CHRONIC BENIGN INTRACTABLE LOW BACK PAIN (CBILBP):
How do occupational therapists working in primary care facilitate
patients with this condition?
CONTENTS
Section
Page Numbers
Introduction
Definitions for study
1
Background
1
Aims of study
3
Literature review
4
Methodology
13
Ethics
16
Design
18
Pilot study
18
Method
Sample
19
Data collection
20
Data analysis
23
Results
Survey
25
Telephone interviews
29
Trustworthiness
38
Discussion
Results
41
Literature
48
1
Methodology
48
Design
49
Sample
50
Data Collection
50
Data Analysis
54
Limitations of the Study
54
Conclusions
55
Recommendations
56
Acknowledgements
58
References
59
Appendices
72
2
Abstract
The prevalence of chronic low back pain is increasing and is apparent in the number
of patients who continue to be referred to a tertiary pain management service. Ten
years ago the Clinical Standards Advisory Group (CSAG) recommended a
biopsychosocial assessment of all patients with acute low back pain to identify the
potential risk factors for future chronicity and disability. With no concrete evidence to
refer to, this study investigated the experiences of occupational therapists in primary
care under the themes of assessment and intervention, knowledge of clinical
standards, prevention of disability and multi-disciplinary working to measure the
provision of occupational therapy with low back pain patients before referral to a
tertiary programme. An exploratory design, employing a five step phenomenological
approach was chosen to elaborate information drawn from a survey questionnaire.
Telephone interviews were conducted with five occupational therapists working with
chronic low back pain. The combined data revealed that there were no specific
services for chronic low back pain and that the primary reason for referral to
occupational therapy, whether in physical or mental health, was not the low back
pain. Occupational therapists proved well equipped to deal with this client group in
their caseloads due to their focus on occupational performance. Assessment and
intervention were holistic and demonstrated a full understanding of the effects of low
back pain and the ability to be active with the pain and this facilitated patient
empowerment. Occupational therapists were not conversant with the CSAG
recommendations but there was evidence to suggest that disability could be
minimised. Occupational therapists were competent to work independently and in a
multi-disciplinary approach with this client group. A lack of services for chronic low
back pain was identified.
3
Introduction
Definitions for study
In areas of rural Wales hospital care is often in generic community facilities
supported by General Practitioners. The establishment of local health boards in April
2003 has revised the politics of care again. Some patients have to travel long
distances to access consultant physicians and surgeons, although there is some
provision for outpatient appointments in local day hospitals. For the purpose of this
analysis primary care is the period before patients are referred to one of the few
residential pain management programmes in tertiary care. The primary care runs
from the patient’s first appointment with the GP, complaining of low back pain, to the
time when no further pathological intervention is considered useful.
Chronic back pain is defined as pain that has persisted for longer than 3 months or
past the time of healing (The College of Anaesthetists and the Pain Society, 2003)
and ‘most commonly it is assumed that pain which persists for six months
progressively leads to the chronic pain state, resulting in preoccupation with pain,
depression, anxiety and disability’ (Wall, Melzack, 1999, p540). This leads to
‘occupational role disruption, psychosocial withdrawal, feelings of helplessness, loss
of self esteem and physical incapacity’ (Strong, 1996, p6).
Background
The prevention of chronic low back pain is a major concern and efforts to contain the
situation continue to emerge (NICE, 2003). Strong (1996) reports that the incidence
of chronic pain is as high ás 82% of the community and at least 50% of these are
related to chronic back pain, which is a major problem. GP consultations for low back
pain have been estimated at 14 to 15 million per year in the United Kingdom (Clinical
Standards Advisory Group (CSAG), 1994). Two prospective studies (Thomas et al.,
1999, Croft et al., 1998) of patients who consulted the GP concluded that although
4
many patients discontinued to visit the GP about back symptoms after the first few
months, they reported pain and increased disability at twelve months. Thomas et al.,
(1999) concluded that persistent low back pain was related to the patients’ premorbid state. Prevalence appears to be increasing due to cultural changes that have
influenced attitudes and beliefs, contributing to psychological distress and long term
disability (Buchbinder et al., 2001, Palmer et al., 2000, Waddell et al., 1999,
Bandolier, 1995).
Patients referred to a multi-disciplinary residential pain management centre present
with acquired bio-psycho-social disabilities resulting from their inability to cope with
chronic low back pain. Recent studies (Frost et al., 2001, Birkholz & Aylwin, 2000,
van Tulder et al., 2000, Gibson, Strong 1998) focus quite emphatically on patients’
severe physical, emotional and social impairment, with limited reference to the input
of specific health disciplines or occupational therapy intervention in particular.
Personal experience advocates that occupational therapists are well qualified to
facilitate improvement in some patients presenting with the effects of chronic low
back pain and this is supported in the literature (Carruthers 1997, Strong, 1996,
McCormack, 1990, Heck, 1987). Occupational therapists assess the impact of pain
on occupational performance in all activities from self-care to family relationships,
and work in partnership with patients to develop an optimal programme for living with
the pain (Unruh et al., in Strong et al., 2002). They are holistic in approach,
acknowledging emotional and social, as well as physical distress. However, it seems
that occupational therapists have not recorded their personal experiences of
assessment and treatment of patients with chronic low back pain, whether working
individually, or in a multi-disciplinary team. It is unclear what, if any, occupational
therapy is available in the pre-tertiary pain management programme period, or
whether in fact it has any significant effect on patients, before admission or in
preventing admission. It is not unusual to become insular in our own field of work,
5
losing sight of the approaches or treatments of fellow therapists working in other
sections of medicine. As an Occupational Therapist working in a tertiary pain
management programme, it is important to be informed about the pre-treatment
history of the patients that are referred to, and treated at, the centre. A colleague
investigated iatrogenic factors contributing to patients’ consequent disability with low
back pain and discovered that poor information from clinicians, influencing patient
beliefs about their condition, was a contributing factor (Hafner, 1999). The author
considered that occupational therapists may be contributing to patient disability.
This study sets out to:

Record the experiences of occupational therapists working with chronic low back
pain in primary care.

Evaluate the knowledge of occupational therapists in primary care working with
chronic low back pain patients.

Assess the potential of occupational therapy in primary care preventing disability
in patients with chronic low back pain.

