Identifying contrasting embodied voices of identity: a qualitative meta-synthesis of experiences of change among patients with chronic musculoskeletal pain in long-term physiotherapy

Figures & data

Table 1. Search strategy across databases.

	Results	Search strategy, 3-March 16, 2020
AMED (Ovid)	9
Cinahl (Ebsco)	20	TI psychomotor physiotherapy OR AB psychomotor physiotherapy OR MW psychomotor physiotherapy
Cochrane	7
Embase (Ovid)	29	Database: Embase <1980 to 2020 Week 11>Search Strategy: – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – -1 psychomotor physiotherapy.mp. (29)2 ”psychomotor physiotherapy”.ab,ti. (27)3 psychomotor physiotherap*.ab,ti. (27)4 ”norwegian psychomotor physiotherapy”.mp. (19)5 ”norwegian psychomotor physiotherapy”.ab,ti. (19)6 1 or 2 or 3 or 4 or 5 (29)
Medline (Ovid)	21
Oria (Norwegian academic libraries)	106
PsycINFO (Ovid)	9
Scopus (Elsevier)	29	(TITLE-ABS-KEY(“psychomotor physiotherapy”) OR TITLE-ABS-KEY(“norwegian psychomotor physiotherapy”))
SportDiscus (Ebsco)	15
SveMed+	17
Web of Science	14
Total	276

Figure 1. Flow diagram.

Table 2. Features of the nine primary studies included in the analysis.

Source	Title	Data collection	Sample origin	Participants	Key findings
Dragesund and Råheim (2008)	Norwegian psychomotor physiotherapy and patients with chronic pain: Patients’ perspective on body awareness	Focus groups	Patients with chronic muscle pain on waiting lists or in treatment in outpatient clinics	Thirteen patients, eight females and five males, between 26 and 68 years.	Themes of body awareness: 1) Being aware of one’s own body 2) Associations about one’s own body 3) Feelings for one’s own body
Dragesund and Øien (2020)	Transferring patients’ experiences of change from the context of physiotherapy to daily life	Focus groups	Patients with long lasting musculo-skeletal pain, in and subsequent to treatment in outpatient clinics	Eleven patients, ten females and one male, between 34 and 67 years.	Overarching structure: To develop embodied ownership of oneself over time Themes: 1) To get an embodied grip on oneself through treatment 2) To give oneself space in daily life
Ekerholt and Bergland (2006)	Massage as interaction and a source of information	In-depth interviews	Patients with psychosomatic or long lasting musculo-skeletal pain after end of treatment in outpatient clinics	Ten patients, nine females and one male, between 41–65 years.	Core category: Massage as interaction and source of information Categories: 1) The ambiguity: Pleasure and provocation 2) The ambiguity: Losing control-gaining control 3) The intra- and interpersonal dialogue
Ekerholt and Bergland (2008)	Breathing: A sign of life and a unique area for reflection and action	In-depth interviews	Patients with psychosomatic or long lasting musculoskeletal pain after end of treatment in outpatient clinics	Ten patients, nine females and one male, between 41 and 65 years.	Categories: 1) Breathing: An incomprehensible and disparate phenomenon 2 non 2) Breathing: Access to meaning and understanding 3) Breathing: Enhancing feelings of mastery
