of severe cognitive impairment, or other severe illnesses or diagnoses that could prevent them from completing the physiotherapy treatment. The participants were chosen purposively according to the study aim and the inclusion and exclusion criteria (Holloway and Wheeler, Citation2010). The physiotherapists at each primary health care service identified patients who fulfilled the eligibility criteria. They presented brief information about the current study. If the person gave consent, the physiotherapist e-mailed the contact information to the first author, who in turn contacted each person by phone. Inclusion and exclusion criteria were checked over the phone. Details and practical information about the study, as well as assurance of the option to withdraw from the study at any time, were given to each participant as well as guaranteed confidentiality. In keeping with those criteria and a purposeful sampling strategy, eleven participants came to participate in the study, recruited from three different health care services. They attended physiotherapy treatment from six different physiotherapists. describes the details of the participants’ characteristics. A flow chart of the study procedure is described in .
Table 1. Participants’ characteristics
Figure 1. Flow chart of recruitment to the study
The first author (TC) is a physiotherapist with previous extensive clinical experience in meeting persons with persistent pain in a treatment context. He has a PhD degree and this study was part of his doctoral thesis. The second author (GI) is a professor in occupational therapy, and especially experienced in qualitative research. The third author (PM) is a physiotherapist with both previous and current comprehensive clinical experience in the area of persistent musculoskeletal pain. He is an associate professor in the research field of persistent musculoskeletal pain. None of the authors had any prior relationship to any of the participants.
Data collection
Data were collected through interviews conducted by the first author using a semi-structured interview guide in order to cover issues of interest in line with the aim of the study and to collect similar data from all participants (Brinkmann and Kvale, Citation2015). The interviews with the six participants from the previous study were conducted between January and October 2014, and the interviews with the additional participants were conducted between August and October 2016. The interviews focused on the participants’ experiences of the physiotherapy treatment process and began with the open-ended question: “You have attended physiotherapy treatment. Tell me about your experiences”. Follow-up questions were based on the individual participant’s response. All participants were encouraged to describe their experiences in as much detail as possible, thereby covering as many aspects of the aim of the study as possible. An example of a general type of follow-up question used was “Can you tell me more about what that means to you?” An example of a more specific follow-up question was “Is there any event that you remember in particular? Can you tell me more about that?”. Corresponding to recommendations from Elo et al. (Citation2014) and to confirm and further develop the interview questions, a preliminary analysis was conducted as each interview was discussed among the three authors. Minor adjustments to the interview guide were made after the first interview (Appendix 1). The interviews lasted between 20 and 63 minutes and were recorded on a MP3 player and transcribed verbatim. Data collection continued until comprehensive and rich data responding to the study aim were obtained.
Analysis
Data were analysed using qualitative content analysis with an inductive approach according to the process suggested by Graneheim, Lindgren, and Lundman (Citation2017). The first author carefully listened to the interviews one by one and made notes of core features and meaning related to the aim of the study. In the next step, the first author read all the transcribed text in order to get an overview of the content and obtain a sense of the whole. The data were then analysed for meaning units; phrases and/or paragraphs containing aspects related to the aim of the study. The meaning units were condensed, abstracted, and formulated into codes by the first author, and discussed with and confirmed by the two other authors. This part of the analysis process preserved the core features of the meaning units and described the manifest content. The codes were interpreted and abstracted to sub-themes, describing the latent content with a hermeneutic interpretation (Graneheim, Lindgren, and Lundman, Citation2017). The sub-themes were checked, discussed and revised in relation to the core features and meaning through the whole text in dialogue among all three authors. Finally, a theme was identified and formulated as the thread running through the sub-themes, constituting the meaning of the participants’ experiences (Graneheim, Lindgren, and Lundman, Citation2017). shows examples of the research procedure from coding to developing sub-themes and identifying a theme.