Discover whether occupational therapists in primary care can contribute to the
management of chronic low back pain more effectively alone, or in a multidisciplinary team.
Aims of Study
Patients presenting at a chronic pain management programme with chronic benign,
intractable low back pain are not always reliable witnesses about occupational
therapy input in previous interventions. Many have been subjected to several
treatments with no success or long lasting effect and they are frequently only able to
identify the doctor or consultant involved. The report about other clinicians is often
vague and identities confused. However it is apparent that patients are often more
6
disabled than they need to be due to poor or unhelpful advice (Hafner, 1999). It is
possible that occupational therapists are equally responsible for contributing to this
disability following the assessment and treatment they offer patients in primary care,
or that in fact there is no occupational therapy input available or provided. This study
asks:
How does Occupational Therapy assessment and intervention, in primary care, affect
patients with chronic, benign, intractable, low back pain?
Answers to the following queries will help to verify a satisfactory conclusion.
1. What occupational therapy assessment and intervention is offered to patients
with low back pain?
2. Are occupational therapists in primary care conversant with clinical guidelines
and recommendations for low back pain?
3. Can occupational therapy in primary care prevent disability in low back pain
patients?
4. Can occupational therapy assessment and intervention for low back pain stand
alone in primary care or contribute more effectively within a multi-disciplinary
approach?
Literature Review
Experiences and approaches of occupational therapists working with CBILBP
in primary care
A literature search on the Ovid Database (Medline, Cinahl, Amed, PsychINFO,
Healthstar and Embase), Evidence Based Medicine, including Bandolier and the
Cochran Library as well as a manual search revealed no articles about the
occupational therapists’ experiences of working with chronic low back pain in primary
7
care. Several early articles (McCormack, 1988, Baptiste, 1988, Strong, 1987, Giles &
Allen, 1986, Flower, 1981) commonly described the role of occupational therapists
with chronic pain, not principally low back pain. Assessment and treatment focussed
on improving performance and occupational roles through the use of graded activity,
stress management and counselling. Towards the end of the decade chronic pain
was being recognised as an illness rather than a disease (Waddell, 1987) and
medical approaches to treatment were evolving.
A more structured approach to pain management was observed in the 1990s.
Carruthers (1997) identified an increasing interest of occupational therapists in pain
management in the ten years leading up to her study. Strong (1996) had no doubt
that occupational therapists are well equipped to enhance patients’ performance
skills in the assessment (Gibson, Strong, 1998), and treatment of chronic low back
pain and O’Hara (1996) advocated their role as facilitators and advisers to enable
independent functioning. The authors favoured a cognitive behavioural approach to
the overall management of chronic pain. Occupational therapists are certainly
recognised as an integral member of the residential pain management multidisciplinary team (Birkholz, Aylwin, 2000), and are recommended by the Pain Society
as team members in the treatment of chronic pain (1997b). The potential of
occupational therapy is not in doubt but there is sparse evidence of implementation
or practice experiences.
Knowledge of occupational therapists working in primary care working with
CBILBP
An initial report (CSAG, 1994) and subsequent clinical guidelines (Waddell et al.,
1999, Newton et al., 1999, Royal College of General Practitioners, 1999) recommend
the bio-psycho-social assessment and treatment of patients with acute low back pain.
The intention is to minimise future chronicity and disability by the identification of
8
psychosocial risk factors and to recommend multi-disciplinary treatment and
management. Occupational therapists are well qualified to offer biopsychosocial
assessment and treatment programmes for patients, to encourage problem solving
skills and to prevent the onset of a chronic lifestyle (O’Hara, 1996). Their focus on
occupational performance makes them essential personnel for the patient with
reduced physical and emotional strategies consequent to the pain (Unruh et al., in
Strong et al., 2002). Little et al., (1996) and Newton et al., (1999) were not reassuring
about the implementation of the CSAG recommendations overall and occupational
therapy was not categorised: neither was occupational therapy included in the
advisory group (Waddell et al., 1999).
Koes et al (2001) compared international clinical guidelines for the management of
low back pain in primary care and commented that guidelines for the United Kingdom
included acute pain, rather than chronic pain, assessment and treatment. However
four main groups of psychosocial risk factors for the development for chronic
disability are listed. The United Kingdom guidelines are commended, as they are
common for all primary care health professions although the list does not include
occupational therapists. Further commendations are cited for a compilation of their
recommendations and for upgrading the recommendations as new evidence has
become available (Newton et al., 1999). Specific recommendation for chronic pain is
to refer for exercise therapy. No literature was found on occupational therapists’
contribution, knowledge of, or adherence to clinical guidelines for assessment and
treatment of acute or chronic low back pain.
The National Occupational Therapy Pain Association (NOTPA, 2004, Appendix G)
recommends that therapists have a certain level of knowledge about pain and its
management. The joint publication of the College of Anaesthetists & the Pain Society
(2003) reinforces that all personnel involved in the management of chronic pain, not
9
specifically low back pain, should be trained ‘adequately to ensure a safe and
effective service’. NOTPA (2004) and Birkholz & Aylwin (2000) stipulate occupational
therapy remit as goal setting and graded activity pacing, to reduce flare-ups and
setbacks, to improve occupation, as part of the interdisciplinary pain management
team. It is unclear if they relate this to primary care, as well as the established
residential pain management programmes in tertiary care, for patients with prevalent
symptoms.
There is concern that lack of training for occupational therapists in chronic pain may
account for the lack of input (Strong et al., 1999, Carruthers, 1997). A study by Jones
et al (2000) concluded that education about chronic pain had a significant effect on
the beliefs of occupational therapists working with this client group, but a study has
yet to emerge about the evidence of the impact on practice as a consequence.
Brown (2002) and Steuart-Corry et al., (1997), discerned that occupational therapists
working with chronic pain patients were unable to reach a consensus on treatment
approaches, although they did not define low back pain or refer to primary care
specifically. In their letter to Carruthers & Madeley, Steuart-Corry et al (1997) state
that although there is basic training for occupational therapists in pain management
at undergraduate level, there is every need for further training to extend
understanding and techniques in pain management.
Potential of occupational therapy in primary care preventing disability in
CBILBP patient
Gaynord (1996) presented a case study of a patient with fibromyalgia and
osteoarthritis in an endeavour to clarify the role of the occupational therapist in
primary care. She wanted to demonstrate that primary care therapists were well
suited to long term rehabilitation support by reporting clinical details. The co-
10
operation of the patient, family and occupational therapist lead to improvements in
the patient’s coping strategies. The patient enhanced functional levels through
improved sleep, relaxation practice, goal setting and pacing and the provision of
appropriate household aids.
It has been recognised that occupational therapists are well qualified to manage pain
from a holistic perspective (McCormack, 1990) with their focus on increasing the
patients level of functioning (Shannon, 2002, Chesney, Brorsen, 2000, Moran &
Strong, 1995). There is no indication in the literature that pure occupational therapy
intervention in primary care prevents disability in long term chronic back pain, rather
it decreases disability. Taylor’s (2001) examination of undergraduates over their
three year training established that patient independence is only empowered when
they have some choice in their treatment. O’Hara (1996) opined that specialist
equipment, for patients with chronic pain, is provided when its use will help the
patient to regain control over the practical aspects of their lives. If the equipment
enables the family member to care more easily for the patient, then the invalid role is
reinforced. The therapist’s role can be to provide information relating to equipment so
that the patient is able to make informed choices about purchasing equipment.
Davis (1996) in her paper on primary care management of chronic musculoskeletal
pain identified chronic pain as a common problem and that treatment was
inconsistent. Having acknowledged the ongoing effects of chronic pain she made
suggestions for the assessment and treatment in primary care. Several theories were
recommended
including
pharmacological
intervention,
physical
therapy and
relaxation, with no suggestion of appropriate therapists or of low back pain
specifically. Turner (1996) undertook a meta-analysis of educational and behavioural
approaches for back pain in primary care based on randomised trials. She concluded
11
that a cognitive behavioural approach to treatment may be appropriate, particularly
as a means of preventing the progression of acute back pain to chronic disabling
back pain. However more studies are recommended. A physical therapist is
mentioned as a contributor to treatment, but it is unclear if this is a physiotherapist or
an occupational therapist as the article is of American origin. Apparently occupational
therapists have the skills and approach for clients with low back pain but there is no
account of the outcomes of the intervention.
Can occupational therapy in primary care stand alone for CLBP or is a multidisciplinary approach more effective?
Desirable Criteria for Pain Management Programmes (The Pain Society, 1997a)
stipulates that no single profession can possess all the skills required to effectively
address patient needs in pain management programmes. Fixed sessions for
healthcare
personnel
including
occupational
therapists
(Royal
College
of
Anaesthetists & the Pain Society, 2003) should be available. O’Hara (1996) supports
the multi-disciplinary approach to chronic pain as it provides mutual support for the
patients and a forum within which they have shared experiences, symptoms and
fears. She sees it as an extension of what she calls the uni-disciplinary model, which
is an interaction between the patient and one clinician only. Emulating much of the
literature she interprets, rather than researches, the role of occupational therapists
opining that the aim of intervention in pain management is educative and
participative, so that the patients play an active role in their own treatment. Clinicians
suggested include an occupational therapist, physiotherapist, clinical psychologist
and nurse and she maintains that the range of core skills available in this
combination support the patient in learning to manage pain.
12
Birkholz & Aylwin (2000) reinforce the premise that occupational therapy is a
specialist area within a specialised multi-disciplinary team and that pain management
is successful because of the mixed input of the specific skills. Criteria for pain
management programmes as prepared by the Pain Society (1997a) recommended
an occupational therapist trained in pain management as a key clinical member. One
short report was found relating to an occupational therapy treatment programme for
chronic pain (Carruthers, 1997), but this was not specific to low back pain. The
paucity of exercise was identified, and physiotherapy input as part of the programme
was recommended as essential to address this limitation. Patients attended for two
hours weekly, learning to take responsibility and control through task performance
and education. Interactive group work was a positive approach, repetition of
information facilitated learning, and the format of the programme was continuing to
evolve despite the lack of resources.
Several years ago Strong (1987) suggested that patients with chronic benign pain
including low back pain, needed to be treated by a team of variously skilled
practitioners including occupational therapists. The consensus between her (Strong,
Unruh in Strong et al., 2002) and O’Hara (1996) is that occupational therapists are
core members of a multi-disciplinary team. Both authors favoured a multi-disciplinary
approach to all chronic pain management and discussed occupational therapy as
part of that formula. In a separate article Strong (1998) did suggest incorporating
cognitive behavioural therapy with occupational therapy as a psycho-educational
treatment for low back pain. Patients in the treatment group showed greater
improvement over time than the control group in terms of increased patient control
and reduced helplessness, disability and pain intensity. The occupational therapy
programme complemented the input of the psychologist.
13
Phenomenology as an approach to occupational therapists experiences with
CBILBP.
That phenomenology is well suited to occupational therapy study has been
acknowledged by Kelly (1996), and demonstrated and debated at length by Finlay
(2000, 1999, 1998, 1997). Finlay’s (1999) evidence was based on her study of
clinical reasoning strategies, which lead her to conclude that occupational therapists
actually use a phenomenological process of multi-dimensional thinking anyway to
understand individual’s meaning.
Tryssenaar’s (1999) study enabled understanding of the phenomenon or experience
of what it was actually like becoming an occupational therapist in practice. The case
study approach generated elaborate and extensive data to identify the emergent
themes of the experience, while encouraging the researcher to reflect on her own
experience and practice in an empathic fashion. Very recent studies (Reynolds &
Prior, 2003, Reynolds, 2003) questioned patients about the value of artistic
intervention. Reynold’s (2003) own study favoured in depth interview rather than the
template approach to gather clues of the patients’ experiences. Henare et al (2003)
employed patients’ paintings, and their explanations of these paintings, to gain an
understanding of the reality and experience of patients’ chronic pain. The
phenomenological methodology of exposing emergent themes in that study enabled
one practising occupational therapist, one occupational therapy lecturer and one
nurse lecturer to gain a greater understanding of the common losses and lives of
chronic pain patients, while encouraging patients to share their experiences.
When questioning parents of children with Juvenile Idiopathic Arthritis, Schroder et al
(2003) were able to gain greater perception of parents’ perceptions through semistructured, flexible interviews, which extracted information on the struggles and
concerns of parents. The information would be utilised when working with other
14
parents with arthritic children. In similar vein, Finlay (1998) was able to gain insight
and make sense of what occupational therapists felt about their patients. While
acknowledging certain limitations of their study, Helm & Dickerson (1995) gained
useful feedback on the effect of hand therapy to modify intervention in occupational
therapy using video taped interviews. Udell & Chandler (2000) confirmed that their
phenomenological study was well suited to the topic and yielded rich data on the
opinions of three Christian Occupational Therapists addressing the spiritual needs of
clients, using an interview format.
The phenomenological methodology in the quoted studies was receptive to the
experiences and expressions of the therapists and patient interviewed. The
information was gathered at face value, and the emergent themes of the studies
were collated as evidence-based practice for future interventions. A more formal
quantitative approach may have been stilted and failed to allow the data to evolve
through the descriptions of those studied (Schroder et al., 2003, Finlay, 1998). A
close biographical account of the experiences of higher degree graduates (Dawkins
& May, 2002), could never have been explained in quantitative terms.
Vigilance about trustworthiness reinforced the researchers’ desire to elaborate the
true facts (Schroder et al., 2003, Udell & Chandler, 2000, Finlay, 1998). Crotty (1996,
p19) reasons that nurse researchers require a ‘method of enquiry that will not
prejudice the subjectivity of the experience under study’. Reflexivity is the
responsibility of the researcher and bracketing presuppositions and preconceptions
(Henare et al., 2003, Schroder, 2003, Udell & Chandler, 2000, Finlay, 1999, Crotty,
1996) during data collection and analysis recorded as true an account of the
subjects’ viewpoint as possible. Common themes in the data were identified and
recorded, with minimum bias.
15
The literature review has identified the current state of research, located theoretical
frameworks and drawn implications for the research to explore (Grbich, 1999). The
paucity of evidence of occupational therapists’ experiences suggested potential to
elaborate. Much of the more recent research on chronic low back pain is based on
the outcomes of multi-disciplinary pain management programmes working in a
cognitive behavioural approach (Williams et al., 1996, Gough & Frost, 1996, Moran &
Strong, 1995). The responsibilities of each team member are not isolated, even if the
team members are identified. A systematic review (van Tulder et al., 2000) of
behavioural treatment makes no reference to clinicians involved, or occupational
therapists’ experiences.
The literature established that the knowledge and input of occupational therapists
with this client group is unclear. Shannon (2002) confirmed the dearth of
documentation on the efficacy of occupational therapy treatment in multi-disciplinary
pain management programmes. While opinion suggested there was no shortage of
confidence in the ability of occupational therapists to work with this client group, there
was little evidence of their experiences or effectiveness. Particularly difficult to
decipher is the occupational therapy contribution in the preferred multi-disciplinary
care approach to pain management or the occupational therapists providing
individual treatment. Phenomenology has been rationalised as a suitable
methodological approach for research founded in occupational therapy particularly as
a rich source for evidence based practice (Henare, et al., 2003, Taylor, 2000, Helm &
Dickerson, 1994).
Methodology
Methodology has been interpreted as the theory or approach underlying the method
(Racher, 2003, Sim, Wright, 2000, Koch, 1995, Silverman, 1993). Phenomenology is
a qualitative research approach with roots in philosophy and psychology, and it
16
focuses on the lived experience of humans (Taylor, 2000, Corben, 1999, Polit &
Hungler, 1997, Bowman, 1994). Crotty (1996) suggests that humanistic psychology
has played a significant role as it centres on experience as a phenomenon in the
study of man. Phenomenology allows individuals to describe their real experiences in
their own words (Sim, Wright, 2000, Grbich, 1999, Bowman, 1994). Polit & Hungler
(1997) present it is a useful approach when a phenomenon has been poorly
conceptualised or defined, as is the topic for this study.
The concurrence is that phenomenological research is underpinned by the writings of
Edmund Husserl (1859 -1938), (Racher, 2003, Grbich, 1999, Corben, 1999, Finlay,
1999, Seymour & Clark, 1998). Husserl posited phenomenology as the only rigorous
science that was not tainted by subjectivity and this is measured by the researcher‘s
ability to suspend previous knowledge while gathering new knowledge (Racher,
2003, Lowes, Prowse, 2001, Seymour & Clarke, 1998). Suspension is achieved by
bracketing out or putting to one side preconceptions and beliefs following
examination and acknowledgement, while remaining open to the participant’s point of
view in the experiences reported (Finlay, 2000). This openness is termed intuiting
(Grbich, 1999, Polit & Hungler, 1997). The focus of the theory is the interpretation of
people’s experiences with a certain phenomena or concept and to describe lived
experience and perceptions (Finlay, 1997, Polit & Hungler, 1997) by returning to the
phenomenon (Sim, Wright, 2000, Grbich, 1999). This makes the key elements
description and interpretation of the gathered information (Seymour & Clark, 1998).
Traditionally the philosophy considers that humans exist quite independently (Grbich,
1999) and their unique experience of the world is a result of that existence (Dawkins
& May, 2002). Phenomenologists attempt to understand phenomena or human
activity from the viewpoint of the person being studied, in the belief that individuals
need to be understood within their everyday environment (Dawkins & May, 2003,
17
Shepherd et al., 1993). The phenomenon here is the therapeutic strategies used by
occupational therapists working with patients with low back pain (Guidetti, Tham,
2002).
Phenomenology has been proposed as an exercise in critique (Crotty, 1998,
Seymour & Clark, 1998, Koch, 1995), which encourages some evaluation of all that
is taken for granted (Grbich, 1999, Kelly, 1996). The main source of data in
phenomenological research is the co-participation of researcher and participant in
deep conversation. The participant takes the lead and the researcher strives to enter
the individual participant’s world or experience (Lowes, Prowse, 2001, Polit &
Hungler, 1997). Everything is examined at first hand with an open mind, and ‘the data
must be allowed to emerge in their own form and speak for themselves’ (Crotty,
1996, p20) as common themes relating to the phenomenon under discussion. The
research interview is a purposeful, data-generating activity and a good interview
generates quality data (Lowes, Prowse, 2001).
Due to the debate surrounding the phenomenological approach (Lowes, Prowse,
2001, Annels, 1999, Finlay, 1999, Koch, 1995), this study chose to adopt Crotty’s
(1996) theory. He posited that phenomenology today is about ‘people’s subjective,
everyday experiences’: that is ‘ experience as people understand it in everyday
terms,’ where the term ‘phenomenon’ is interchanged with the term ‘experience’
(1998, p83). In his book (1996) he debated the use, and interpretation of,
phenomenology in nursing research, referring to thirty studies apparently employing
the phenomenological approach. As a result of his study he devised a ‘step by step
methodological research process’ (Crotty, 1996, p158-159) based on the core
principles (Grbich, 1999) of phenomenology philosophy.
18
The research question and the evolution of the data often dictate the framework of
qualitative research, and Crotty’s theory lent itself to the flow of the topic under
investigation. The aim of this study was to determine how occupational therapists
facilitate patients in primary care with chronic benign intractable low back pain. One
way to determine the outcome was to question occupational therapists about their
work, to record, analyse and understand their experiences, while suspending and
bracketing any personal preconceptions and beliefs of the author in production of the
findings.
The stepwise process runs through five stages.
1. The focus on the point of interest, that is the phenomenon.
2. The phenomenon is as it really is. This is established by listening and laying
aside all previous ideas judgements, feelings, assumptions, connotations and
associations that the researcher would think about in a general situation.
3. The documentation of the description of the experience is based on specific
responses.
4. The description comes from the sample and it does not include any interpretation
on the part of the researcher.
5. The information is true and characteristic.
(Adapted from Crotty, 1996, p158-159).
This process will be demonstrated by this study.
Ethics
Ethical approval for this study was granted by the local Research and Development
Committee, the University Ethics Board and the local Research Ethics Committee.
Ethics committees may be the gatekeepers but ultimately it was the researcher who
19
was responsible for ensuring that the project was ethical throughout the study (Sim,
Wright, 2000, Seale, Barnard, 1999).
The fundamental ethical principles for research (Butler, 2003, College of
Occupational Therapists, 2003, Sim, Wright, 2000, Seale & Barnard, 1999, Polit &
Hungler, 1997) required that the researcher:
 protect the autonomy of others (autonomy),
 respect the dignity of others (respect),

