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The patient experience of osteopathic healthcare
Manual Therapy xxx (2015) 1e7
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Original article
The patient experience of osteopathic healthcare Paul J. Orrock* Southern Cross University, PO Box 157, Lismore, NSW 2480, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 September 2014 Received in revised form 10 August 2015 Accepted 15 November 2015
Background: Osteopathy in Australia is a primary care limited scope practice. Practitioner surveys suggest that patients present with chronic pain and receive manual therapies, exercise and lifestyle advice. Further research is required to deepen the understanding of this intervention from the perspective of patients. Objective: To explore the experience of patients receiving osteopathic healthcare. Design: Mixed methodology. Method: A quantitative survey of a convenience sample of patients was followed by qualitative semistructured interviews in a purposive sample of respondents with chronic non-specific low back pain. The transcripts were analysed using a phenomenological approach. Results: The survey results suggested directions of enquiry for the interviews. Eleven subjects were interviewed and reported commonalities in their clinical histories with multisystem co-morbidities. Four themes became apparent: patient decision-making, patient shared experiences of the osteopathic healthcare consultation, tailored patient-centred care, and therapeutic relationship in healthcare. Conclusion: This data suggests that patients experience osteopathic healthcare after trying other disciplines; that there are shared aspects of the consultations, with a thorough assessment, education about their condition, multiple manual therapies and lifestyle advice; that the experience is patient-centred and tailored to their context; and that the therapeutic relationship is a key aspect of the experience. These results reflect a number of aspects of osteopathic healthcare from workplace surveys. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Osteopathic healthcare Patient experience Chronic low back pain
1. Introduction Osteopathy is an approach to healthcare underpinned by guiding principles that place importance on the interconnectedness of the structure and function of the body (Ward, 2003). In Australia osteopathy is a primary care limited scope practice, and the practitioners and patients of osteopathic practices have been researched in a limited way (Adams et al., 2003; Xue et al., 2008; Orrock, 2009a, 2009b; Burke et al., 2013). Current knowledge of this practice, based on workplace surveys, suggests that osteopaths in Australia see patients who self refer, present with pain and stiffness in various regions, of which chronic lower back pain is a dominant presenting symptom, and that the osteopathic intervention includes a range of manual therapies, exercise and lifestyle advice (Xue et al., 2008; Orrock, 2009b; Burke et al., 2013). The validity of the data from these surveys is limited, with relatively
* Tel.: þ61 2669136. E-mail address: [email protected].
small samples, and is dependent on the practitioner's recall, which may be biased or incorrect (Newell and Burnard, 2011). Evidence suggests that osteopathic practice in Australia is similar in many aspects to that in the UK (Froud et al., 2008; Strutt et al., 2008; Rajendran et al., 2012; Fawkes et al., 2013; Leach et al., 2013) and other countries e particularly in Europe, but different from the US e where osteopaths are primary care physicians. The expectations and experiences of patients of osteopaths have been studied in the UK, in both private (Leach et al., 2013) and teaching clinics (Strutt et al., 2008; Rajendran et al., 2012). Themes emerging from these studies identified the importance of the therapeutic relationship and communication, the development of trust and hope, outcome measures of pain relief and quality of life, and the incidence of treatment after-effects. There has been no similar direct research of patients in Australia. Osteopathy has been reported as one of the fastest growing allied health professions in Australia (IDA Economics, 2008; Australian Bureau of Statistics, 2008), and further detail of this practice is necessary to deepen the understanding of a clinical intervention that has not as yet established an evidence base.
http://dx.doi.org/10.1016/j.math.2015.11.003 1356-689X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Orrock PJ, The patient experience of osteopathic healthcare, Manual Therapy (2015), http://dx.doi.org/10.1016/ j.math.2015.11.003
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The research questions were what is the lived experience of osteopathic healthcare for patients with non-specific low back pain, and are patients' experiences of osteopathic healthcare consistent with characteristics suggested by previous survey results? The preliminary survey was to provide directions of enquiry for interviews and also to recruit patients with a target condition of chronic non-specific low back pain. 2. Methods A qualitative approach to researching the experience of patients of a health service is appropriate to establish the nature of that experience (Bryman, 2006; Neumann, 2000; van Krieken et al., 2000; Grady, 2007; Higgs and Cherry, 2009; Glenn, 2010). The patients' perspective is a fundamental foundation in any patientcentred service (Luxford et al., 2011; Patwardhan and Spencer, 2012; Reuben and Tinetti, 2012), and the factors influencing consumer choice need to be explored with regards to osteopathy, which is predominantly a private fee-paying service (Orrock, 2009a; Burke et al., 2013). 2.1. Study design The project employed a mixed methodology, using an explanatory sequential design described by Creswell et al. (2011), where a quantitative survey was followed by qualitative semi-structured interviews (Creswell et al., 2011). The initial survey had questions that were designed to seek information about patient demographics, referral patterns, condition history, improvement level, characteristics of the consultation and management, and outcomes experienced. The methodology for the interviews was descriptive phenomenology, which is appropriate to explore the core commonalities and meaning, structure and essence of the patients' lived experiences (Patton, 2002; Stark and Trinidad, 2007; Wojnar and Swanson, 2007; Higgs and Cherry, 2009). The Human Research and Ethics Committee of Southern Cross University provided approval for the project.