Table 2. Examples of codes, sub-themes and theme
Results
The analysis resulted in four sub-themes that describe the participants’ experiences of physiotherapy treatment: 1) Establishing and maintaining a therapeutic alliance; 2) Being active, taking initiative and facing challenges; 3) Appreciating guidance, incentive and having a sounding board; and 4) Acquired knowledge and new body awareness change behaviours. Finally, the theme Towards acceptance and management of pain was formulated, capturing a thread running throughout the four sub-themes.
Towards acceptance and management of pain
Overall, the theme gives meaning to the participants’ experiences described in the sub-themes, which led to their current situation, constituting a vantage point for the future. The theme also encompasses the participants’ reflections on their own process in light of the physiotherapy treatment process and their current status. During the physiotherapy process, they acquired acceptance of their pain regarding how the pain made them prioritize. They further learned to draw personal boundaries and take better care of themselves than before the physiotherapy treatment. In contrast, accepting their pain could also be a frustrating struggle (i.e. realising that their pain may never go away and that some activities will be difficult or impossible to conduct in the future). They used their increased knowledge and developed body awareness, as well as movements and exercises to develop strategies to manage the impact of pain. In that sense, the participants managed their everyday lives in several new ways.
Establishing and maintaining a therapeutic alliance
This sub-theme describes the participants’ expressions of the importance of establishing a therapeutic alliance with the physiotherapist. Gaining trust for and confidence in the physiotherapist and being seen as an individual were initially deemed necessary for creating this alliance. These initial factors were prerequisites for the treatment process. Continual dialogue and the individualisation of treatment options and activities were also considered important.
Most participants described that the physiotherapist showed interest in them from the very beginning, including giving them time to tell their stories, starting from the beginning of their pain problems. According to one participant with several previous experiences with the health care system, this was the first time a health care professional had done that. Being acknowledged as an individual made the participants feel safe and that they were taken seriously enough to be confident and tell the physiotherapist how they really felt.
“A very sensitive physiotherapist who … I felt immediately that she saw all of me and that she really tried to understand how I was feeling and why I felt the way I did. And she examined me very thoroughly. Well, it was fantastic. I experienced that I was really seen.” (Participant 6)
Most participants indicated that they received affirmation regarding their symptoms, health status and functional status, which was considered to be important and created an initial alliance of trust and safety. Several participants described how this bond continued during the treatment process; however in the end, it also made them feel insecure and uncertain when they faced the obstacle of managing on their own conclusion of the treatment. In contrast there were also descriptions of the physiotherapist not seeing the participant as a whole person or fully understanding their situation or the implications of having pain problems or having been injured. The gender of the physiotherapist also emerged as an important factor for building trust and safety among some participants.
“It feels safer that it is a woman … I don’t know, I can’t really put it into words, but … It feels more comfortable, more relaxed than if it was … because I stand there in my bra and panties. You’re almost half-naked, you know. So it feels more comfortable that it is a woman.” (Participant 5)
In line with being validated and acknowledged as individuals, most participants described having individualized exercises. This was manifested as the participants described how the exercises, activities and other treatment modalities in the treatment process were explained, practiced and checked so that the participants felt the programs suited them. The participants expressed that the initial experiences were the beginning of an appreciated dialogue and communication pattern since they felt welcomed by the physiotherapist. The participants experienced that dialogue and communication continued and reported that this was of great importance throughout the treatment process. Participants gave concrete examples of dialogue about exercise choices and motivational discussions on how to perform them. They also spoke of the benefits of alternative treatment choices and options. Most participants felt that the physiotherapist was open to their views about and suggestions for treatment, which made it a collaborative dialogue.
“I feel that she listened and we experimented and added some exercises to those we already had and I believe that was an effective method … because in that sense it was real communication and that’s very important.” (Participant 3)
There were also descriptions of a lack of communication. Some responses related that the physiotherapist was not open to discussing treatment options and choices in the participant’s preferred way or that the physiotherapist seemed to have a different view than the participant regarding the most favourable treatment options.