promote others wellbeing (beneficence),

refrain from causing harm (non-maleficence),
 deal with others fairly (justice).
The design of this study involved the use of a survey questionnaire and telephone
interview. Each approach had some ethical implications for the researcher. Both
approaches required participant consent: one was implied by the return of the
questionnaire and the other written, to take part in a telephone interview. Informed
consent is sometimes problematic in a qualitative approach to research as the
exploratory nature makes it difficult to introduce and explain (Polit & Hungler, 1997).
The introductory letter (Appendix C) to occupational therapists contained a full
explanation of the process and nobody was approached for telephone interview
without the opportunity to acquire sufficient information (Sim, Wright, 2000), or to ask
for further explanation. Written consent was obtained for all telephone interviews and
all parties were offered the right to withdraw from the study at any time (Seale,
Barnard, 1999, Parahoo, 1997). Telephone interviews were offered as a paced
experience to minimise any discomfort, at the therapists’ convenience. Ongoing or
process consent (Polit & Hungler, 1997) was recognised by member checking when
participants collaborated in the ongoing decision making within the study.
20
Confidentiality of data was protected as transcripts and data were coded and
identities were secured elsewhere (Taylor, 2001, Seale, Barnard, 1999, Grbich,
1999). All information was respected as valid, and consent to formal member check
was agreed at the conclusion of the telephone interview to ensure that participants
felt fairly represented in the analysis of the data (Tryssenaar, 1999, Polit & Hungler,
1997). Moral or legal obligation about exposing confidential information was not
challenged (Butler, 2003, Polit & Hungler, 1997). The tape-recorded interviews were
erased at the conclusion of the study.
Continued contact with the sample can be an issue if participants are known to the
researcher, or if they work in the same environment, as it can blur the specific role as
researcher or practitioner (Butler, 2003, Conneeley, 2002). Co-opting clinicians from
other Health Boards and Trusts gave the parity of sample but guarded against the
perils of direct daily contact. It precluded potential bias or flawing of data by
researcher or the participants (Butler, 2003), due to familiarity or misguided loyalty.
The author is satisfied that she has adhered to the research standards of the College
of Occupational therapists. (2003).
Design
Since the literature review revealed a lack of research in the experiences of
occupational therapists working with patients with chronic low back pain, an
exploratory approach to this study was elected.
Pilot Study
21
A pilot study was carried out to improve and assess the feasibility of the projected
study (Sim, Wright, 2000, Polit & Hungler, 1997, Ballinger & Davey, 1998, Walker,
1996), particularly to establish clarity of the questions, to obtain constructive criticism
on the format, content, and the length of the questionnaire. Questionnaires were
posted to three occupational therapists not included in the main study with an
explanatory letter, a comments sheet (Ballinger & Davey, 1998), and stamped
addressed envelope (Appendix B). The study resulted in minor adjustments to the
questionnaire to encourage completion of the questionnaire.

Please complete ALL the questions whether this is your remit or not.

