Development of a framework for person-centred physiotherapy

Figures & data

Table 1. Search terms.

Concept	Search	Boolean operator
Person-centredness	‘Person cent*’ OR ‘patient cent*’ [AB]	AND
Physiotherapy	Physiotherap* OR ‘physical therap*’ [AB]	AND
Framework	Framework or model* or conceptual or theor* or approach* or tool*

Table 2. Inclusion/exclusion criteria.

Inclusion	Exclusion
Focus on patient or person-centred practice	Where the focus is on an intervention to enhance person-centredness rather than on developing an understanding of person-centredness as a construct
Focus on physiotherapy or physical therapy	Study protocols
Evidence of a framework, model, or theory of person-centred physiotherapy practice developed based on the study findings	Expert opinions and grey literature
Primary or secondary studies
English language studies published in peer-review journals

Table 4. Study characteristics.

Study	Aims	Study design	Setting and participants	Original constructs from the individual study findings
Bastemeijer et al. 2021	To describe the aspects of physiotherapy practice that people with musculoskeletal pain value in high-quality care to develop a taxonomy of patient values in healthcare.	Qualitative design Content analysis	Setting: The Netherlands Participants: 17 adults (nine female, eight male) with chronic or recurrent musculoskeletal pain Aged between 33–79 years old (average of 57 years)	Values about oneself (uniqueness and autonomy) Values regarding actions of the professional (technically skilled professional, conscientious professional, compassionate professional, responsive professional) Values regarding interactions between patients and the professionals (partnership and empowerment)
Dukhu et al. 2018	To critically review evidence for barriers to, and facilitators of, person-centred care in adults living with long-term conditions in a physiotherapy context and identify its components and outcomes in practice.	Critical review Synthesis of eight articles (three qualitative, four quantitative, one mixed methods)	Setting: Studies were from Canada, Australia, or United Kingdom Participants: 439 adults with long-term conditions who experienced physiotherapy in hospital or the community	Patients and physiotherapists were key stakeholders Communication and individualisation influence outcomes Outcomes include comprehensive care, goal achievement, self-efficacy, therapeutic relationship Components of person-centred care were identified as self-management, ongoing care, decision making, individualisation, information sharing and goal setting These relationships take place within the wider context of care
Kidd et al. 2011	To determine patients’ perspectives of components of patient-centred physiotherapy and its essential elements.	Qualitative design Grounded theory	Setting: New Zealand, musculoskeletal outpatient physiotherapy department Participants: 8 individuals who recently received physiotherapy (4 male, 4 female) Age 20–68 years	Ability to communicate Confidence Knowledge and expertise An understanding of people and an ability to relate Transparency of progress and outcome
Melin et al. 2021	To analyse definitions and related requirements, processes, and operationalization of person-centred goal setting in the physiotherapy research literature	Literature review A synthesis of 21 studies Content analysis	Geographical location of studies not included. 12 studies included data from both patients and physiotherapists; three studies included data from only patients five studies from physiotherapists only; one perspective paper did not include any generated data.	Understanding goals that are meaningful to the patients Setting goals in collaboration Facing challenges with person-centred goal setting Developing skills by experiences and education Changing interaction and reflective practice. These categories were abstracted into two higher-ordered interlaced themes: To seek mutual understanding of what is meaningful to the patient; and To refine physiotherapy interaction skills, which we suggest would be useful for further conceptualization.
Miciak et al. 2018	To identify and provide in-depth descriptions of the necessary conditions of engagement of the therapeutic relationship between physiotherapists and patients.	Interpretive descriptive study Qualitative Semi-structured interviews Content analysis	Setting: Private practice clinics in Edmonton, Canada. Participants: 11 physiotherapists with a minimum 5 years of clinical experience and seven adult patients with musculoskeletal disorders. Age not included.	Conditions identified for established a therapeutic relationship for a person-centred approach: present receptive genuine committed