“I wanted to get more help with, not just the back of the neck … I have had a lot of care for that. But the rest of my problems, it is very hard to get help for them actually. I asked about that several times but I haven’t managed to get her (the physiotherapist) to examine me further” (Participant 3)
Being active, taking initiative and facing challenges
This sub-theme captures how the participants were aware of their role in the treatment process and gradually took responsibility for being active, attending the sessions frequently and performing their exercises. Some participants also took the initiative to participate in activities and performed exercises on their own, which was encouraged by the physiotherapist. At the same time, attending physiotherapy treatment was considered to be an effort and a challenge that demanded self-discipline and took energy. Several participants were offered the opportunity to renew their contacts after the conclusion of the treatment, but they were responsible for initiating the next round of treatment.
The participants were aware of their responsibility to be active and perform the exercises, partly at the physiotherapy unit and partly at home or in the gym. They described the self-discipline and effort needed to do the exercises and programs and acknowledged that they had to keep practicing and doing exercises to maintain their status or improve further. They realized that they had to create a routine for doing their exercises. Most participants did so and made it work.
“I have to do the exercises myself, and it’s me who really must make room in my everyday life to do this, otherwise it’s not going to get better … ” (Participant 1)
Some participants managed on their own, doing all exercises at home, while others preferred to do their exercises at the physiotherapy unit or health care centre. They expressed various success rates regarding these new routines over time. Several participants experienced increased self-discipline to exercise after their symptoms and functionality improved; consequently, they prioritized the exercises that yielded the best results. Some participants found it difficult to maintain the self-discipline, especially in the beginning, and some found it hard trying to keep up with the physiotherapist’s expectations.
Some participants took initiative regarding activities and exercised outside the physiotherapy program and found that this was encouraged by the physiotherapist. As function improved, there were several descriptions of activities that participants were capable of performing once again. A couple of participants described how the physiotherapist tailored specific exercises to enable their capabilities within these activities.
“I have tried cross-country skiing a little this autumn. And I got some great exercises from my physiotherapist” (Participant 9)
Even though the participants were aware of their responsibility to be active, they described experiencing considerable effort and stress in attending physiotherapy treatment. Some found it exhausting taking the time to attend frequent appointments as well as scheduling and performing exercises at home or at a gym. They explained that this was due to for example high pain levels, increased sensitivity and lower thresholds for exhaustion. Another aspect of exertion was described as experiencing difficulties in performing exercises where the physiotherapist did not understand that it was too difficult, which made the exercise programs even more exhausting. Therefore, the participants expressed the importance of finding a balance in their exercises, frequency, total load and how advanced and challenging the exercises should be.
“When you have that much pain, you really can’t cope with training, it’s a strain to go there and exercise. It’s an appointment you have to keep. In that sense, physiotherapy can be a huge strain. Even if it’s good for you, you still have to get yourself there; you must endure being there, even when you have so much pain … ” (Participant 2)
Appreciating guidance, incentive and having a sounding board
This sub-theme describes how all participants expressed that the physiotherapist’s initiatives and actions were important for the treatment process and for their own progress. They primarily described the physiotherapist as being in charge of the treatment process on several levels. The physiotherapist acted like a guide and a sounding board throughout the process as participants trusted the physiotherapist to develop programs and exercises according to their results and performance. The physiotherapist was also described as being an incentive for sustaining exercises.
The physiotherapist was considered to be responsible for the choice, progression and dosage of exercises and movements. The participants also stated that they needed and appreciated guidance and instructions, preferably both written instructions and physical demonstrations. There were also several descriptions of the physiotherapist acting as a sounding board and coach, showing interest in the participants’ activities and exercises, encouraging their progress and discussing further development of exercises.
“And you know, at one time, I told the physiotherapist that my back pain had increased, I said to her ‘I don’t know if I’m doing something wrong’. So the next time she said ‘OK, you are lifting a bit too much there, remember to keep it down a bit’. Then I felt the difference.” (Participant 7)
Frequent follow-ups were considered important to the participants since many of them were afraid of doing something wrong that could exacerbate their problems. Meeting with the physiotherapist regularly, they experienced that the performance of their exercises could be corrected or confirmed if necessary. In most cases, the participants were offered and attended these frequent, beneficial follow-up meetings.