Please answer the following questions even if you have answered ‘No’ to
questions 12 and 13.
A question was added to clarify respondents’ definition of chronic pain to ensure
parity of understanding of the condition for discussion, and a larger box was provided
to elaborate on multi-disciplinary preferences. Due to the constraints of time the
study ran with these adjustments. In terms of face validity, the respondents were able
to relate the content of the questionnaire to the study under review. Content validity
was assured by requesting information on various facets of the occupational
therapists’ experiences of patients with low back pain (Sim, Wright, 2000, FoulderHughes, 1998 Parahoo, 1997). The answers to the pilot study confirmed reliability as
the participants interpreted the instructions in the same way (Foulder-Hughes, 1998,
Parahoo, 1997).
It was decided to use the original telephone interview format, as it was designed to
encourage participant lead with only prompts or reflection from the interviewer,
allowing flexibility to encourage the richness of data. The same ethical considerations
applied as for the main study.
22
METHOD
Sample
Permission and names of practising occupational therapists were obtained from eight
Head Occupational Therapists (Appendix A), from four areas of Mid-Wales. The list
of names made it easier to follow up those who did not return the initial survey (Curtin
& Jaramazovic, 2001). Only one Head declined due to shortage of clinicians and an
emphasis on hospital discharge. Forty occupational therapists were selected at
random by an independent clerk. A postal survey questionnaire (Appendix C) was
distributed to ascertain that there was occupational therapy available for patients
prior to attending the tertiary in-patient programme. This was to record a profile about
the respondents (Foulder-Hughes, 1998), and included open questions to gain
detailed views and perceptions of the sample (Curtin & Jaramazovic, 2001). A
questionnaire was chosen to encourage respondents to comply because they were
not faced directly with an interview (Foulder-Hughes, 1998, Ballinger & Davey, 1998),
and to gain a smaller sample for telephone interview. Returned questionnaires
implied consent to use the data. Inclusion criteria for telephone interview were,
occupational therapists working with low back pain patients in primary care. A
purposive, that is a typical (Sim, Wright, 2000, Polit & Hungler, 1997), criterion
sample of five occupational therapists working with chronic low back pain was
selected.
All volunteered (Dawkins & May, 2002) to take part in the telephone
interview at a time convenient to them for which individual informed consent was
obtained.
Data Collection
Data collection tools were:
1. A survey questionnaire (Appendix C) to identify occupational therapists working
with chronic low back pain, requesting demographic background and open
23
questions designed to elicit the broader context of the occupational therapists’
experiences with patients with chronic low back pain.
2. A tape-recorded telephone interview with a prepared interview schedule
(Appendix D) to elucidate the verbal account of occupational therapists’
experiences with chronic low back pain.
Triangulation which is the implementation of more than one collection technique in
one study increases the probability of revealing richer data (Hammell, 2002, Sim,
Wright, 2000, Polit & Hungler, 1997, Silverman, 1993), leading to richer information
for analysis.
Survey
So that non-respondents could be sent another questionnaire to maximise the
response rate (Curtin & Jaramazovic, 2001), postal questionnaires were coded and
logged (Ballinger & Davey, 1998) and sent to forty occupational therapists in the
Local Health Boards and Trusts. Information on the study, consent forms for
telephone interviews and stamped addressed envelopes were included (Appendix
C). Non respondents received the questionnaire twice over a two-month period.
Returned questionnaires were logged and the data recorded under question numbers
and topics. Demographic data was tabulated and numbered under the headings of
1. age, gender, years worked, title, type of work, client group, qualifications
2. training in pain, additional training in pain, work with pain now, ever worked with
pain
3. reason for referral, origin of referral, multi-disciplinary working and requirements
for additional training about pain
and confirmed the background of the respondents.
Open responses were recorded as question numbers and headings under definition
of chronic pain, clinical guidelines for low back pain, effects of chronic low back pain,
24
strengths and weaknesses of patients with low back pain, interventions offered,
progress observed and the effects of occupational therapy intervention. These
questions elaborated the therapists’ observations and understandings of the patient
with chronic low back pain.
Interviews
Unstructured interviews were designed to elucidate the participants experience
without imposing any of the researchers personal views, particularly when the
researcher had no concrete views (Polit & Hungler, 1997), and took place over a four
week period. Interviews were preferred as potentially they yielded deeper data
(Parahoo, 1997). The integrity of the interviewee was respected at all times (Sim,
Wright, 2000), and the primary data collection instrument was the researcher who
interviewed and listened to the recorded data (Conneely, 2002, Beck, 1994, Sheperd
et al., 1993). The resulting data was a creation between the researcher and the
researched (Polit & Hungler, 1997, Koch, 1995) with an emphasis on the opinion of
the participant (Seymour & Clarke, 1998).
Telephone interviews were chosen to limit the amount of travelling involved for face
to face interviews in a large rural area, and were arranged following receipt of
consent forms from volunteer therapists. Background information was discussed and
times were set to cause least disruption in the busy schedules of participants and
researcher. Interviewees were advised to ask for breaks at the outset of the interview
to avoid fatigue. Interviews lasted from 15 minutes to 45 minutes and were numbered
one to five.
The interviews were guided, semi-structured and circular to yield conversation (Sim,
Wright, 2000, Crotty, 1996). The interviewer prepared broad, open ended questions
25
on the interview schedule, to avoid bias (Pearce & Richardson, 1996), initially inviting
the therapist to ‘tell’, as an icebreaker to talk (Hand, 2003) about the assessments
and interventions they offered patients with low back pain. The researcher
demonstrated active listening (Sim, Wright, 2000, Crotty, 1996) and encouragement
by prompting, probing, reflecting, paraphrasing and discussing with the interviewee.
The interview did not follow an exact order, as some flexibility was desirable to allow
the researcher to follow up issues raised. The interview schedule was prepared to
ensure that all participants reported on the same topics to aid reflection, but was not
designed to inhibit the intuiting of the researcher or the flow of the participant. The
interviews explored the experience of working with chronic low back pain to generate
data based on the respondents’ personal experiences (Dawkins & May, 2002,
Parahoo, 1997). Permission to member check was requested at the conclusion of
each interview. All participants agreed to read the interview hard copy to authenticate
the content.
The researcher jotted phrases in a reflective diary as the interview allowed and then
recorded related reflections (Taylor, 2001, Sim, Wright, 2000, Grbich, 1999, Finlay,
1998), within two hours of the completed dialogue. There were also opportunities to
debrief with colleagues, none of whom are occupational therapists, but who are
experts in the area of pain management and one who is an experienced researcher.
The tape-recorded interviews were scribed individually by an independent cleric and
the hard copies distributed to the participants for authentication (Appendix E).
Data Analysis
Analysis and results were based on the aptitude of the analyst (Lowes, Prowse,
2001, Holloway, Wheeler, 1998), and the individuals’ representation of their
experiences (Seymour, Clark, 1998). Initially the accuracy and quality of the data
26
depended on what the respondent wanted to disclose and the integrity of the sample
to contribute accurately (Pope et al., 2000, Parahoo, 1997, Silverman, 1993). The
analysis of survey and interview texts was performed manually (Sim, Wright, 2000)
with the aid of a word processor. The researcher devised her own method of
analysing the data, which on later reading compared to the editing analysis or
categorisation scheme described by other writers (Taylor, 2001, Polit & Hungler
1997, Bowman, 1994). This involved comprehending, synthesising, theorising and
recontextualising, moving backwards and forwards from the raw data to emergent
themes. This approach worked best for the researcher (Sim & Wright, 2000, Polit &
Hungler, 1997). Data provided a description, but not an explanation, and the role of
the researcher was to sift and interpret to make sense of what had been reported
(Pope et al., 2000). Although critiqued as a rather laborious process it enhanced the
data rather than reduced it to numerical coding.
Survey
The demographic material had been coded and sectioned under headings at
collection and the categories were then totalled, collated, recorded and reported.
Individual open questions were analysed independently on separate sheets and
categorised into common topics. By reading and rereading the responses new
categories emanated from the text until no new categories were realised. The
responses to these open questions reported broader data on therapist experience
than anticipated. It was decided to store these findings before the interview process
began (Polit & Hungler, 1997). This was to reduce bias and to bracket the information
before collecting data yet to be revealed by the telephone interview.
Interview
27
After verification of the text by the sample therapists, the researcher read the texts
several times to get a feel of the interview and the experiences of the interviewees
and the interviewer. Themes emerged after repeated reading and were drawn from
common words, phrases, sentences and themes that highlighted any commonality
(Dawkins & May, 2002, Taylor, 2001, Corben, 1999). The highlighted text was then
categorised in accordance with the aims of the study, and recorded on separate
sheets under the headings of Assessment and Intervention, Clinical Guidelines,
Disability Prevention, and Multi-disciplinary/Individual Therapy. During the reading
additional themes emerged which were tabulated under the headings of Reasons for
Referral, Holistic Approach, Concerns of Occupational Therapists and Independence
and Empowerment. All quotations were numbered according to coding of participants
and page numbers from the text. Each category was reread and re-evaluated several
times to compare and synthesise the comments of each section. Therapist
quotations were reported to support the outcomes presented.
The open question response and interview response themes were compared for
further commonality (Henare et al., 2003, Bowman, 1994) using the same technique,
and the findings were presented in the Discussion (p 40).
Results
SURVEY QUESTIONNAIRE
Demographic Background: (Questions 1 to 9, 11 to 13, 15 to 17, 23, 24, 26)
Twenty six occupational therapists responded to the postal survey. Eight were unable
to complete the exercise either because there was no service in their area or they did
not feel qualified to answer. One therapist was actually taking a career break. Some
questions were omitted by respondents, and the figures for individual question
response are included in each question result.
28

The majority of participants were aged 30 to 50 years with one under 30 and
three over 50 years.

Sixteen females and two males responded.

Twelve therapists had qualified by Diploma in Occupational Therapy, Five BSc
OT and one had a post graduate MSc OT.

Therapist years of service were recorded as:
1 to 5 years
5 to 10 years
11 to 15 years
> 15 years
4 Therapists
3 Therapists
3 Therapists
8 Therapists

The majority ranked themselves Senior Occupational Therapists, five were
Heads of Departments and two Basic Grade therapists.

Many therapists were employed in more than one area of work in hospital and
community settings, Acute Psychiatry, Elderly Mentally Ill, Out Patients and
Community. No one worked purely with chronic low back pain patients although
eleven clinicians reported some input with low back pain patients now.

Patients were not referred for low back pain alone, but rather for depression or
physical assessment in mental health services and general functional
assessment and rehabilitation at home or work for non specific physical
conditions in physical health.

Referrals were taken mainly from GPs with fewer from other professionals and
Consultants. Therapists reported seeing patients for assessment and treatment
who had experienced low back pain for:

3 months
6 months
1 year
18 months
2 years
>2 years
1 therapist
4 therapists
4 therapists
1 therapists
2 therapists
6 therapists
Only one therapist reported definite training for chronic low back pain, although
two had actually spent a short time at a back school, and two had done short
29
placements. Therapists had not attended additional training and were generally
self-taught through reading of journals or talking to physiotherapists. Ten
therapists said they would like more training.