Sviland, Martinsen, and Råheim (2014)	To be held and to hold one’s own: Narratives of embodied transformation in the treatment of long-lasting musculoskeletal problems	Focus groups	Patients with psychosomatic or long lasting musculoskeletal pain after end of treatment in outpatient clinics	Seventeen patients, fourteen females, and three males, between 26 and 69 years.	Narrative core themes: 1) Time and trust: To be the main character 2) Embodied identity: Finding one’s own voice 3) To speak out 4) The paradox of control
Sviland, Martinsen, and Råheim (2018)	Toward living within my body and accepting the past: A case study of embodied narrative identity	Focus group, in-depth interview, autobiographic text	Patient with psychosomatic or long-lasting musculoskeletal pain after end of treatment in outpatient clinics	One female patient, 30 years old	A narrative of Rita 1) Coercive hospitalization – corroborative distrust 2) Going to Norwegian psychomotor physiotherapy – chaos and discoveries 3) Struck by a droplet – reminiscences in sensation 4) Anger shifting direction – blaming the responsible 5) Revelation of embodied tranquility – hope for a future 6) Compassion – coming to herself in the eyes of the others 7) Ready for love – time to harness the process 8) Life as it is – a new way of being in the world
Øien, Iversen, and Stensland (2007)	Narratives of embodied experiences – Therapy processes in Norwegian psychomotor physiotherapy	In-depth semi-structured interviews, observations, video-recordings, reflective notes	Patients with chronic muscle pain in treatment in outpatient clinic	Two female patients, between 33 and 40 years.	A narrative of Gina 1) Physiotherapy for the whole person 2) Being divided in body and mind 3) The treatment sessions – Reflection and physiotherapy 3a) My back as a tortoiseshell 3b) I’m not to be blamed 3c) Breathing more deeply 3d) My legs – My “stepchildren” 4) Reflecting on the treatment course – My body was asleep
Øien, Råheim, Iversen, and Steihaug (2009)	Self-perception as embodied knowledge. Changing processes for patients with chronic pain	In-depth semi-structured interviews, observations, video-recordings, reflective notes	Patients with chronic muscle pain in treatment in outpatient clinics	Nine patients, eight females and one male, between 22 and 47 years.	Two step procedures 1) Identified patient groups of limited and considerable change 2) Identified patterns of change 2a) To move restricted and non-restricted 2b) To breathe restricted and non-restricted 2c) To reflect in a non-exploring and exploring way 2d) To not transfer and transfer experiences from treatment to daily life 2e) To be detached from and to be in touch with the body
Øien, Steihaug, Iversen, and Råheim (2011)	Communication as negotiation processes in long-term physiotherapy: A qualitative study	In-depth semi- structured interviews, observations, video-recordings, reflective notes	Patients with chronic muscle pain in treatment in outpatient clinics	Eleven patients, ten females and one male, between 22 and 47 years.	Identified main pattern of communication 1) Seeking for common ground – demanding negotiating process Identified episodes of interrupting challenges 2) The pattern of ambivalence and uncertainty 3) The pattern of impatience and disagreement