“I believe that it’s good to come here, that [the physiotherapist] picks up on my faults a little, and decides which exercises to do, maybe add one or remove another, and make sure that I do it right … ” (Participant 4)
There were also examples when this did not turn out as the participants needed or expected. When the physiotherapist did not check in with participants or help them with their performance of the exercises frequently enough, participants felt unsure and even abandoned for weeks.
For many participants, the frequent visits and follow-up appointments with the physiotherapist served as an incentive to continue doing the exercises at home or at the gym according to the treatment plan. Several participants expressed that they believed that they would have otherwise failed in frequent exercise practice.
“I’m motivated as long as I have someone to work with like this, like with [the physiotherapist]. But when I stop physiotherapy, I know my motivation will drop since I won’t have anyone following up with me.” (Participant 9)
Acquired knowledge and new body awareness change behaviours
This sub-theme captures how the participants described that the treatment process made them acquire knowledge and develop new awareness, leading to new behaviours and beneficial movement patterns.
The participants described acquiring important understanding and theoretical knowledge by receiving information, explanations and answers to their questions from the physiotherapist. This knowledge was expressed foremost as an understanding of pain mechanisms, how and why pain increases or decreases, and understanding how movements, posture and tension patterns could trigger their pain. Several participants expressed that the exercises, specific movements, or techniques learned and practiced in the physiotherapy process increased their body awareness. This was described as new awareness of habits and patterns in posture, breath, muscle tension and movements. For some participants, this brought change in posture or movement patterns.
“I became more aware of the body and these minor movements. To keep the body together so to speak, to be more aware of … how I should move and to have more of a holistic view, you might say.” (Participant 2)
On the other hand, there were descriptions of how new body awareness brought change in posture or movement patterns only during physiotherapy sessions. Participants described how they found new postures or movement patterns when guided by the physiotherapist but could not find them again on their own.
New body awareness, together with increased theoretical knowledge, was useful for the participants in understanding disadvantageous movement patterns/postures. Thanks to these experiences, the participants were able to learn new and more favourable movement behaviours and patterns in their daily activities including work. This could, for instance, mean adopting new posture patterns while sitting at home, in the car or at work. Body awareness combined with this increased knowledge could also lead to using specific movements or exercises to reduce pain or muscle tension or to increase mobility before or after an activity or during frequent pauses at work.
“That’s something I have to be aware of at work too – the way I sit and how I move. That I get up and walk around every now and then and that I really must remember that, well, okay, ‘now you’re sitting in the wrong way again, you must change your position.” (Participant 1)
Discussion
Our findings show that from the treatment, participants learned to develop strategies for managing pain by using knowledge, awareness, movements and exercises. To develop these strategies, it was important to establish an alliance with the physiotherapist, based on trust and a continual dialogue. When exercises, activities and other treatment modalities were individualized, participants were actively involved in the process. This was rewarding but also considered an effort and a challenge. The physiotherapist’s initiatives and actions were an important incentive and support.
The different expressions of acceptance suggest that treatment is a challenge and can be regarded as an ongoing process where knowledge and management strategies are important factors. To the best of our knowledge, the process of acceptance is rarely described in physiotherapy research. Previous studies of Pietilä Holmner, Stålnacke, Enthoven, and Stenberg (Citation2018) and Ernstzen, Louw, and Hillier (Citation2016) indicated that increased knowledge of chronic pain and its consequences have a positive impact on a person’s perspective of pain and enhance pain management. We believe that our findings expand the understanding of acceptance as a process rather than a static condition. The process of acceptance is difficult and encompasses becoming reconciled to the idea of living with pain and finding ways to balance and manage everyday life with pain and its consequences. In that sense, acceptance is an active process related to meaningful goals and activities for each individual. Further research on this would contribute important knowledge of how physiotherapy can contribute to and facilitate the process of acceptance.