Miciak et al. 2019	To identify the various ways that physiotherapists establish meaningful connections with their patients	Interpretive descriptive study Qualitative Semi-structured interviews Content analysis	Setting: Private practice clinics in Edmonton, Canada. Participants: 11 physiotherapists with a minimum 5 years of clinical experience and seven adult patients with musculoskeletal disorders. Age not included.	Acknowledging the individual (meeting as an equal, validating the patient’s experiences, individualizing the treatment approach) Giving of self (inside the interaction, outside the interaction) Using the body as a pivot point (clarifying physical problems and solutions, facilitating the patient’s connection to the body, using touch to bridge a gap)
Rodriguez et al. 2020	To develop a tool for evaluating person-centred therapeutic relationships within physiotherapy services	Mixed-methods study in three phases: literature review and focus groups with patients and PTs e-Delphi survey Interviews to evaluate the items	Thirty-one items were generated based on seven domains identified after the analysis of four focus groups of physiotherapists and four patient focus groups. Nine experts participated in the e-Delphi survey. Fifty-five patients participated in the two rounds of the cognitive pre-tests.	Personal characteristics of the professional Motivating and encouraging the involvement of the patient in the process based on a positive attitude Perception of security, trust in oneself The physiotherapist shows empathy towards the patient Authenticity of the physiotherapist towards the patient Unconditional acceptance Communication capacities of the professional Congruence between verbal and non-verbal communication Non-verbal communication Active listening skills Verbal communication Assertiveness Professional aspects Skill, competence, technical experience, and knowledge Professionality Physiotherapist as educator Follow-up of home prescriptions Relational aspects Affinity with the physiotherapist Care Warmth (sensitive, kind, affectionate) Close attitude Displaying interest and involvement in the patient’s problem Emotional support Personalized therapy Psycho-social-cultural sensitivity Sensitivity to changes in the patient’s status Partnership Mutual trust Mutual respect Collaboration/active involvement Environment Perception of coordination in the communication between the physiotherapist and other professionals Perception of the physiotherapist as having professional autonomy Physical space allowing privacy
Søndenå et al. 2020	To present a concept analysis of therapeutic alliance	Literature review 14 literature reviews and qualitative studies included Concept analysis	Characteristics in terms of settings and participants of studies not included	Master attributes relating to the concept: Seeing the person—individualized care, person over pathology, equality, unique individual, world view, values and beliefs, acceptance (Giving of self—something more, teamwork, self-disclosure) Sharing the journey—role change, holistic, behaviour change (Legitimising the experience—their story, legitimising the biological, therapeutic touch) Communication—attention to the narrative, verbal and non-verbal, empathy, active listening, language Therapeutic space—safety, time, physical space (Physiotherapist characteristics matter—personal attributes, socio-cultural, competence, age) Fostering autonomy—shared decision-making, self-awareness, self-reflection, self-efficacy, behaviour change, self-management, responsibility (Interpersonal collaboration—trust, motivation, agreement)
Ward et al. 2018	To explore perceptions of person-centred practice and how it can be enacted	Qualitative online focus group was undertaken through an international tweet chat within the existing social media communities Interpretive phenomenological framework analysis	Tweets from 23 physiotherapists were analysed	Service structure Patient expectations Finding out what matters to the patient Collaboration influences Balance of power and control Education to empower Informed decision making Choices Patient engagement Leads to Shared decision making Person-centred practice Self-management
Wijma et al. 2017	To summarise themes related to person-centredness in physiotherapy and construct a proposed conceptual framework for utilization within physiotherapy	Qualitative systematic review 14 articles	Combined number of participants = 231 Seven studies included views of physiotherapists; five included patients two included both Age range: 18–84 years	Patient-physiotherapist interactions Individuality Support Goal setting Education Communication Physiotherapist characteristics Social characteristics Confidence Knowledge and skills

Figure 1. Flow chart of study selection.

816 records were identified through database and hand searching; 783 were excluded at the title and abstract screening stage due to removing duplicates, being conference proceedings or not physiotherapy specific; 33 articles were assessed at the full text stage—23 of these were excluded as they had no model, theory, or framework of person-centred physiotherapy (n = 15), the focus was on an intervention (n = 4), not physiotherapy specific (n = 3), or were an editorial. This left 10 articles which met the inclusion criteria and were included in the synthesis.

Table 3. Core constructs in relation to the individual studies.