of the pain. Those included were then sent the information, guide questions (Appendix 1) and consent forms. 2.3. Data collection and analysis 2.3.1. Survey Patients were invited to read the survey information and complete the survey. Completed surveys were held in a private box and collected by the researcher after three weeks. Data were entered into the statistics package (IBM SPSS Statistics version 20.0.0). Descriptive statistics were used to explore the data. The results from this analysis informed the approach to the interview questions and areas of enquiry by clarifying details of the clinical assessment and therapy employed during the consultation. 2.3.2. Interviews After screening and consent checking, the enrolled subjects were interviewed by phone for 30e40 min. Probe questions were used to seek clarification. The interviews were recorded and transcribed, and the data were analysed using an approach informed by the seven-step thematic analysis described by Collaizzi (Wojnar and Swanson, 2007), outlined in Table 1. The researcher was aware of previous survey results and employed a strategy of “bracketing” e putting aside preconceptions by maintaining a constant sense of caution regarding bias, and by the use of an assistant researcher (Wojnar and Swanson, 2007). The researcher categorised themes as they became apparent by repetition during multiple readings into two levels (sub- and meta-) and the process was reviewed and audited by an assistant researcher to ensure they were both well represented in the transcripts and were plausible. The number of participants was not predetermined, and by the eleventh interview there were no new themes apparent. This was considered to be theoretical saturation. Individual summaries and initial sub-themes based on verbatim transcripts were sent to each participant for their feedback. 3. Results The results of the survey and interviews will be presented separately for methodological clarity and then integrated. 3.1. Survey
2.2. Participants 2.2.1. Survey The survey was distributed to five osteopathic practices, involving nine practising osteopaths. This was a convenience sample in the geographical region of the researcher, selected to ensure a range of practitioner gender (2 female, 7 male), experience level (ranged from 4 to 21 years of clinical experience) and training background (NSW, Victoria, UK, Germany). Inclusion criteria for responding to the survey were adults (over 18 years of age) who were returning patients who could speak and read English. Internal validity was established with feedback from a senior academic, five osteopathic clinical teaching staff, and a sample of three osteopathic patients. These nine people were asked to provide feedback on the relevance and clarity of the questions, and questions were amended to accommodate feedback. 2.2.2. Interviews A purposive sample of patients who responded on the survey that they had chronic low back pain that had been treated by the osteopath and were willing to be interviewed were contacted and screened to confirm the target condition. Respondents were excluded if they had a confirmed diagnosis of a pathological cause
Completed surveys (n ¼ 161) were collected. A summary of respondent characteristics is presented in Table 2. Activities commonly reported by respondents were: questioning about the detail of the presenting problem; assessment of both the presenting problem and other areas; soft tissue, stretching and manipulative techniques to multiple regions; and exercise advice. Common outcomes reported were reduced pain, increased flexibility/range of motion, the ability to complete daily tasks and improved posture. These findings helped structure the interviews. 3.2. Interviews Thirty people responded to the request for an interview. Twelve of these respondents were unable to be contacted, four were unavailable during the data collection period, two did not pass screening for the target condition and one was a new patient. The eleven remaining all consented and phone interviews proceeded. A summary of their characteristics is presented in Table 2. The participants reviewed their interview summaries and all agreed that the points reflected their experience. Twenty sub-themes emerged from the data and were grouped into meta-themes (Table 3). The meta-themes were:
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Table 1 Summary of Collaizzi's method of analysis for descriptive phenomenology (Wojnar and Swanson, 2007). Step
Description
1 2 3 4 5 6 7
Reading and rereading transcriptions to acquire general feeling for experience Extracting significant statements to generate information pertaining directly to phenomenon studied Formulating meanings to illuminate meanings hidden in various contexts of the phenomenon Categorizing into clusters of themes and validating to identify experiences common to all informants with original text Describing to generate a prototype of a theoretical model Returning to participants to validate the findings Incorporating any changes based on the informants' to present a theoretical model that comprehensively reflects the feedback universal features of phenomenon
Table 2 Summary of subject characteristics. Variable
Survey respondents, n (%)
Interview subjects, n (%)
Gender Male Female
66 (40.7) 94 (58.0)
5 (45.5) 6 (54.5)
Age 18e29 30e39 40e49 50e59 60e69 70þ
11 36 45 34 30 5
(6.8) (22.2) (27.8) (21.0) (18.5) (3.1)
0 2 3 4 2 0
(0) (18.2) (27.3) (36.3) (18.2) (0)
Condition e number treated One 43 (26.7) Two 42 (26.1) Three 24 (14.9) Four or more 52 (32.3)
2 2 3 4
(18.2) (18.2) (27.3) (36.3)
Main condition e time since onset 1 daye12 weeks 54 (33.5) Over 12 weeks 107 (66.5)
1. 2. 3. 4.
11 (100)
Patient decision-making Patient shared experiences of the osteopathic encounter Tailored patient-centred care Therapeutic relationship in healthcare
These meta-themes and sub-themes will now be described in more detail with salient quotes from the transcripts.
3.2.1. Patient decision-making Participants engaged in an autonomous process of deciding about their healthcare, having explored various options and finding their own way to the osteopath. They consulted the osteopath usually after trying other healthcare professions for their problem, and most were not clear initially about what osteopathy was. There was a dependence on word of mouth referral, most commonly by friends and family: She was recommended to me by a lady at the newsagency. (PI4) My mother persuaded me. (PI10) Participants had commonly visited chiropractors and/or physiotherapists before seeking osteopathy. Six of the eleven participants specifically mentioned that they visited an osteopath as a choice after chiropractic care had not met their expected outcomes. One stated: I was seeing a chiropractor ten years earlier … and they didn't massage before they manipulated … and I wasn't getting any better, I was getting worse. (PI6) There were reports of General Practitioner (GP) referral, with a number stating that they gained referral from their GP through their own request, for example: My doctor recommended I go and see the physio, but I got (the GP) to write out a referral for the osteopath instead. (PI3)
Table 3 Thematic analysis e sub themes grouped into meta-themes. Meta-themes
Subthemes
Patient decision making
Trusting word of mouth referral Choosing after tried all else Alternative to chiropractic GP referrals driven by patient choice
Patient shared experiences of the osteopathic encounter
Holistic Making musculoskeletal connections with presenting complaint Comprehensive assessment and review at each session Searching for a cause Consistently applied manual and adjunctive therapies Education about the condition and lifestyle advice for self management
Tailored patient-centred care
Encounter is tailored to patient Individualised plan is matched to patient Goals of plan are patient centred Helps body to help itself Plan is a negotiated partnership Co-management
Therapeutic relationship in healthcare
Personal story is valued Extensive communication Encounter described as trusting, caring, gentle and instilling hope Supportive ongoing relationship if required