All therapists preferred multi-disciplinary team work to give the maximum input to
patients, utilising the breadth of combined expertise. Quotations included ‘each
discipline would have unique perspective and advice’, ‘so that the person is
worked with holistically’.
The initial sample experiences then were broad, working in physical and mental
health, generally at a senior level. Low back pain was not a primary cause for referral
and back pain assessed was chronic (had lasted longer that six months). Training in
chronic pain was sparse and multi-disciplinary working was the favoured option.
Clinical Guidelines for Low Back Pain (Questions 18, 19)
Acute low back pain
Chronic low back pain
Not one of the seventeen responding Not
one
of
the
fifteen
responding
therapists was aware of any formal therapists was aware of any formal
clinical assessments
clinical assessments
In Practice
Reported approaches and suggestions Reported approaches and suggestions
for assessment of acute low back pain
for the assessment of chronic low back
pain

Read medical history, noting previous 
full medical history as would expect
interventions,
patient
take
history
from
patient’s view,

Observation

Occupational
probably
already
altered
lifestyle to accommodate problem

therapy
functional 
30
observation
occupational
therapy
functional
/

assessment / ADL
lifestyle
Review of exacerbating pain features,
measure the effects of the pain rather
patients perception of level of pain,
than causes
posture,
transfers
seating/bed, 
assessment
/
ADL
to
patient’s perception of pain and
driving, work, leisure
exacerbating
features,
posture,

Concentrate on patient goals
transfers, seating/bed, driving, work,

Would pass on to physio
leisure
Although there was no knowledge of the CSAG guidelines (1999, 1996, 1994),
particularly acute guidelines and the prevention of disability, the consensus report in
approach to assessment in both clinical areas focussed mainly on the physical
presenting symptoms and the patients’ ability to cope with their everyday demands.
One therapist wrote that she would look at the triggers for both and focus on how to
minimise them.
CATEGORIES FROM OPEN QUESTIONS
The results not directly answering the aims are presented in Appendix F.
Interventions (Question 21)
This question asked for interventions offered or that would be offered to patients with
chronic low back pain. The analysis of fourteen responses revealed a high proportion
of physical interventions including the use of equipment, emotional issues, problem
solving and education.
Physical interventions recommended:
 functional, environmental, workplace, home, driving, ergonomics of home and
work environment assessments

graded exercise

fatigue management, relaxation, energy conservation and joint protection
31

physical coping strategies and lifestyle advice such as transfers from chair,
posture and manual handling,

providing equipment for example a wheelchair, and compensatory techniques to
enable maximum performance
One therapist working in mental health recorded referral to colleagues in physical
service for specialist input and another, immediate referral to a Consultant, GP or
general hospital for specialist input. Neither defined the nature of specialist input.
Interventions for emotional issues recommended

anxiety management

assertiveness training

talking therapies mainly
The enhancement of problem solving skills, were suggested as well as patient
education to enable self-sufficiency and independence. Specific approaches were