The participants in our study described how they acquired new knowledge and body awareness in the physiotherapy treatment process. This made it possible for them to develop strategies for managing their pain and enhancing their performance in daily activities. To the best of our knowledge, body awareness associated to pain management is not described in previous research regarding those with persistent pain. In our previous study, we found that participants hoped to manage and reduce their pain with strategies and learn new behaviours or specific methods to help them handle their pain. (Calner, Isaksson, and Michaelson, Citation2017). The contribution of increased body awareness for behaviour change seems to be a new and interesting dimension that could be further studied.
Wilson, Chaloner, Osborn, and Gauntlett-Gilbert (Citation2017) described how individuals increased their body awareness, which in turn facilitated finding new patterns of movement and increased activity choices. Some previous studies corroborate the importance of knowledge for pain management. Semmons (Citation2016) emphasized the importance of teaching sessions and education as part of pain management programs. Additionally, Pietilä Holmner, Stålnacke, Enthoven, and Stenberg (Citation2018) recognized that knowledge of chronic pain increased the individuals’ ability to manage their pain in everyday life. Bunzli et al. (Citation2016) also described results in line with ours, where the participants’ improvements after intervention were related to their ability to self-manage their condition as result of gaining new information and improved body awareness. We find it interesting and encouraging that our findings of behaviour change in the primary care setting are aligned with the findings from studies focused on multidisciplinary and cognitive treatment programs (Pietilä Holmner, Stålnacke, Enthoven, and Stenberg, Citation2018; Wilson, Chaloner, Osborn, and Gauntlett-Gilbert, Citation2017).
Our findings emphasize the importance of establishing a therapeutic alliance with the patient built on initial trust, a continuous dialogue and communication through the treatment process. In a previous study, we found that participants, prior to physiotherapy treatment, expected a good interaction, respect, and affirmation. They also expected the physiotherapist to acknowledge and focus on their specific problems (Calner, Isaksson, and Michaelson, Citation2017). The importance of communication and a trusting relationship is in line with the studies of Bunzli et al. (Citation2016) and Slade, Underwood, and Keating (Slade, Patel, Underwood, and Keating, Citation2014). The patient’s need to be recognized and affirmed as an individual is another aspect of a therapeutic alliance (Stenberg, Fjellman-Wiklund, and Ahlgren, Citation2012). The participants in our study expressed the importance of being seen as individuals, including individualisation of the treatment options and exercises throughout the treatment process. This also corresponds to our previous study where the participants expected that their specific needs would be acknowledged, and hoped to get individually tailored exercise programs (Calner, Isaksson, and Michaelson, Citation2017). The importance of individualised treatment and management has previously been described in studies about persons with persistent pain (Cooper, Smith, and Hancock, Citation2008; Wilson, Chaloner, Osborn, and Gauntlett-Gilbert, Citation2017).
The participants in our study were actively involved in the treatment process, attended the unit frequently, conducted their exercises and took initiative in activities and exercise programs. Active involvement in treatment is favourable according to Semmons (Citation2016) and also acknowledged by Bernhardsson, Larsson, Johansson, and Öberg (Citation2017) and May (Citation2007). Active patient involvement also corresponds well to our previous study of pre-treatment expectations, where participants expected exercise programs to be either something natural and desirable (Calner, Isaksson, and Michaelson, Citation2017).
In the current study, some participants described their experiences of their process of active involvement and initiatives regarding exercises, although the programs were often considered to be a challenge. Active involvement also demanded self-discipline, which could be experienced as exhausting. We believe that our findings regarding the effort and strain of physiotherapy treatment is new and important knowledge and that more research is needed to explore this further. We also believe that this illuminates an important aspect of the persons’ own process, which the physiotherapist should consider when involving the patient actively in the physiotherapy treatment process.