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3.2.2. Patient shared experiences of osteopathic healthcare A commonality of experiences emerged from the data about the approach taken by the osteopathic practitioners. This theme encompasses both the interpretation of osteopathy as an holistic form of healthcare, as well as descriptions of activities and methods used in the consultation. Participants consistently described the experience as holistic, but they had mixed views regarding what that meant to them. Some described it in purely physical terms based on the connection made between their presentation and the muscular and skeletal structures. For example one reported that: its a discipline about musculo-skeletal connectivity. (PI1)
When a certain technique's not working, osteopaths are happy to look elsewhere and try new things. (P10) The respondents reported that their expectations of outcomes from treatment were considered. These outcomes were most often reduction in pain and increased mobility, but also included improved general functionality, ability in daily tasks, and general wellbeing. These quotes illustrate the broad range of outcomes reported: It effects my personal wellbeing. (PI1) Puts my energy and my strength up, I'll sleep right through again. (PI2) Improved breathing. (PI7)
Others felt that the experience was holistic because broad aspects of their healthcare were considered, including the engagement with their psychological state. One stated that the osteopath explored: everything from the endocrinology side to the mental side of things, as chronic pain can lead to depression and vice-versa. (PI10) Another interpretation was reflected in the following quotation, where holism meant searching for the cause: I would say it's a little more holistic, they look a little more at what's causing it. (PI2) It was commonly reported that a thorough assessment of the presenting condition and related regions was carried out, as well a consideration of its possible causative factors. The range of enquiry and assessment was summarised by one respondent: She asks how is it interfering (with life), then she looks at my feet and shoes, how I walk, about the desktop ergonomics, even sexual function and such; so she asks questions and I give her the answers. (PI4) The respondents experienced that the intervention involved education about the condition, multiple manual therapies and adjunctive techniques as well as lifestyle advice, which included advice regarding exercise rehabilitation, ergonomics and stress reduction. One participant expressed this as: a combination of information, communication, and treatment, a complete package. (PI8)
3.2.3. Individualised patient care The respondents experienced osteopathic healthcare as tailored to their context, where the activities of each consultation was based on the patient presentation at each encounter. This individualisation of the intervention was reported as being negotiated between patient and practitioner, and was present in assessment, treatment and outcome planning. Tailoring of the intervention was evident for one respondent as a range of techniques used in different situations: He might expand upon his repertoire and do a whole lot of different things. (PI3) Another experienced that there was flexibility in how the practitioner responded to a review of previous management outcomes,
Like taking off a heavy coat. I'd gone from nothing to two kilometres (walking). (PI8) The focus of care was not solely on externally applied manual therapy, but was reported by many to be on education and progress towards self-management, for example: They give me ideas and things to help myself rather than expecting someone else to fix it. (PI2) Empowering you a little bit better to enable you to make things right. (PI7) As a corollary to these themes on individualisation, education and self-management, there appears to be a partnership between these patients and practitioner, described by two as: It was more a joint effort. (PI6) He just listens to everything that you have to say, and what you want done. (P11) Finally, a common theme emerged regarding the relationship with other practitioners. Respondents experienced inward and outward referrals between the osteopath and other practitioners, including with mainstream medical practitioners. One respondent regarded the osteopath and GP as: completely linked. (PI8) This extended to co-managing with medical specialists: She did my pre-surgery and post-surgery rehab, in conjunction with talking to the surgeons, so she's open minded to mainstream. (PI4)
3.2.4. Therapeutic relationship in healthcare The interviewees felt that their personal stories were heard and respected. It appears that osteopathic consultations comprised a substantial level of communication and dialogue, with a therapeutic relationship built on trust and respect. One respondent stated that their aim was: to have a meaningful one-to-one sort of truth-based direct, frank relationship with the therapist, (PI1) and another used the consultation to express issues about his health, It's good to get a few concerns off your chest talking to (the osteopath). (PI4)
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The practitioners' listening skills, professionalism and knowledge were reported as key aspects of the relationship. Many patients present to osteopaths with chronic pain, and the need for understanding and information becomes paramount, as explained by two participants: I use him as a sounding-board. (PI10) With knowledge comes hope a lot of the time. I am not alone in the fight. (PI10) Respondents placed importance on trust, caring and hope, and many experienced these aspects as they began to gain control over their chronic condition. Two responses illustrate the depth and stability of the therapeutic relationship experienced: Its someone I trust. (PI4) He got me through it. (PI9)
4. Discussion Most of the respondents reported that they choose to visit an osteopath only after already consulting physiotherapists and/or chiropractors, and depended on word of mouth referral. The lack of awareness of osteopathy could stem from the fact it is the smallest allied health profession in Australia (IDA Economics, 2008; ABS, 2008; AIHW, 2013) and is not available in the public health system. In 2012 there were 20,081 physiotherapists (10,131 in a musculoskeletal scope of practice), 4029 chiropractors and 1543 osteopaths (AIHW, 2013). The finding that these patients are acting autonomously in exercising their right of choice of a health practitioner matches a central principle of the Australian healthcare system, with a recent review stating the goal was to “develop a ‘person-centred’ approach to healthcare, enabling consumers to be at the centre of their own care” (Department of Health and Ageing, 2009, p. 42). This is also an issue in other developed nations, as healthcare systems have to allow for choices being made by increasingly educated consumers who make unique decisions in a competitive environment (Fotaki et al., 2008; Victoor et al., 2012). Patient Centered Care (PCC) is thought to be the future of effective healthcare (Parsons et al., 2007; Dwamena et al., 2012; Luxford, 2012). There is no global definition of PCC. The Picker Institute has been researching PCC since the early 1990s, and commissioned a systematic review of nine models and frameworks (Schaller, 2007), which found the core elements of PCC most frequently cited were:
Education and shared knowledge Involvement of family and friends Collaboration and team management Sensitivity to non-medical and spiritual dimensions of care Respect for patients needs and preferences Free flow and accessibility of information
There are a number of findings from this data that support the proposition that these patients experienced osteopathic healthcare as patient centred. The intervention was reported as tailored to the patient context. Patients with chronic pain are heterogeneous (Turk, 2005), especially with regards to their cognitive impairment (Turk et al., 2008; Kreitler and Niv, 2007). Respondents reported that there was regular review, a search for causative factors, and different techniques were employed. The patients felt engaged in the relationship, based on being autonomous in choosing