Table 3. Preliminary main themes and supporting quotes.

Preliminary main themes	Selected supporting quotes from included primary studies
Body and mind disconnected and connected	“I wish someone could help me as a whole person to experience less pain, and less anxiety and insecurity, and to manage to look forward to the future” (Øien, Iversen, and Stensland, 2007, p. 34). “I am my mind, and I have a body I just have to carry around. It is hard to be at work and talk to people when you are anxious because the body has to express itself as normal and healthy.” (Øien, Iversen, and Stensland, 2007, p.34) “I kind of disappeared mentally from my body” (Ekerholt and Bergland, 2006, p.140). “For many years I have been using my power of will, I’ve tried to control my body, which seem to be a bad idea. If symptoms are to abate, I think you have to learn to listen to your body” (Dragesund and Råheim, 2008, p.248). “Very much, my son’s needs determined my movements and daily routines. For years I had to ignore my bodily signals of tiredness and pain. In treatment I enjoyed becoming in touch with my own body again” (Dragesund and Øien, 2020, p.4). “It became important to keep an untouched face. I learned to feel extremely sad inside without letting my family see how hurt I was” (Øien, Iversen, and Stensland, 2007, p.34) “Nothing started happening, until I made contact with my body and breathing. The body as well as the mind sort of let go – opened up again. More positive thoughts started taking root” (Ekerholt and Bergland, 2008, p.836). “I live within my body, instead of living beside myself. I live with my history instead of within my history, I don’t live in the feelings that I had, but I live with them” (Sviland, Martinsen, and Råheim, 2018, p.368)
NPMP change: Being detached from and being in touch with functions of moving and breathing	“Occasionally, I can feel myself standing or sitting in a painful way” (Øien, Iversen, and Stensland, 2007, p.35). “Being aware of my diaphragm makes a difference. I am not out of breath, I stand more relaxed” (Øien, Råheim, Iversen, and Steihaug, 2009, p.125). “When thinking of change during therapy, what means the most to me is being in contact with the ground and breathing properly. Before treatment started, I felt like I was walking on pillows of air. To become aware that muscle tension in my stomach is causing me to breathe high up, to be able to sense that I am tense, and to try and loosen up. When I get dizzy and lose touch with everything, I don’t need to be afraid, I know it’s because of muscle tension.” (Dragesund and Råheim, 2008, p.247). “I was always locked in my jaws, I was breathing in a sort of tube. Everything felt so stretched that I was completely tied up” (Ekerholt and Bergland, 2008, p.835). “I learned to dare to react; it loosened up tension, I could breathe more freely. I finally dared to try. I’m still not very good at expressing my feelings or letting go of my aggression, but I’m much better. I don’t get those physical reactions so frequent any more” (Ekerholt and Bergland, 2008, p.836).
Becoming in touch with embodied feelings	“My back was extremely painful afterwards. Maybe because I felt so angry” (Øien, Iversen, and Stensland, 2007, p.35). “I understood that my tension may be related to what I have experienced earlier in my life and what I experience today” (Ekerholt and Bergland, 2006, p.139).
The body as source of identities	“To have good contact with my own body, helps me, and the foot is essential to get better contact with my own voice. What do I want now? I simply know more about who I am” (Sviland, Martinsen, and Råheim, 2014, p.8). “Who can tell us who we are if not the body” (Sviland, Martinsen, and Råheim, 2014, p.9) “Being a body is being oneself” (Sviland, Martinsen, and Råheim, 2014, John p.14). “Who am. I Who is Johanna? This has to do with my legs” (Sviland, Martinsen, and Råheim, 2014, p.9). “I feel less passive, I feel angry and ready for action. I returned a kick” (Øien, Råheim, Iversen, and Steihaug, 2009, p.25). “The treatment benefits me, I have learned a lot about myself. Now, I can sense how I am straightening myself up too much, pulling myself together. I was not aware of that before” (Dragesund and Øien, 2020, p.4).
Dependency between change of embodied functions and the therapeutic relationship	“I couldn’t have gone through the process without help; it’s important to feel supported” (Ekerholt and Bergland, 2008, p.836). “It feels so strange, I sense my legs at a distance compared to my shoulders. I only sense them when you touch them” (Øien, Iversen, and Stensland, 2007, p.35). The physiotherapist: “Do you perceive that you restrict your breathing?” The patient: “Oh, no, I don’t notice anything or may be sometimes I do, when you point it out” (Øien, Steihaug, Iversen, and Råheim, 2011, 57). “The touch of the therapist’s hands sort of drew my breathing along the spine and down to pelvis and to my stomach. It was a new feeling. I had to concentrate, had to be mentally present. It was a little bit scary, but it felt good” (Ekerholt and Bergland, 2008, p.835). “Her hands just touching me were enough, and I would start crying, something I could never do unless I was alone. It was embarrassing, but I was given time and support. It felt good.” (Ekerholt and Bergland, 2006, p.140).
The therapeutic relationship: trust and distrust	“In a subconscious way, I may have felt that this particular person could be trusted, with time” (Sviland, Martinsen, and Råheim, 2018, p. 366).
The therapeutic relationship: dependency and independency	“If I tensed my muscles, the physiotherapist said, “Let your breath go”” (Ekerholt and Bergland, 2006, p.140). “I feel she responded to my body. I didn’t have much contact with my body. When I spoke, she saw where I was, from seeing my body, she took the body as point of departure, so this was where we started” (Sviland, Martinsen, and Råheim, 2014[, p.10).

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