Methodological considerations
Lincoln and Guba (Citation1985) discussed the evaluation of trustworthiness, such as credibility, dependability and transferability. We recruited persons who had musculoskeletal pain and had taken part in the physiotherapy treatment process, which is an important aspect of the credibility of this study. There was a variation in age, duration and types of pain among the participants, as well as their experiences of attending physiotherapy treatment. More women than men were included in the study, and most of the participants had an academic background and/or a university degree. As a whole, the participants’ characteristics were sufficiently varied to cover several aspects of the research aim and address the credibility of the study.
The most appropriate sample size is important for ensuring the credibility of a content analysis study (Graneheim and Lundman, Citation2004); however, there is no commonly accepted sample size for qualitative studies, as the sample size depends on the purpose, research questions, and richness of data. In order to ensure richness in data, the interviews of the six participants from the previous study were complemented with five interviews from new participants. Still only eleven participants were included in this study, which can be seen as a limitation of the study.
The length of the interviews varied considerably. Nevertheless, the participants reflected on the questions and expressed a variety of aspects concerning their physiotherapy experiences. We believe that the interviews resulted in comprehensive and rich enough data to answer the aim of the study.
The constant, open, and reflective dialogue among all three authors through the analysis process strengthens the credibility of the study. In order to enable rich material, we also started the preliminary analysis of data during the data collection phase and made minor adjustments to the interview guide accordingly. Illustrating how condensations, codes, and themes stemmed from meaning units in the original texts also enhances the credibility of this study. In order to illustrate the relationship between the theme, sub-themes and the original text, a selection of quotations was used.
To address dependability, we used the same core questions of the interview guide to cover the same areas for all participants. The follow-up questions were adjusted or complemented during the data collection, since this was an evolving process where new insights were acquired. We had an open dialogue within the research team about these insights, thereby following the recommendations of Graneheim, Lindgren, and Lundman (Citation2017).
We strived to enhance transferability by describing the context, characteristics of participants, data collection, and process of data analysis as fully and accurately as possible (Graneheim, Lindgren, and Lundman, Citation2017). Our findings indicate the need for further studies on persons with other types and localisations of persistent pain. We encourage further qualitative studies exploring persons’ experiences of physiotherapy treatment. Still, our findings do not imply a single meaning, but merely present the most probable meanings according to the researchers. It is up to the reader and their preferences to decide whether the findings are transferable to another context.
Implications for clinical practice
The effort and strain of physiotherapy appears to be important to acknowledge in the individualization of exercise programs. We suggest that a continuous dialogue regarding this strain as well as the appropriate level of exercise programs appears to be vital for the physiotherapist to address. Acceptance seems to be an active process towards meaningful goals and activities for each individual. We suggest that individualized physiotherapy treatment can contribute to and facilitate the process of acceptance. The participants acquired theoretical knowledge as well as increased body awareness, which in turn seemed to contribute to pain management and behaviour change. We propose that these findings support the importance of providing knowledge, exercises and specific movements for new body awareness for patients with persistent musculoskeletal pain.
Conclusion
Our findings suggest that physiotherapy treatment in primary care setting provides strategies and beneficial behaviour changes for persons with persistent pain. In a trustful, therapeutic alliance, the participants as well as the physiotherapists were actively involved in the treatment process. Individualized exercises and other treatment modalities caused the participants to acquire new knowledge and body awareness. This was important in the process of acceptance and managing pain. The physiotherapy treatment was considered rewarding but also strenuous and challenging.
Declaration of Interest
The authors report no conflict of interest.
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Appendix 1.
Interview guide
Initial questions
To be asked to the additional participants who were new for this study:
Age and type of pain including localization and duration?
Main question
Tell me about your experiences of the physiotherapy treatment?
Example of follow up questions
Always with a focus on the participant’s experience regarding each aspect. If needed: ask the participant to begin from the first appointment:
Details of the treatment process: what was the physiotherapist doing, what were you doing? Who was active and/or took initiative? How and when?
Is there anything in particular you remember? If so, why?
The conclusion of the treatment period. How did the treatment process end?
Tell me about you experiences in the light of your expectations before the treatment?
Has the treatment had any impact on how pain affects your daily life? If so, can you tell me more about that?