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osteopathy, feeling that they were listened to, and being partners in decision-making. A number of participants reported that their overall wellbeing and mental state were explored and supported during the consultations. These are all reported aspects of collaborative PCC. Findings from this study, along with workplace and patient surveys (Adams et al., 2003; Xue et al., 2008; Strutt et al., 2008; Orrock, 2009a, 2009b; Rajendran et al., 2012; Leach et al., 2013; Burke et al., 2013) further suggests that osteopathic healthcare involves a multi-modal approach. The participants experienced an internal consistency to the experience that included assessment of the whole musculoskeletal system, linking of multiple regions, a depth of enquiry, multiple manual therapies, education about their condition(s), and advice on exercise and lifestyle strategies. Current best evidence demonstrates that the use of self help strategies including exercise, the consideration of co-morbidities, the involvement of the mental state of the patient, education and reassurance need to be used in the management of people in chronic pain (Schnitzer, 2006; IASP, 2010). Findings from this and other studies appear to support that osteopathic healthcare encompasses these aspects. In Australia, osteopathy emerged as part of complementary and alternative medicine (CAM), a field of healthcare that has experienced substantial increases in utilisation in the past two decades (Xue et al., 2007). The reasons why patients use CAM services have been grouped under push or pull factors (Andrews et al., 2012). The push factors revealed in this data appear to be a level of dissatisfaction with other manual therapy providers. The pull factors from this data may relate to the participant experience that osteopathic healthcare was holistic and engaged the patient at more depth of understanding of their problem. A number of researchers (Furnham and Vincent, 2000; Bishop et al., 2007) suggest that the people who attend CAM practitioners can be classified into three groups: those who believe in CAM on principle, those who are frustrated with the mainstream health services, and a third group who simply shop around to find an effective approach. The participants in this research appear to fit into the latter two groups, although the respondents who found their way to osteopathy after chiropractic could be seen to be finding the alternative to the alternative. The finding that a number of interviewees experienced osteopathic healthcare as holistic suggest elements of the biopsychosocial (BPS) model of health (Engel, 1980). Penney (2013) argues that the osteopathic principles are interchangeable with the BPS approach to healthcare, which is widely accepted as a comprehensive framework for the management of chronic conditions (WHO, 2013). A focus on quality of life and functional outcome measures is apparent in the reports of these survey respondents and the experience of interviewees. Patients with this target condition have expectations that they improve in a number of domains (Parsons et al., 2007; Sanderson et al., 2012). Hsu et al. (2010) reported on unanticipated effects of interventions in CAM trials for low back pain, finding that there were a number of non-standard results from the intervention, like increased hope, energy and general wellbeing. Xue et al. (2008) found similar outcomes from osteopathic management. The value and depth of the therapeutic relationship emerged as a theme in this research. Placing importance on this relationship is inherent in the BPS model of healthcare (Toye and Barker, 2012; Penney, 2013). Exploring aspects of the patient's psychosocial history demands a substantial consultation time and an advanced level of communication skill (Mauksch et al., 2008). These respondents reported that trust, hope and reassurance were important elements in their consultations with the osteopath. How the practitioner communicates with patients is known to have an impact on therapeutic outcomes (Darlow et al., 2013). A relevant
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example of this is a practitioner suggesting to a patient with chronic musculoskeletal pain that their body is vulnerable and should be protected, which may promote the development of a fear-avoidance belief and limit outcomes (Rainville et al., 2011). The provision of cognitive reassurance through explanations and knowledge about the condition, as well as affective reassurance through empathy and showing interest is known to influence outcomes (Pincus et al., 2013), and this was apparent in this study. The valuing of the therapeutic relationship under a BPS or holistic approach to healthcare is not unique to osteopathy. Interventions like reassurance and hope, while central to the development of a therapeutic relationship, are considered nonspecific effects in terms of clinical research. Although this data suggest that the osteopathic intervention includes this focus, it is known that the observed positive effects of an intervention may be due to the non-specific effects of the therapeutic relationship on the belief of the patient that they will improve, and not the effect of the technical intervention (in this case the manual therapy techniques) which may be placebo (Mitchell and Cormack, 1998; Kaptchuk et al., 2008; Foot and Ridge, 2012). Another common aspect of the experience of this sample was that there was a focus on self-help. Self-management is a vital link in the long-term outcome of people with chronic pain (National Institute for Health and Clinical Excellence, 2009; Carnes et al., 2012), although in isolation has recently been shown in metaanalysis to have small effects compared to minimal intervention (Oliviera et al., 2012). The patients who finally arrive at the osteopathic clinic may be a self-selecting group of motivated people, who are searching for help and have not come to the osteopath as their first choice. This has been discussed with regards to patients of CAM, that they want to participate in their treatment and believe that lifestyle changes are essential in healing (Bishop et al., 2007). The limitation in this research is primarily responder bias as only returning patients and those willing to fill in the survey in the waiting rooms were included in the survey and as interviewees. Even though the completed surveys were kept from the practitioners, the responders may have been hesitant to report negative aspects of the service and their outcomes. The limitations of the survey was that it was a convenience small sample of patients, and the people who consented to be interviewed were likely to have responder bias as satisfied clients. As with any qualitative data, the interviews and themes emerging are subjective experiences of the interviewees and the interviewer. The use of an assistant researcher checking the coding of transcripts, the use of mixed methods and the comparison with other research results strengthen the generalisability of the findings. 5. Conclusion The detail of patients' lived experience reported in this sample reflects and deepens previous survey data. These patients experienced that osteopathic healthcare is a late health choice, involves regular assessment, a range of manual therapies at multiple regions, therapeutic advice regarding exercise and posture, and education about the proposed aetiology of their main problem. Their experience reflects a patient-centred approach to healthcare. These results also reflect elements of an evidence-based management of the chronic pain patients common in these practices (NICE, 2009; IASP, 2010). The lack of formal clinical evidence supporting the specific osteopathic intervention is concerning. This data contributes to what is known about osteopathic healthcare from the patients' experience of it, and triangulated with other data can assist in developing an authentic model of osteopathic healthcare that may be tested for its effectiveness. Complex interventions like osteopathy require a carefully planned research strategy in order to
establish its evidence, including ensuring authenticity before major clinical trials are attempted (MRC, 2008; Luce et al., 2009; Coulter, 2010). Appendix 1. Guide interview questions
Why did you go to an osteopath in the first place? How would you explain osteopathy to a friend? To your doctor? What is it like being treated/managed by an osteopath? Describe the treatment session for me. In your experience, what aspects of your healthcare are managed by the osteopath? In your experience, what are the effects of osteopathic treatment?