Physiotherapist characteristics
Knowledge and skills for clinical proficiency	Technically skilled: Competent; communicative skilled; goal and process oriented; positive [38] Knowledge and expertise [39] Professional aspects: Skill, competence, technical experience and knowledge; Professionality; Physiotherapist as educator; Follow-up of home prescriptions [42] Knowledge and skills [43]
Attributes of the physiotherapist	Conscientious: act morally in clinical decision making; act morally on commercial / financial level; in control [38] Compassionate: concerned; personal contact; take patients seriously [38] Responsive: adapt to the patient; continuity of care; aware of vulnerability / dependency; respect the patient boundaries; culturally sensitive; make patients feel safe [38] Communication [37] Ability to communicate [39] Understanding people and able to relate [39] Confidence [39] Transparent focus on progress and outcomes [39] Giving of self (inside the interaction, outside the interaction) [41] Personal characteristics of the professional: Motivating and encouraging the involvement of the patient in the process based on a positive attitude; Perception of security, trust in oneself; The physiotherapist shows empathy towards the patient; Authenticity of the physiotherapist towards the patient; Unconditional acceptance [42] Communication capacities of the professional: Congruence between verbal and non-verbal communication; Non-verbal communication; Active listening skills; Verbal communication; Assertiveness [42] Seeing the person—individualized care, person over pathology, equality, unique individual, world view, values and beliefs, acceptance (Giving of self—something more, teamwork, self-disclosure) [52] Communication—attention to the narrative, verbal and non-verbal, empathy, active listening, language [52] Therapeutic space—safety, time, physical space (Physiotherapist characteristics matter—personal attributes, socio-cultural, competence, age) [52] Fostering autonomy—shared decision-making, self-awareness, self-reflection, self-efficacy, behaviour change, self-management, responsibility (Interpersonal collaboration—trust, motivation, agreement) [52] Confidence [43] Social characteristics [43]
Reflection and self-awareness	To refine physiotherapy interaction skills (responsiveness can be enhanced by self-awareness, reflection, and education) [40] Developing skills by experiences and education [40] Changing interaction and reflective practice [40]
Person-physiotherapist interaction(s)
Partnership	Partnership: Equality; cooperation and creating space; take the lead [38] Decision making [37] Information sharing [37] Active partnership [39] Establish good relationship [39] Therapist’s expertise and self-confidence creates a confident patient [39] To seek mutual understanding of what is meaningful to the patient [40] Understanding goals that are meaningful to the patients [40] Setting goals in collaboration [40] Conditions of engagement in therapeutic relationship: Committed, Genuine, Receptive, Present [41] Acknowledging the individual (meeting as an equal, validating the patient’s experiences, individualizing the treatment approach) [41] Relational aspects: Affinity with the physiotherapist; Care; warmth (sensitive, kind, affectionate); Close attitude; Displaying interest and involvement in the patient’s problem; Emotional support [42] Partnership: Mutual trust and respect; Collaboration/active involvement [42] Seeing the person—individualized care, person over pathology, equality, unique individual, world view, values and beliefs, acceptance (Giving of self—something more, teamwork, self-disclosure) (Søndenå et al. 2020) Sharing the journey—role change, holistic, behaviour change (Legitimising the experience—their story, legitimising the biological, therapeutic touch) (Søndenå et al. 2020) Patient expectations [21] Finding out what matters to the patient [21] Collaboration influences [21] Informed decision making [21] Choices (freedom to make choices throughout the journey) [21] Patient engagement [21] Shared decision making [21]
Empowerment and self-management	Empowerment: empowerment; support self-control [38] Therapeutic relationship [37] Individualisation [37] Goal setting [37] Ongoing care [37] Goal achievement [37] Self-efficacy [37] Self-management [37] Patient engaged in therapeutic process—becomes self-directed [39] Using the body as a pivot point (clarifying physical problems and solutions, facilitating the patient’s connection to the body, using touch to bridge a gap) [41] Fostering autonomy—shared decision-making, self-awareness, self-reflection, self-efficacy, behaviour change, self-management, responsibility (Interpersonal collaboration—trust, motivation, agreement) [52] Patient-physiotherapist interactions [43] Individuality [43] Support [43] Goal setting [43] Education [43] Communication [43] Self-management [21] Balance of power and control [21] Education to empower [21]
Environment
Coordinated healthcare delivery	Continuation of care [21] Service structure [21] Time to care [21] Perception of coordination in the communication between the physiotherapist and other professionals; Perception of the physiotherapist as having professional autonomy [42] Therapeutic space—safety, time, physical space (Physiotherapist characteristics matter—personal attributes, socio-cultural, competence, age) [52]
Philosophy of the organisation and practice environment	Patient-centred culture [21] Service structure [21]
Physical environment	Physical space allowing privacy [42] Safety and dignity [38] Therapeutic space—safety, time, physical space (Physiotherapist characteristics matter—personal attributes, socio-cultural, competence, age) [52]
Ongoing unique journey of the person and self-management	Uniqueness: a unique individual; a deep understanding; holistic vision [38] Autonomy: right to decide; independence [38] Responsive: adapt to the patient; continuity of care; aware of vulnerability / dependency; respect the patient boundaries; culturally sensitive; make patients feel safe [38] Individualisation [37] Goal achievement [37] Self-efficacy [37] Self-management [37] To seek mutual understanding of what is meaningful to the patient [40] Acknowledging the individual (meeting as an equal, validating the patient’s experiences, individualizing the treatment approach) [41] Personalized therapy: Psycho-social-cultural sensitivity; Sensitivity to changes in the patient’s status [42] Sharing the journey—role change, holistic, behaviour change (Legitimising the experience—their story, legitimising the biological, therapeutic touch) [52] Fostering autonomy—shared decision-making, self-awareness, self-reflection, self-efficacy, behaviour change, self-management, responsibility (Interpersonal collaboration—trust, motivation, agreement) [52] Patient expectations [21] Finding out what matters to the patient [21] Self-management [21]