Solution Focussed Therapy

goal setting, planning and pacing

alternatives, enabling techniques for carrying out ADL, work and leisure

balancing work, rest and play and evaluation

education about the back and potential damage

education re-good posture, exercise programme and back strengthening
One therapist
noted working
in conjunction
with the patient
to identify
ADL/occupation the individual is having difficulty with, and to provide interventions to
address these areas. Overall the interventions recorded, emulated the holistic
approach gathered from other open questions.
TELEPHONE INTERVIEWS
32
Nine therapists gave consent to a telephone interview although only five actually
confirmed working now or ever with chronic low back pain. Three therapists worked
in community mental health, one in hospital and community physical, and one
worked with elderly rehabilitation in hospital and community. All were of a senior
grade and carried their own caseload. Results emerged during the analytical process
(Polit & Hungler, 1997), and were scribed under headings taken from the aims of the
project and additional themes that emerged in the analysis.
Assessment and Intervention
Assessment
Therapists reported the use of a holistic and general occupational therapy
assessment, not specifically geared to low back pain but which highlighted the effects
of back pain.
Primary assessment would be from a mental health perspective and
obviously we take into account then if people are having problems
with pain management….
(Therapist 3)
No specific assessments ………………….general occupational therapy
assessment……..I would find out exactly how it’s affecting their everyday life
to make sure we can gear the intervention part for them
(Therapist 1)
Most problems….are sort of multi-complicated………….I tend to look
at them as what are the problems and what can I do to help.
(Therapist 2)
One therapist favoured a common sense approach to find the patient’s perspective
on what they wanted and what they felt would help, as well as a home visit to check
out the environment for potential adaptations. She used a talking solution focused
approach to enable patients to identify the immediate functional difficulties impeding
their lifestyle. Another used a broad multi-disciplinary physical and cognitive
assessment, also used by nurses and physiotherapists, to identify all the problems
the patients were having. They looked at patients’ lifestyle, perception and beliefs
about increased pain. The patients with low back pain were very chaotic and so
previous interventions and present coping strategies were reviewed. One therapist in
33
mental health suggested that she would refer the patient to an occupational therapy
physical service if available. Another identified the appropriate referrals herself from
the weekly referral meeting.
Intervention
The patients with back pain were fairly entrenched and required longer-term
intervention. Common approaches to intervention were improving function by
employing activity scheduling, goal planning, and pacing, while problem solving
through talking.
Showing them how to do things in a different way rather than the way
they did things before ……their back pain………….perhaps they used
to cut the whole hedge…………….to do half an hour today and half
an hour tomorrow……….looking at how they manage their anxiety….
things like confidence building
(Therapist 3)
A variable approach to the supply of aids and adaptations was apparent and
therapists:-
…….would deal with the practical side of things….….there is a fair
bit of chair raising, and toilet raising, grab rails and that kind of thing
(Therapist 2)
………do look at equipment in the short term……we try not to use
equipment at all………….unless we feel we cannot work with the
client………..if they’re not ready to accept that the pain can be
alleviated
(Therapist 5)
One therapist found that moving and adapting the home with equipment reduced
physical dysfunction and emotional distress and improved patient control. It was a
joint problem solving process between the patient and therapist to find a way of doing
things. She was not the only therapist to offer relaxation exercises. Three therapists
focused on talking therapy, and detailed pacing and cognitive plans to manage the
over activity cycle. She was the only clinician to address the unthreatening nature of
chronic pain with the patients.
34
The data revealed a limited range of specific intervention for chronic back pain which
focused mainly on enabling patients to work with their pain. One therapist identified
the need for education about chronic pain and no therapists mentioned pain relief. It
was a management of ongoing pain, allowing the patients to live more easily with it.
The general approach to intervention demonstrated practical coping strategies with
some cognitive input to increase the patients’ overall self-management. The supply of
aids and adaptations was seen as a facilitator by two therapists, while one
considered them unnecessary. All therapists were competent to offer some pain
management strategies using occupational therapy principles.
Clinical Guidelines
No interviewees had knowledge of any clinical guidelines for the assessment and
treatment of chronic low back pain.
I don’t follow any particular guidelines.
(Therapist 1)
I haven’t got access to any specific to low back pain. (Therapist 4)
However one therapist admitted that she would like some and another assumed that
they existed but she did not know.
Disability Prevention
There were varying attitudes to the ability of occupational therapy to prevent patient
disability. Prevention was impeded by the timing of referral and, therefore, the timing
of intervention as well as on the poor understanding of chronic pain by other
professionals.
Things have become really entrenched and we often wonder if they’d
been seen earlier or if psychological problems had been tackled
earlier, whether or not the outcomes of people would be different.
(Therapist 3)
I feel that what we can offer is just a glimpse really of the fact that
there is a way forward………………….I feel that it is fine when
we can provide the intervention but I don’t think it’s enough, it’s
35
not intensive enough for them……….There is a perception that nothing can
be done…….it’s the time factor…..it’s so much easier to be handing out a
prescription than to work with the client.
(Therapist 5)
However one therapist reported timely intervention by astute colleagues.
Nursing staff are very good - if they think there is a functional
problem, that I can help with they do actually refer straight on to me.
(Therapist 4)
Prevention depended on the attitude and motivation of the patient concerned and the
willingness to take things on board, and was not necessarily related directly to the
input of the therapist, but that did not exempt or limit input.
……. there are interventions that can be done, but mostly I get people in
this area who accept that they’ve got aches and pains and get on with it
(Therapist 2)
…..we find that people look after their pain and are unwilling to view
things
(Therapist 5)
There was conflict of interest and potential impediment if patients were over cared for
by family or external agencies. A vicious circle evolved because patients were
inactive due to somebody else doing it for them. There was a difference of opinion
about the supply of aids and adaptations. This concerned what the patient was ready
to accept and what the therapist felt was suitable.
Often I find that people don’t really want things [aids] ……unless they
absolutely have to have them because they don’t want people seeing
them in a wheelchair as much as anything.
(Therapist 2)
…..look at maybe equipment and adaptations to people’s property
and their home…….to see if there is anything we can do to change
(Therapist 4)
There was an awareness of therapist responsibility to enable the patient to visualise
intervention, to achieve the potential while being cognisant of what the patient
wanted and was prepared to accept. Alternative approaches were sought to reduce
stress on painful joints and looking at what patients can do within their living patterns,
rather than focussing on the pain.
Patients referred to mental health facilities, sometimes as a last resort, presented for
multiple reasons and interventions were prioritised.
36
Often the physical services do not feel that they can cope with people
with mental health problems, especially if they are psychotic……
……..They’re re-presenting because of their mental health problems,
the back pain is something that we work with to try and reduce some
of the problems. Because if you’ve got severe mental health problems
and you’ve got chronic back pain it’s not going to be very easy is it? So
by trying to get rid of some of the physical symptoms it can actually
help with their mental health.
(Therapist 4)
Therapists accepted that timely assessment and intervention would go some way to
limiting disability but this could depend on patient motivation and goals, and
sometimes external factors inhibited progress. Prioritising patient needs when they
presented with multiple difficulties was a consideration. Provision of aids as
prevention was not conclusive.
Multi-disciplinary/Individual Working
Availability of multi-disciplinary team work was favoured to maximise patient
opportunity through the use of complementary and individual philosophy.
Other team members get involved and I think because we’ve got
the ability to refer to each other quite quickly things get sorted
…………………it works very well I think
(Therapist 2)
We can’t say that occupational therapy is the best thing out, it’s just
part of an overall treatment plan for people, we need everybody.
(Therapist 4)
I think it’s essential with a multi-disciplinary team because I feel people
that we have worked with have been looking for the magic cure and I
think the fact that we do have an occupational therapist, physiotherapist
and nurse……………………using the same approach ……………..
gives the clients confidence that there isn’t another professional out
there that may be able to cure that.
(Therapist 5)
I do work quite closely with our community psychiatric nurses here
………
(Therapist 1)
Recognition of the strengths of multi-disciplinary working did not discredit individual
occupational therapy input, and occupational therapists’ skills were recognised with a
confidence in their own professional ability. In fact one therapist suggested:I think it would be the depth of the service that I could offer as an
occupational therapist. I actually think occupational therapists can
take a lead in it, but I may be biased
(Therapist 5)
37
While managing her own caseload in mental health one therapist was sometimes
called in as a co-worker for specific occupational therapy intervention, like relaxation,
or to carry out an assessment for aids and adaptations. This was a short term contact
and the patient was under the overall supervision of the psychiatric nurse keyworker.
There was flexibility within teams to use both approaches.
……..a lot of work is done individually and then I suppose we work in both
ways really so not everybody that we see has got anybody else involved
in the team. It depends on the individual really………….Say you’ve got
someone being treated for depression they might refer them broadly to the
team or they might refer strictly to the occupational therapist or depending
on what they identify and then from our assessment if we think we need to
involve other people we do……………I think one person being involved is
O.K. as well
(Therapist 3)
I do go in as an occupational therapist and do an occupational therapy
assessment, and just be the only professional involved then
(Therapist 2)
The multi-disciplinary approach is favourable to give patients access to maximum
skills according to assessment of need, but it is recognised that occupational therapy
can stand alone. One comment however gave concern as it was suggested that as
professionals ‘not everyone knows what everyone does’. Anecdotal discussion on the
understanding of professional roles is ongoing.
ADDITIONAL THEMES
Reasons for Referral
No therapist recollected a referral specifically for low back pain. The nearest was an
example of a basic referral in mental health.
Please can you see this man who had an accident at work and has
been off with back pain and is now saying he’s depressed and asking for
counselling
(Therapist 3)
Other therapists confirmed that the referrals were more general and that back pain
was only part of the presenting problem:I don’t remember anybody ever being referred for low back pain
………they’d probably be referred for a stroke or hip replacement …
…..with maybe lower back pain as part of that……..I think a lot of back
pain would really be referred to the physiotherapist (Therapist 2)
38
Referral to us would be the mental health condition like depression
or anxiety . We don’t offer a service specifically for pain management
(Therapist 3)
usually mental health and it’s usually because they are unable to
function on a daily basis………………………..problems come from
things like low back pain, that the back pain is actually so much it’s
affecting their mental health
(Therapist 4)
The lack of a specific service for low back pain was identified, but this did not
preclude appropriate treatment as part of presenting difficulties.
Holistic Approach
An obvious aspect of occupational therapy was the holistic approach to patient
assessment and intervention. One therapist acknowledged ‘looking at the whole
package’ as the patient could be having a social problem or difficulties with the home
and another tended to look at everything to do with the person’s lifestyle.
…..if there’s a problem that we need to look at it from all aspects
whether it’s physical, mental or psychological…………I think as
O T s we’re trained to do all of it………….It’s an ongoing holistic
assessment
(Therapist 4)
I think occupational therapists have a good grounding in looking
at the whole person. They have medical training………psychological
training…………physical training………..allows the occupational
therapist to look at the understanding of occupation in a client’s
life.
(Therapist 5)
Occupational therapists identified the effects of chronic back pain on patients’
lifestyle and addressed physical, emotional and social aspects of life, recognising
that improvement impinges on all these aspects of life style.
Concerns of Occupational Therapists
A lack of actual occupational therapy services for chronic low back pain is apparent.
I don’t know where people go if they haven’t got a mental health problem
as well …….who would deal with it on the physical side actually………
…………some doctors or departments are more familiar with OT…
………perhaps there isn’t a service in some places (Therapist 3)
39
However the participant occupational therapists were competent and motivated to
treat the patients referred, while two expressed specific interest in the work of other
therapists to improve knowledge.
We have the skills to work with them……………I do feel it’s a huge
area that occupational therapists could work with (Therapist 5)
always questioning yourself whether there is any more that you could be
offering…………………………..in process of changing assessments
to look into a lot more detail to do with occupation…(Therapist1)
Therapist 5 concluded that therapists with a specific interest in low back pain would
find relevant courses to develop their skills further. The interest and competency of
the sample was apparent.
Independence/Empowerment
Occupational therapists recognised the right of patients to be involved in their own
treatment and to have an opinion about their individual needs.
There’s no point in going about what I might think is best for them
because it might not be what they want so it’s got to be working
with them…….they are capable of doing things themselves despite
them being in pain….It’s trying to get them to be a bit more confident so
that they are capable of doing things themselves despite being in pain…..
the aim for them is to realise this for themselves. (Therapist 1)