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Original article
The patient experience of osteopathic healthcare Paul J. Orrock* Southern Cross University, PO Box 157, Lismore, NSW 2480, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 September 2014 Received in revised form 10 August 2015 Accepted 15 November 2015
Background: Osteopathy in Australia is a primary care limited scope practice. Practitioner surveys suggest that patients present with chronic pain and receive manual therapies, exercise and lifestyle advice. Further research is required to deepen the understanding of this intervention from the perspective of patients. Objective: To explore the experience of patients receiving osteopathic healthcare. Design: Mixed methodology. Method: A quantitative survey of a convenience sample of patients was followed by qualitative semistructured interviews in a purposive sample of respondents with chronic non-specific low back pain. The transcripts were analysed using a phenomenological approach. Results: The survey results suggested directions of enquiry for the interviews. Eleven subjects were interviewed and reported commonalities in their clinical histories with multisystem co-morbidities. Four themes became apparent: patient decision-making, patient shared experiences of the osteopathic healthcare consultation, tailored patient-centred care, and therapeutic relationship in healthcare. Conclusion: This data suggests that patients experience osteopathic healthcare after trying other disciplines; that there are shared aspects of the consultations, with a thorough assessment, education about their condition, multiple manual therapies and lifestyle advice; that the experience is patient-centred and tailored to their context; and that the therapeutic relationship is a key aspect of the experience. These results reflect a number of aspects of osteopathic healthcare from workplace surveys. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Osteopathic healthcare Patient experience Chronic low back pain
1. Introduction Osteopathy is an approach to healthcare underpinned by guiding principles that place importance on the interconnectedness of the structure and function of the body (Ward, 2003). In Australia osteopathy is a primary care limited scope practice, and the practitioners and patients of osteopathic practices have been researched in a limited way (Adams et al., 2003; Xue et al., 2008; Orrock, 2009a, 2009b; Burke et al., 2013). Current knowledge of this practice, based on workplace surveys, suggests that osteopaths in Australia see patients who self refer, present with pain and stiffness in various regions, of which chronic lower back pain is a dominant presenting symptom, and that the osteopathic intervention includes a range of manual therapies, exercise and lifestyle advice (Xue et al., 2008; Orrock, 2009b; Burke et al., 2013). The validity of the data from these surveys is limited, with relatively
* Tel.: þ61 2669136. E-mail address: [email protected].
small samples, and is dependent on the practitioner's recall, which may be biased or incorrect (Newell and Burnard, 2011). Evidence suggests that osteopathic practice in Australia is similar in many aspects to that in the UK (Froud et al., 2008; Strutt et al., 2008; Rajendran et al., 2012; Fawkes et al., 2013; Leach et al., 2013) and other countries e particularly in Europe, but different from the US e where osteopaths are primary care physicians. The expectations and experiences of patients of osteopaths have been studied in the UK, in both private (Leach et al., 2013) and teaching clinics (Strutt et al., 2008; Rajendran et al., 2012). Themes emerging from these studies identified the importance of the therapeutic relationship and communication, the development of trust and hope, outcome measures of pain relief and quality of life, and the incidence of treatment after-effects. There has been no similar direct research of patients in Australia. Osteopathy has been reported as one of the fastest growing allied health professions in Australia (IDA Economics, 2008; Australian Bureau of Statistics, 2008), and further detail of this practice is necessary to deepen the understanding of a clinical intervention that has not as yet established an evidence base.
http://dx.doi.org/10.1016/j.math.2015.11.003 1356-689X/© 2015 Elsevier Ltd. All rights reserved.
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P.J. Orrock / Manual Therapy xxx (2015) 1e7
The research questions were what is the lived experience of osteopathic healthcare for patients with non-specific low back pain, and are patients' experiences of osteopathic healthcare consistent with characteristics suggested by previous survey results? The preliminary survey was to provide directions of enquiry for interviews and also to recruit patients with a target condition of chronic non-specific low back pain. 2. Methods A qualitative approach to researching the experience of patients of a health service is appropriate to establish the nature of that experience (Bryman, 2006; Neumann, 2000; van Krieken et al., 2000; Grady, 2007; Higgs and Cherry, 2009; Glenn, 2010). The patients' perspective is a fundamental foundation in any patientcentred service (Luxford et al., 2011; Patwardhan and Spencer, 2012; Reuben and Tinetti, 2012), and the factors influencing consumer choice need to be explored with regards to osteopathy, which is predominantly a private fee-paying service (Orrock, 2009a; Burke et al., 2013). 2.1. Study design The project employed a mixed methodology, using an explanatory sequential design described by Creswell et al. (2011), where a quantitative survey was followed by qualitative semi-structured interviews (Creswell et al., 2011). The initial survey had questions that were designed to seek information about patient demographics, referral patterns, condition history, improvement level, characteristics of the consultation and management, and outcomes experienced. The methodology for the interviews was descriptive phenomenology, which is appropriate to explore the core commonalities and meaning, structure and essence of the patients' lived experiences (Patton, 2002; Stark and Trinidad, 2007; Wojnar and Swanson, 2007; Higgs and Cherry, 2009). The Human Research and Ethics Committee of Southern Cross University provided approval for the project.