Figure 2. Person-centred physiotherapy framework.

Two stick persons are in the centre of the framework to represent the construct of person-physiotherapist interaction(s) and are climbing up the left-hand side of a mountain. The construct of the environment is at the top of the mountain and the construct of physiotherapist characteristics below. The mountain and constructs are surrounded by a box. A dashed arrow enters the box from the left, moves up the left-hand side of the mountain, down the right-hand side of the mountain and then continues outside the box with the construct of the ongoing unique journey of the person.

Bastemeijer CM, van Ewijk JP, Hazelzet JA, et al. Patient values in physiotherapy practice, a qualitative study. Physiother Res Int. 2021;26(1):e1877.

 PubMed Web of Science ®Google Scholar

Kidd M, Bond C, Bell M. Patients’ perspectives of patient-centredness as important in musculoskeletal physiotherapy interactions: a qualitative study. Physiotherapy. 2011;97(2):154–162.

 PubMed Web of Science ®Google Scholar

Rodríguez Nogueira O, Botella-Rico J, Martínez González MC, et al. Construction and content validation of a measurement tool to evaluate person-centered therapeutic relationships in physiotherapy services. PLoS One. 2020;15(3):e0228916.

 PubMed Web of Science ®Google Scholar

Wijma AJ, Bletterman AN, Clark JR, et al. Patient-centeredness in physiotherapy: what does it entail? A systematic review of qualitative studies. Physiother Theory Pract. 2017;33(11):825–840.

 PubMed Web of Science ®Google Scholar

Dukhu S, Purcell C, Bulley C, Walk It Off Spinal Cord Recover and Wellness Centre, Toronto. Person-centred care in the physiotherapeutic management of long-term conditions: a critical review of components, barriers and facilitators. IPDJ. 2018;8(2):1–27.

 Google Scholar

Miciak M, Mayan M, Brown C, et al. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Arch Physiother. 2018;8:3.

 PubMedGoogle Scholar

Søndenå P, Dalusio-King G, Hebron C. Conceptualisation of the therapeutic alliance in physiotherapy: is it adequate? Musculoskelet Sci Pract. 2020;46.

 PubMed Web of Science ®Google Scholar

Melin J, Nordin Å, Feldthusen C, et al. Goal-setting in physiotherapy: exploring a person-centered perspective. Physiother Theory Pract. 2021;37(8):863–880.

 PubMed Web of Science ®Google Scholar

Ward A, Eng C, McCue V, Sengkang General Hospital, Singapore, et al. What matters versus what’s the matter – exploring perceptions of person-centred practice in nursing and physiotherapy social media communities: a qualitative study. IPDJ. 2018;8(2):1–18.

 Google Scholar