…..making sure the person is in the centre and it’s all their ideas….
……….the answer has come from within us……….if you’ve got the
expert telling you what you should or shouldn’t be doing, it doesn’t
sink in as much…………finding out what they want and what they feel
will help and trying things out………..
(Therapist 4)
I think we can work with people……………….which then enables them
to go off and explore other avenues.
(Therapist 5)
A particular patient was asked what it would take to put the washing on the line and
she suggested a basket on a trolley would be higher up. Because the patient came
up with the idea then she was the expert. Empowerment through efficacy, as the
patients realise their own potential, was a criterion for occupational therapy in the
management of low back pain.
Resume
40
Although the main presenting patient problem was not low back pain, and
occupational therapists were not specifically trained for low back pain intervention,
they demonstrated competence to work with this condition. They were able to identify
the effects of low back pain, as well as work with the patient to enable them to live
with the pain. Physical and emotional recommendations and problems were
addressed through talking to the patient and working with patient identified needs.
Aids and adaptations had some value but patients were not always receptive to using
them. Whether the use of aids contributed to disability or empowerment is not
conclusive. Some patients chose to manage independently without occupational
therapy or multi-disciplinary intervention whether through habit or lack of motivation is
undecided. All the therapists interviewed had an interest in facilitating the patient to
the limit of their present knowledge, and at least two wanted more knowledge and
understanding to improve intervention.
Trustworthiness
The author has worked in an interdisciplinary residential pain management
programme for ten years and is expert in the cognitive behavioural approach to low
back pain and other chronic pain disturbance. The purpose of this study was to
explore occupational therapists’ experiences with low back pain in a different clinical
setting. The tendency to compare her own setting actually opened up the interview
discussion, and she did not assume that occupational therapists would be
inappropriate in their approach to chronic back pain (Hafner, 1999). Acknowledged
flaws (Savin-Baden & Fisher, 2002) in this study were mainly related to the
researcher’s inexperience and her learning curve, the one impinging on the other.
She understood that rigour is ensured by the use and description of systematic
design (Barbour, 2001, Mays, Pope, 1995), and by reflexivity (Hand, 2003, Koch,
Harrington, 1997) but took time to fully grasp the process. However by the third and
41
fourth interviews she was more immersed and relaxed into the interview content
through more comprehensive listening and understanding. The researcher
acknowledged her values, assumptions and background (Hand, 2003, Henare et al.,
2003, Conneeley, 2002) and acknowledged the expertise of the participants within
the framework of their broad case load. Reflexivity ‘distinguished how subjective and
inter-subjective elements impinged (and possibly transformed) both the data
collection and the analysis’ (Finlay, 1998, p 453) and recorded the researcher’s
personal sensitivity to the collected data (Hammell, 2002, Mays, Pope, 2000, Koch,
Harrington, 1998, Krefting, 1991) consequent to her personal experiences. The
descriptions collected were a reflection of the participants’ perceptions of their own
world (Finlay, 1998).
The criteria of credibility, transferability, dependability and confirmability (SavinBaden & Fisher, 2002, Taylor, 2001, Polit & Hungler, 1997) were applied in this
study. Credibility relied on the integrity of the occupational therapists taking part and
the recurring themes in the texts. The researcher recorded in a reflective diary and
took the opportunity to debrief with experienced colleagues to maintain objectivity.
Triangulation was employed to ensure internal validity (Barbour, 2001, Shepherd et
al., 1993), which enhanced reliability by identifying convergence of data to
corroborate the overall results (Conneeley, 2002, Mays, Pope, 2000, Grbich, 1999).
Member checks confirmed the accuracy of the typed interview (Dawkins & May,
2002, Trysennaar, 1999, Helm & Dickerson, 1995). The researcher’s credentials
established that she was well qualified to undertake the study (Hammell, 2002,
Trysennaar, 1999).
The interview sample were representative occupational therapists and the full
description of the research design is transferable to other settings (Taylor, 2000, Polit
& Hungler, 1997, Krefting, 1991), although the reader rather than the researcher
42
takes responsibility to establish transferability to test the trustworthiness (Taylor,
2000). There was no hypothesis in this phenomenological research so there was
nothing to prove or contest. Dependability was related to the consistency of the data,
and was confirmed through triangulation and detailed explanation of the research
process (Pearce, Richardson, 1996, Krefting, 1991). Different types of data were
reconciled and proved accurate (Sim, Wright , 2000, Grbich, 1999, Silverman, 1993),
and the combination of survey questionnaire with open ended questions and semistructured interview, facilitated an exploratory approach (Sim, Wright, 2000). Peer
evaluation of this study may have strengthened dependability (Taylor, 2000), but the
study was an assessment of personal competence.
Confirmability, the objectivity and neutrality of the data (Polit & Hungler, 1997), was
addressed as the researcher recorded intrusive personal opinions about the
phenomenon in a reflective diary (Henare et al., 2003, Taylor, 2001), with a view to
dismissing, judging and defending against any interpretation in the researcher’s self
interest (Conneeley, 2002, Fisher & Savin-Baden, 2001, Koch, 1995). Confirmation
of the data was achieved by member checking, informally and formally (Conneeley,
2002, Polit & Hungler, 1997, Parahoo, 1997), so that any misunderstandings or
misinterpretations on the part of the researcher were checked. The complete
interview was despatched for inspection and no comments were altered, therefore
reliability was not compromised (Savin-Baden & Fisher, 2002, Polit & Hungler, 1997).
A clear audit trail described data collection, interpretation, and sufficient data for the
reader to judge the outcomes as credible (Hand, 2003, Lowes, Prowse, 2001,
Barbour, 2001, Mays, Pope, 1995). Due to the sample size and the non-experimental
nature of the methodology, the goal of the project was not replication or
generalisation of the results (Sim, Wright, 2000, Polit & Hungler, 1997, Corben, 1999,
Krefting, 1991). Rigour was ensured by the use of a systematic design demonstrating
43
data collection, interpretation, and sufficient data for the reader to judge the
outcomes as credible (Barbour, 2001, Mays, Pope, 1995). Rigour was achieved by
ensuring maximum trustworthiness and minimum bias (Hand, 2003, Finlay, 1998).
The researcher wanted to focus on the pure data (Taylor, 2001, Crotty, 1996). It was
not possible to test the data descriptions with other occupational therapists’ (Pearce,
Richardson, 1996), experienced in pain management and member checking only
established clarification during interview and the accuracy of the printed text.
Member checking has been questioned, as a measure of proof that results are
believable (Polit & Hungler, 1997) and because of the inconsistencies in its use
(Savin-Baden, Fisher, 2002). This study sent the typed interview for verification,
although this is not necessarily standard procedure. The researcher was dependent
on the integrity of each participant to establish credibility and dependability. However,
the validity of the interview responses was enhanced by the researcher, who,
informally sought clarification during the interview process (Parahoo, 1997).
Bracketing has been queried as a reliable approach to objectivity (Lowes, Prowse,
2001) and it has been suggested that trustworthiness and rigour are only proven
when the interview process has been fully explained. If the researcher had not
reported her reservations the reader would be unable to make a valid judgement
about trustworthiness of the study (Crotty, 1996). Idealisation of the process would
have served no purpose and the researcher took responsibility and acknowledged
the reality of the process. The completed study was proof read by an independent
scrutiniser.
Discussion
This study set out to gather the experiences of occupational therapists working with
patients with chronic low back pain in primary care, and to establish available input
before admission to a multi-disciplinary residential pain management programme. It
44
revealed that occupational therapy assessment and intervention is available in
primary care and those therapists were equipped to enhance patients’ skills by
facilitating and advising (O’Hara, 1996), although no specific service for low back
pain was available. Patients were not referred for low back pain specifically, either in
mental or physical health, but felt physically and emotionally empowered following
assessment and intervention, due to taking responsibility for their own intervention.
Achievement improved their confidence and self esteem so that they continued with
self-management, increasing their leisure activities and sometimes returning to work.
However some therapists felt that they could have done more, if time and structure of
approach were improved.
There were few contrasts (Guidetti & Tham, 2002) between the outcomes of the two
sets of data. All those interviewed had worked with chronic back pain whereas the
survey only identified eleven out of the eighteen working with back pain now. It is
impossible to comment on the caseload of the non-respondents. The discussion will
look at the combined results using the headings of the interview themes.
Assessment and Intervention
Assessment
Assessment as described in the survey concentrated more on the physical
components of the pain. A full medical history and the patient’s perception of the pain
was recommended, although they identified the effects of chronic back pain and the
strengths and presenting problems of patients, (Appendix F) very comprehensively.
These included emotional, social difficulties and aspects of loss, as well as goal
setting and motivation, which suggested deeper therapist knowledge than at first
deduced. The interviews elaborated a more holistic approach employing an
occupational therapy or multi-disciplinary assessment, relevant to the client group, to
45
identify all the presenting problems. Referral to mental health was on emotional
grounds and back pain was not always identified, but became apparent from the
holistic assessment. The two therapists in physical health quoted broad referrals
requiring thorough assessment to isolate all the difficulties experienced by the
patient, including back pain. In the 1980s assessment focussed on improving
performance and occupational roles (McCormack, 1988, Flower, 1981), and later
writers (Gibson & Strong, 1998, O’Hara, 1996) identified the expertise of
occupational therapists as assessors. There is no significant change in the expertise
of occupational therapists in assessment.
Intervention
It has been suggested that occupational therapists have been unable to reach a
consensus about their treatment approaches to chronic pain (Brown, 2002, SteuartCorry et al., 1997, Davis, 1996). The survey elicited more specific interventions for
patients as if therapists had been able to focus better on a written response.
Suggestions included graded exercise, fatigue management, relaxation, transfers,
manual handling, anxiety management, assertiveness training and education about
the back and posture. Interviews revealed some focus on goal setting, activity
scheduling and pacing, supply of aids and adaptations; ergonomics and relaxation
were also recommended, and education on chronic pain in one case emulating
NOTPA (2004) recommendations. Both reports recognised the value of talking
therapy and therapeutic support. The interview could have probed further to reveal
individual interventions and examples. However on further review it appeared that
both revealed physical, emotional and problem solving skills to enhance patient selfsufficiency. Recommended interventions (Baptiste, 1988, Strong, 1996) do not seem
to have evolved specifically and the cognitive behavioural approach (Birkholz, Aylwin,
2000, Strong, 1996, O’Hara, 1996) remains the prerogative of the multi-disciplinary
46
pain management programme reported in the literature (Williams et al., 1996, Gough
& Frost, 1996).
Clinical Guidelines
Occupational therapists were not aware of any specific guidelines for the assessment
of acute or chronic low back pain. This general lack of knowledge and
implementation of clinical guidelines by all clinicians is supported in the literature
(Newton et al., 1999, Waddell et al., 1999), and in fairness occupational therapists
were not involved in the working party (1994). Whether this is a valid reason for lack
of knowledge may go to debate, but it is increasingly challenging for all clinicians to
be conversant with all guidelines, particularly when they cover a broad client group.
The occupational therapists in this study did not avoid patients with back pain and
their assessments highlighted patient difficulties, while their intervention enabled
patients to deal with the effects and nature of the chronic back pain.
The special interest group (NOTPA) is beginning to gain notoriety outside the multidisciplinary pain management programmes. There are specific recommendations
and guidelines for occupational therapy practice for patients with chronic pain, which
includes low back pain. Therapists in the survey confirmed that they had received
very little training, if any, in chronic pain interventions, but credit goes to those who
had expanded their knowledge by self learning. Only ten showed interest in further
training, but therapists choose their own areas of interest in continuing development.
Those who had worked with chronic back pain have unknowingly embraced several
of the NOTPA recommendations by adapting their occupational practice. This
suggested that occupational therapists are well qualified to apply their expertise in
occupational performance to chronic low back pain, even though it is recommended
that all therapists working with pain undergo extra training (Steuart-Corry et al., 1997,
47
NOTPA). Establishing consistency of practice is challenging in all areas of medicine
and progress is a process.
Disability Prevention
The survey findings confirmed that occupational therapists were unaware of clinical
guidelines for acute back pain which have been introduced to prevent the
development of disability and chronicity, consequent to poor screening in the early
stages of acute low back pain (CSAG, 1994). In the interview it was acknowledged
that timing of referral was important to provide or encourage suitable intervention,
before patients became entrenched in their condition. Motivation and aptitude of the
patients to make changes to their lifestyle to enable them to live with the pain, was a
concern, while it was recognised that disability could be enhanced by the acceptance
of input from family or carers. One therapist in agreement with O’Hara (1996) saw
suitable aids and adaptations to the home as an enabling rather than disabling factor,
but O’Hara recommended caution to provide for the patient, not the carers, and
patient choice was important (Taylor, 2001). The fact that some patients seemed to
cope independently with aches and pains and declined aids and adaptations did not
highlight the direct need for occupational therapy intervention in one case. However
no opinion on the effect of discussion between therapist and patient was addressed,