of the pain. Those included were then sent the information, guide questions (Appendix 1) and consent forms. 2.3. Data collection and analysis 2.3.1. Survey Patients were invited to read the survey information and complete the survey. Completed surveys were held in a private box and collected by the researcher after three weeks. Data were entered into the statistics package (IBM SPSS Statistics version 20.0.0). Descriptive statistics were used to explore the data. The results from this analysis informed the approach to the interview questions and areas of enquiry by clarifying details of the clinical assessment and therapy employed during the consultation. 2.3.2. Interviews After screening and consent checking, the enrolled subjects were interviewed by phone for 30e40 min. Probe questions were used to seek clarification. The interviews were recorded and transcribed, and the data were analysed using an approach informed by the seven-step thematic analysis described by Collaizzi (Wojnar and Swanson, 2007), outlined in Table 1. The researcher was aware of previous survey results and employed a strategy of “bracketing” e putting aside preconceptions by maintaining a constant sense of caution regarding bias, and by the use of an assistant researcher (Wojnar and Swanson, 2007). The researcher categorised themes as they became apparent by repetition during multiple readings into two levels (sub- and meta-) and the process was reviewed and audited by an assistant researcher to ensure they were both well represented in the transcripts and were plausible. The number of participants was not predetermined, and by the eleventh interview there were no new themes apparent. This was considered to be theoretical saturation. Individual summaries and initial sub-themes based on verbatim transcripts were sent to each participant for their feedback. 3. Results The results of the survey and interviews will be presented separately for methodological clarity and then integrated. 3.1. Survey
2.2. Participants 2.2.1. Survey The survey was distributed to five osteopathic practices, involving nine practising osteopaths. This was a convenience sample in the geographical region of the researcher, selected to ensure a range of practitioner gender (2 female, 7 male), experience level (ranged from 4 to 21 years of clinical experience) and training background (NSW, Victoria, UK, Germany). Inclusion criteria for responding to the survey were adults (over 18 years of age) who were returning patients who could speak and read English. Internal validity was established with feedback from a senior academic, five osteopathic clinical teaching staff, and a sample of three osteopathic patients. These nine people were asked to provide feedback on the relevance and clarity of the questions, and questions were amended to accommodate feedback. 2.2.2. Interviews A purposive sample of patients who responded on the survey that they had chronic low back pain that had been treated by the osteopath and were willing to be interviewed were contacted and screened to confirm the target condition. Respondents were excluded if they had a confirmed diagnosis of a pathological cause
Completed surveys (n ¼ 161) were collected. A summary of respondent characteristics is presented in Table 2. Activities commonly reported by respondents were: questioning about the detail of the presenting problem; assessment of both the presenting problem and other areas; soft tissue, stretching and manipulative techniques to multiple regions; and exercise advice. Common outcomes reported were reduced pain, increased flexibility/range of motion, the ability to complete daily tasks and improved posture. These findings helped structure the interviews. 3.2. Interviews Thirty people responded to the request for an interview. Twelve of these respondents were unable to be contacted, four were unavailable during the data collection period, two did not pass screening for the target condition and one was a new patient. The eleven remaining all consented and phone interviews proceeded. A summary of their characteristics is presented in Table 2. The participants reviewed their interview summaries and all agreed that the points reflected their experience. Twenty sub-themes emerged from the data and were grouped into meta-themes (Table 3). The meta-themes were:
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Table 1 Summary of Collaizzi's method of analysis for descriptive phenomenology (Wojnar and Swanson, 2007). Step
Description
1 2 3 4 5 6 7
Reading and rereading transcriptions to acquire general feeling for experience Extracting significant statements to generate information pertaining directly to phenomenon studied Formulating meanings to illuminate meanings hidden in various contexts of the phenomenon Categorizing into clusters of themes and validating to identify experiences common to all informants with original text Describing to generate a prototype of a theoretical model Returning to participants to validate the findings Incorporating any changes based on the informants' to present a theoretical model that comprehensively reflects the feedback universal features of phenomenon
Table 2 Summary of subject characteristics. Variable
Survey respondents, n (%)
Interview subjects, n (%)
Gender Male Female
66 (40.7) 94 (58.0)
5 (45.5) 6 (54.5)
Age 18e29 30e39 40e49 50e59 60e69 70þ
11 36 45 34 30 5
(6.8) (22.2) (27.8) (21.0) (18.5) (3.1)
0 2 3 4 2 0
(0) (18.2) (27.3) (36.3) (18.2) (0)
Condition e number treated One 43 (26.7) Two 42 (26.1) Three 24 (14.9) Four or more 52 (32.3)
2 2 3 4
(18.2) (18.2) (27.3) (36.3)
Main condition e time since onset 1 daye12 weeks 54 (33.5) Over 12 weeks 107 (66.5)
1. 2. 3. 4.
11 (100)
Patient decision-making Patient shared experiences of the osteopathic encounter Tailored patient-centred care Therapeutic relationship in healthcare
These meta-themes and sub-themes will now be described in more detail with salient quotes from the transcripts.
3.2.1. Patient decision-making Participants engaged in an autonomous process of deciding about their healthcare, having explored various options and finding their own way to the osteopath. They consulted the osteopath usually after trying other healthcare professions for their problem, and most were not clear initially about what osteopathy was. There was a dependence on word of mouth referral, most commonly by friends and family: She was recommended to me by a lady at the newsagency. (PI4) My mother persuaded me. (PI10) Participants had commonly visited chiropractors and/or physiotherapists before seeking osteopathy. Six of the eleven participants specifically mentioned that they visited an osteopath as a choice after chiropractic care had not met their expected outcomes. One stated: I was seeing a chiropractor ten years earlier … and they didn't massage before they manipulated … and I wasn't getting any better, I was getting worse. (PI6) There were reports of General Practitioner (GP) referral, with a number stating that they gained referral from their GP through their own request, for example: My doctor recommended I go and see the physio, but I got (the GP) to write out a referral for the osteopath instead. (PI3)
Table 3 Thematic analysis e sub themes grouped into meta-themes. Meta-themes
Subthemes
Patient decision making
Trusting word of mouth referral Choosing after tried all else Alternative to chiropractic GP referrals driven by patient choice
Patient shared experiences of the osteopathic encounter
Holistic Making musculoskeletal connections with presenting complaint Comprehensive assessment and review at each session Searching for a cause Consistently applied manual and adjunctive therapies Education about the condition and lifestyle advice for self management
Tailored patient-centred care
Encounter is tailored to patient Individualised plan is matched to patient Goals of plan are patient centred Helps body to help itself Plan is a negotiated partnership Co-management
Therapeutic relationship in healthcare
Personal story is valued Extensive communication Encounter described as trusting, caring, gentle and instilling hope Supportive ongoing relationship if required
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3.2.2. Patient shared experiences of osteopathic healthcare A commonality of experiences emerged from the data about the approach taken by the osteopathic practitioners. This theme encompasses both the interpretation of osteopathy as an holistic form of healthcare, as well as descriptions of activities and methods used in the consultation. Participants consistently described the experience as holistic, but they had mixed views regarding what that meant to them. Some described it in purely physical terms based on the connection made between their presentation and the muscular and skeletal structures. For example one reported that: its a discipline about musculo-skeletal connectivity. (PI1)
When a certain technique's not working, osteopaths are happy to look elsewhere and try new things. (P10) The respondents reported that their expectations of outcomes from treatment were considered. These outcomes were most often reduction in pain and increased mobility, but also included improved general functionality, ability in daily tasks, and general wellbeing. These quotes illustrate the broad range of outcomes reported: It effects my personal wellbeing. (PI1) Puts my energy and my strength up, I'll sleep right through again. (PI2) Improved breathing. (PI7)
Others felt that the experience was holistic because broad aspects of their healthcare were considered, including the engagement with their psychological state. One stated that the osteopath explored: everything from the endocrinology side to the mental side of things, as chronic pain can lead to depression and vice-versa. (PI10) Another interpretation was reflected in the following quotation, where holism meant searching for the cause: I would say it's a little more holistic, they look a little more at what's causing it. (PI2) It was commonly reported that a thorough assessment of the presenting condition and related regions was carried out, as well a consideration of its possible causative factors. The range of enquiry and assessment was summarised by one respondent: She asks how is it interfering (with life), then she looks at my feet and shoes, how I walk, about the desktop ergonomics, even sexual function and such; so she asks questions and I give her the answers. (PI4) The respondents experienced that the intervention involved education about the condition, multiple manual therapies and adjunctive techniques as well as lifestyle advice, which included advice regarding exercise rehabilitation, ergonomics and stress reduction. One participant expressed this as: a combination of information, communication, and treatment, a complete package. (PI8)
3.2.3. Individualised patient care The respondents experienced osteopathic healthcare as tailored to their context, where the activities of each consultation was based on the patient presentation at each encounter. This individualisation of the intervention was reported as being negotiated between patient and practitioner, and was present in assessment, treatment and outcome planning. Tailoring of the intervention was evident for one respondent as a range of techniques used in different situations: He might expand upon his repertoire and do a whole lot of different things. (PI3) Another experienced that there was flexibility in how the practitioner responded to a review of previous management outcomes,
Like taking off a heavy coat. I'd gone from nothing to two kilometres (walking). (PI8) The focus of care was not solely on externally applied manual therapy, but was reported by many to be on education and progress towards self-management, for example: They give me ideas and things to help myself rather than expecting someone else to fix it. (PI2) Empowering you a little bit better to enable you to make things right. (PI7) As a corollary to these themes on individualisation, education and self-management, there appears to be a partnership between these patients and practitioner, described by two as: It was more a joint effort. (PI6) He just listens to everything that you have to say, and what you want done. (P11) Finally, a common theme emerged regarding the relationship with other practitioners. Respondents experienced inward and outward referrals between the osteopath and other practitioners, including with mainstream medical practitioners. One respondent regarded the osteopath and GP as: completely linked. (PI8) This extended to co-managing with medical specialists: She did my pre-surgery and post-surgery rehab, in conjunction with talking to the surgeons, so she's open minded to mainstream. (PI4)
3.2.4. Therapeutic relationship in healthcare The interviewees felt that their personal stories were heard and respected. It appears that osteopathic consultations comprised a substantial level of communication and dialogue, with a therapeutic relationship built on trust and respect. One respondent stated that their aim was: to have a meaningful one-to-one sort of truth-based direct, frank relationship with the therapist, (PI1) and another used the consultation to express issues about his health, It's good to get a few concerns off your chest talking to (the osteopath). (PI4)
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The practitioners' listening skills, professionalism and knowledge were reported as key aspects of the relationship. Many patients present to osteopaths with chronic pain, and the need for understanding and information becomes paramount, as explained by two participants: I use him as a sounding-board. (PI10) With knowledge comes hope a lot of the time. I am not alone in the fight. (PI10) Respondents placed importance on trust, caring and hope, and many experienced these aspects as they began to gain control over their chronic condition. Two responses illustrate the depth and stability of the therapeutic relationship experienced: Its someone I trust. (PI4) He got me through it. (PI9)
4. Discussion Most of the respondents reported that they choose to visit an osteopath only after already consulting physiotherapists and/or chiropractors, and depended on word of mouth referral. The lack of awareness of osteopathy could stem from the fact it is the smallest allied health profession in Australia (IDA Economics, 2008; ABS, 2008; AIHW, 2013) and is not available in the public health system. In 2012 there were 20,081 physiotherapists (10,131 in a musculoskeletal scope of practice), 4029 chiropractors and 1543 osteopaths (AIHW, 2013). The finding that these patients are acting autonomously in exercising their right of choice of a health practitioner matches a central principle of the Australian healthcare system, with a recent review stating the goal was to “develop a ‘person-centred’ approach to healthcare, enabling consumers to be at the centre of their own care” (Department of Health and Ageing, 2009, p. 42). This is also an issue in other developed nations, as healthcare systems have to allow for choices being made by increasingly educated consumers who make unique decisions in a competitive environment (Fotaki et al., 2008; Victoor et al., 2012). Patient Centered Care (PCC) is thought to be the future of effective healthcare (Parsons et al., 2007; Dwamena et al., 2012; Luxford, 2012). There is no global definition of PCC. The Picker Institute has been researching PCC since the early 1990s, and commissioned a systematic review of nine models and frameworks (Schaller, 2007), which found the core elements of PCC most frequently cited were:
Education and shared knowledge Involvement of family and friends Collaboration and team management Sensitivity to non-medical and spiritual dimensions of care Respect for patients needs and preferences Free flow and accessibility of information
There are a number of findings from this data that support the proposition that these patients experienced osteopathic healthcare as patient centred. The intervention was reported as tailored to the patient context. Patients with chronic pain are heterogeneous (Turk, 2005), especially with regards to their cognitive impairment (Turk et al., 2008; Kreitler and Niv, 2007). Respondents reported that there was regular review, a search for causative factors, and different techniques were employed. The patients felt engaged in the relationship, based on being autonomous in choosing
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osteopathy, feeling that they were listened to, and being partners in decision-making. A number of participants reported that their overall wellbeing and mental state were explored and supported during the consultations. These are all reported aspects of collaborative PCC. Findings from this study, along with workplace and patient surveys (Adams et al., 2003; Xue et al., 2008; Strutt et al., 2008; Orrock, 2009a, 2009b; Rajendran et al., 2012; Leach et al., 2013; Burke et al., 2013) further suggests that osteopathic healthcare involves a multi-modal approach. The participants experienced an internal consistency to the experience that included assessment of the whole musculoskeletal system, linking of multiple regions, a depth of enquiry, multiple manual therapies, education about their condition(s), and advice on exercise and lifestyle strategies. Current best evidence demonstrates that the use of self help strategies including exercise, the consideration of co-morbidities, the involvement of the mental state of the patient, education and reassurance need to be used in the management of people in chronic pain (Schnitzer, 2006; IASP, 2010). Findings from this and other studies appear to support that osteopathic healthcare encompasses these aspects. In Australia, osteopathy emerged as part of complementary and alternative medicine (CAM), a field of healthcare that has experienced substantial increases in utilisation in the past two decades (Xue et al., 2007). The reasons why patients use CAM services have been grouped under push or pull factors (Andrews et al., 2012). The push factors revealed in this data appear to be a level of dissatisfaction with other manual therapy providers. The pull factors from this data may relate to the participant experience that osteopathic healthcare was holistic and engaged the patient at more depth of understanding of their problem. A number of researchers (Furnham and Vincent, 2000; Bishop et al., 2007) suggest that the people who attend CAM practitioners can be classified into three groups: those who believe in CAM on principle, those who are frustrated with the mainstream health services, and a third group who simply shop around to find an effective approach. The participants in this research appear to fit into the latter two groups, although the respondents who found their way to osteopathy after chiropractic could be seen to be finding the alternative to the alternative. The finding that a number of interviewees experienced osteopathic healthcare as holistic suggest elements of the biopsychosocial (BPS) model of health (Engel, 1980). Penney (2013) argues that the osteopathic principles are interchangeable with the BPS approach to healthcare, which is widely accepted as a comprehensive framework for the management of chronic conditions (WHO, 2013). A focus on quality of life and functional outcome measures is apparent in the reports of these survey respondents and the experience of interviewees. Patients with this target condition have expectations that they improve in a number of domains (Parsons et al., 2007; Sanderson et al., 2012). Hsu et al. (2010) reported on unanticipated effects of interventions in CAM trials for low back pain, finding that there were a number of non-standard results from the intervention, like increased hope, energy and general wellbeing. Xue et al. (2008) found similar outcomes from osteopathic management. The value and depth of the therapeutic relationship emerged as a theme in this research. Placing importance on this relationship is inherent in the BPS model of healthcare (Toye and Barker, 2012; Penney, 2013). Exploring aspects of the patient's psychosocial history demands a substantial consultation time and an advanced level of communication skill (Mauksch et al., 2008). These respondents reported that trust, hope and reassurance were important elements in their consultations with the osteopath. How the practitioner communicates with patients is known to have an impact on therapeutic outcomes (Darlow et al., 2013). A relevant
Please cite this article in press as: Orrock PJ, The patient experience of osteopathic healthcare, Manual Therapy (2015), http://dx.doi.org/10.1016/ j.math.2015.11.003
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example of this is a practitioner suggesting to a patient with chronic musculoskeletal pain that their body is vulnerable and should be protected, which may promote the development of a fear-avoidance belief and limit outcomes (Rainville et al., 2011). The provision of cognitive reassurance through explanations and knowledge about the condition, as well as affective reassurance through empathy and showing interest is known to influence outcomes (Pincus et al., 2013), and this was apparent in this study. The valuing of the therapeutic relationship under a BPS or holistic approach to healthcare is not unique to osteopathy. Interventions like reassurance and hope, while central to the development of a therapeutic relationship, are considered nonspecific effects in terms of clinical research. Although this data suggest that the osteopathic intervention includes this focus, it is known that the observed positive effects of an intervention may be due to the non-specific effects of the therapeutic relationship on the belief of the patient that they will improve, and not the effect of the technical intervention (in this case the manual therapy techniques) which may be placebo (Mitchell and Cormack, 1998; Kaptchuk et al., 2008; Foot and Ridge, 2012). Another common aspect of the experience of this sample was that there was a focus on self-help. Self-management is a vital link in the long-term outcome of people with chronic pain (National Institute for Health and Clinical Excellence, 2009; Carnes et al., 2012), although in isolation has recently been shown in metaanalysis to have small effects compared to minimal intervention (Oliviera et al., 2012). The patients who finally arrive at the osteopathic clinic may be a self-selecting group of motivated people, who are searching for help and have not come to the osteopath as their first choice. This has been discussed with regards to patients of CAM, that they want to participate in their treatment and believe that lifestyle changes are essential in healing (Bishop et al., 2007). The limitation in this research is primarily responder bias as only returning patients and those willing to fill in the survey in the waiting rooms were included in the survey and as interviewees. Even though the completed surveys were kept from the practitioners, the responders may have been hesitant to report negative aspects of the service and their outcomes. The limitations of the survey was that it was a convenience small sample of patients, and the people who consented to be interviewed were likely to have responder bias as satisfied clients. As with any qualitative data, the interviews and themes emerging are subjective experiences of the interviewees and the interviewer. The use of an assistant researcher checking the coding of transcripts, the use of mixed methods and the comparison with other research results strengthen the generalisability of the findings. 5. Conclusion The detail of patients' lived experience reported in this sample reflects and deepens previous survey data. These patients experienced that osteopathic healthcare is a late health choice, involves regular assessment, a range of manual therapies at multiple regions, therapeutic advice regarding exercise and posture, and education about the proposed aetiology of their main problem. Their experience reflects a patient-centred approach to healthcare. These results also reflect elements of an evidence-based management of the chronic pain patients common in these practices (NICE, 2009; IASP, 2010). The lack of formal clinical evidence supporting the specific osteopathic intervention is concerning. This data contributes to what is known about osteopathic healthcare from the patients' experience of it, and triangulated with other data can assist in developing an authentic model of osteopathic healthcare that may be tested for its effectiveness. Complex interventions like osteopathy require a carefully planned research strategy in order to
establish its evidence, including ensuring authenticity before major clinical trials are attempted (MRC, 2008; Luce et al., 2009; Coulter, 2010). Appendix 1. Guide interview questions
Why did you go to an osteopath in the first place? How would you explain osteopathy to a friend? To your doctor? What is it like being treated/managed by an osteopath? Describe the treatment session for me. In your experience, what aspects of your healthcare are managed by the osteopath? In your experience, what are the effects of osteopathic treatment?
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