and patients may have felt more confident just by discussing their own coping
strategies with an empathic clinician.
No specific question was asked in the survey concerning disability prevention, but it
was reported that weaknesses of patients included reduced stamina, low mood,
negative view of illness and the effort needed to maintain lifestyle (Appendix F). It
could be argued that therapists were only in a position to prevent disability with the
co-operation of the patient, based on the patients’ motivation. Conversely it could be
48
argued that it is the job of the therapist to create that motivation through information
sharing and support to put the theory into practice. Hafner’s (1999) conclusions about
iatrogenic factors were unsupported in this study and there was no other literary
evidence to compare.
Multi-disciplinary or Individual Approach
In the main, both outcomes favoured a multi-disciplinary approach to assessment
and intervention for patients with low back pain. However all therapists in the
interview acknowledged that occupational therapists also had the skills to work
individually with this condition. In fact one was adamant, although maybe biased, that
occupational therapists have the in depth understanding and knowledge to
independently treat patients, with low back pain. The survey offered a straightforward
choice between the two approaches, which limited the information supplied. One of
the advantages of a telephone interview is that the interviewer had the opportunity to
explore further, and was able to encourage discussion on the options rather than
relying on the response to a written multiple choice question. The literature supported
the multi-disciplinary approach (Birkholz & Aylwin, 2000, Pain Society, 1997, Strong,
1996, O’Hara, 1996), emphasising that occupational therapists are core members.
One study by Carruthers (1997) confirmed that although the preference was more
than one discipline to work with the patients, their occupational therapy programme
continued to help patients with chronic pain.
ADDITIONAL THEMES
Reasons for Referral
Both outcomes noted that no patients were referred specifically for low back pain,
and one therapist in mental health expressed concern about lack of specialist
49
services locally. Low back pain was identified at assessment as a contributing factor
to physical and mental dysfunction. The fact that the therapists were able to provide
intervention is commendable and is witness to their holistic skills, but this does not
provide a satisfactory solution to reducing the increasing effects of low back pain.
Essentially a biopsychosocial assessment at an earlier stage of pain, at less than
three months duration, would go some way to reducing the prevalence of debilitating
low back pain reported (Buchbinder, et al., 2001, Waddell et al., 1999). Occupational
therapists with their experience in occupational performance would be well qualified
to contribute, if not organise, the service.
Holistic Approach
Both samples emphasised the holistic approach of occupational therapists to
assessment and intervention. This was the strength of the therapists as they offered
physical, emotional and social support to enable patients to deal with the overall
effects of their back pain. This had already been identified, as part of the
occupational therapy role (O’Hara, 1996, Strong, 1996, McCormack, 1990) in chronic
pain, and occupational therapists will recognise the ethos of the occupational therapy
philosophy. All therapists had an understanding of the nature of chronic pain and
therefore understood that patients were able to function physically, emotionally and
socially with their pain to minimise their disability.
Concerns of Occupational Therapists
Ten of the survey respondents identified the need for further training in chronic low
back pain, and the interviews revealed that there was an interest in the evolution of
pain management and the relevant interventions. One therapist interviewed identified
occupational therapists as the ideal interventionist or leader in this field due to their
specific skills. A lack of services was a concern, as well as a lack of structure and
time, to offer a more comprehensive assessment and intervention.
50
Independence/Empowerment
Taylor’s (2001) study evidenced undergraduates’ understanding of patient choice to
be involved in decisions concerning their own intervention towards empowerment.
Therapists were equally aware that patients are capable of deciding their own goals,
and this is what motivates them to move forward. Returning to O’Hara’s (1996)
theme of only providing aids and adaptations for the patient if they want them,
emphasises the importance of the inclusion of patients in the preparation of their own
treatment plans. This empowerment was reported in the progress and effects of
assessment and intervention in the survey, as generally patients seemed more in
control of their condition, as they were exploring community opportunities and
adapting their approach, while reducing the passive role.
The Literature Review
To date, no studies have been found about the experiences of occupational
therapists working with patients with chronic low back pain in primary care. However
there were some comparisons in the roles described in the literature (Strong, 1996,
O’Hara, 1996, Baptiste, 1988, Giles & Allen, 1986).
There has been some debate about the role of a literature review in
phenomenological research. Provided it is delayed until after data generation to
bracket information, it has been acknowledged as an integral part of a study (Lowes,
Prowse, 2001). Conversely a comprehensive literature search can detract from an
exploratory study (Sim, Wright, 2000). In this study the literature search highlighted
the paucity of evidence and stimulated the research (Lowes, Prowse, 2001).
Methodology
51
Crotty’s (1996) five step process proved a suitable format for this study. He had
recognised (1998) that modern phenomenology research is more a study of the
subjective experience, and that there has been misuse and misunderstanding of the
philosophical underpinnings. Originally designed as a theory and philosophy (Sim,
Wright, 2000), phenomenology had no basic guidelines for research practice (Finlay,
1999). This study relied on a secondary source for a formula and discussion was
based on the theorising of other secondary sources. Purism is a challenge in the
evolving nature of qualitative research (Finlay, 1999, Crotty, 1996), but appraisal of
philosophical underpinnings has been advised (Finlay, 1999, Seymour & Clark, 1998,
Koch, 1995).
This study favoured a basic theory (Hammell, (2002), Shepherd et al.,1993) to
discover the suitability of the framework in practice (Finlay, 1999). Briefly Crotty’s
(1996) process was interpreted as:
1) The phenomenon was the therapists who worked with chronic low back pain.
2) The experiences were described in the telephone interviews and reinforced by
the open question responses of the survey. The interviewer kept a reflective diary
and debriefed with her peers.
3) The interviews were scribed by an independent clerk.
4) The texts were member checked by the participants and the clinical supervisor
verified them.
5) The researcher was dependent on the integrity of the participants and reflexivity
to establish trustworthiness in the study, and reported a clear audit trail for the
data.
The researcher acknowledged that Crotty’s framework was conducive to her study
from the outset (Shepherd et al., 1993), although it would not necessarily be
appropriate for all studies. A more experienced researcher may have been more
confident to let the study flow in a less structured way towards greater maximisation
52
of the data, but there was a desire to get it right. The aim of the study was to remain
faithful to the meanings and intentions of the participants (Walker et al., 1999), and
the structure facilitated trustworthiness.
Design
The exploratory design elaborated the experiences of occupational therapists. The
method was responsive to the phenomenon and the researcher continually engaged
in a dialectical analysis to evaluate the effect of her subjectivity on the research
(Finlay, 1999), while mistakes were acknowledged and evaluated (Savin-Baden &
Fisher, 2002). Richer data than anticipated emerged from the survey questionnaire
(Sim, Wright, 2000, Polit & Hungler, 1997). Storing the collated and analysed survey
data before the interview (Polit & Hungler, 1997) contributed to trustworthiness as
well as improving the quality of the data to answer the research question.
Sample
Personal identification of the sample was unnecessary for the study but the
researcher needed to know where the sample had come from (Corben, 1999), to
assure the credibility of the findings. Primarily five therapists appeared a suitable
number to manage due to the potentially lengthy nature of the data collection and
analysis, in the time available. The response to the postal questionnaire provided the
projected number of participants for interview, but there was no margin for dropout or
extending the sample should the data be insufficient. Sample size gave a
representative figure of the group concerned (Taylor, 2001, Polit & Hungler, 1997),
and the sample was relative to the phenomenon to be researched (Sandelowski,
1995), as volume of data was gained from small numbers (Sim, Wright, 2000).
However a larger choice for sample would have improved the potential for richer
data.
53
It was a ‘purposive’ sample (Dawkins & May, 2002, Sim, Wright, 2000, Corben, 1999,
Sandelowski, 1995), as all participants had direct personal experience and
knowledge of patients with chronic low back pain. All five participants were
enthusiastic, committed to their work, and more than willing to facilitate the
researcher. A broader range of clinical grades may have provided a greater contrast
of experience.
Data collection
The researcher was dependent on the data supplied by the sample, although there
was no guarantee about the accuracy (Parahoo, 1997). Two collection tools
prolonged the collection process. The survey was more prescriptive, as it relied on
the validity and reliability of the questionnaire to elicit the direct responses and
interpretations of the participants. It was also employed to identify a volunteer,
purposive sample for interview (Ballinger & Davey, 1998, Foulder-Hughes, 1998).
The open questions provided unpredicted additional information, which actually
enhanced the credibility of the overall data. Storage of these results enabled the
researcher to focus on the interview. The interview may have been lengthened or
expanded by a more experienced interviewer.
The Survey Questionnaire
No existing survey was found for this study, but the pilot study confirmed the validity
and reliability of the questionnaire design, and there was no reason to query this in
the main study. The postal questionnaire accessed a larger group of therapists and
was easier to administer (Ballinger & Davey, 1998), although the coding demanded
vigilance to assure confidentiality of identity and data received. Vigilance was
rewarded when a second mail shot went smoothly. The questionnaire had twenty six
54
questions and a few were only partially completed, whether due to the respondents’
knowledge of low back pain, waning interest (Walker, 1996, Ballinger & Davey,
1998), or lack of time, is not clear. The closed questions had a better response rate
possibly because the responses were limited to epidemiological data or multiple
choice questions. The majority of the completed questions fell at the beginning
before interest or patience may have wavered, although McGibbon (1997) actually
recommended that open questions be placed either in the middle or the last quarter
of the questionnaire.
A shorter questionnaire would have failed to elaborate on more than the aims of the
study. Open questions often take longer to complete (McGibbon, 1997), as
respondents have to think more carefully about their response. However the majority
of informants reported a wealth of experiences, suggesting that the requirement was
not over taxing. Closed questions on the same topics may have been constrained
(Walker, 1996), and possibly biased, resulting in invalid description of real
experiences. Employing an interview only for experiences of occupational therapists,
while employing the survey only for demographic information and selection of a
sample for interview would have ignored the opportunity to improve trustworthiness
through triangulation.
The first questionnaires were despatched during the summer months when therapists
may have been on vacation, although the follow up elicited fewer replies. Recipients
have choices, and response rates are always unpredictable. However the spasmodic
return of the questionnaire facilitated an organised recording system. There was no
explanation for the dearth of responses from therapists in Trust hospital departments.
Many therapists work single-handed in rural areas and time is precious. The change
in health care structure to Local Health Boards in April 2003 has enforced
reorganisation, and lists of therapists may have been incomplete. Observation of
55
colleagues suggests that questionnaire responses depend on their clinical
commitments at the time of receipt.
The Telephone Interview
Each interview was a unique interaction which was not replicable (Parahoo, 1997)
and was a reflective process for researcher and participant (Finlay, 1999). The
dialogue yielded mainly conversation to elaborate the data, not just question and
answer. The researcher was concerned to allow the participant to take the lead
(Parahoo, 1997). Two short interviews may have been influenced by clinicians taking
their interventions for granted (Guidetti & Tham, 2002), and failure of the researcher
to interject appropriately (Hand, 2003), as well as an unexpected problem with the
equipment in the first interview. Interviews of less than thirty minutes may not actually
get beyond the civilities (Parahoo, 1997). The formalities had been discussed when
arranging the telephone interview and the scribed texts suggested that the
introductory question opened up the interviews straight away. Extra trigger words on
the interview schedule would have facilitated the researcher’s probing skills as would
prior experience and practice in this type of interviewing. A pilot study would have
highlighted these issues and is recommended for future study.
Semi-structured telephone interviews encouraged the participant free expression
while putting them at their ease. Selected topics on the interview schedule helped to
keep the sessions on track as some structure and rapport was essential (Sim,
Wright, 2000, Parahoo, 1997). Verbal rapport was enhanced as participants settled
into the discussion, while body language and physical presentation had no influence,
enabling the researcher to focus on the content of the interchange. The researcher
was tempted to join in discussion using her own experiences, but the reflective diary
evidenced that her expectations were based on her therapeutic environment. Three
56
of the interviews concluded on a less formal note, exchanging views on professional
issues. This indicated a co-participation of researcher and participant towards a
greater understanding of the phenomenon (Lowes, Prowse, 2001). In retrospect, the
employment of an external observer to report on the researcher’s interview style may
have contributed to reflexivity.
The experience of the researcher was enhanced by practice. Although she is an
experienced counsellor and therapist, interviewing for research was a new venture
until she realised that it did not have to be significantly different. She was able to
bring interviewees back on track by focussing on the subject for debate. Versatility
and flexibility were essential but the process was not always easy to assess during
the interview (Parahoo, 1997). The scripts of the member checked texts gave a
clearer account of the process, and clarified the researcher’s description of her
approach.
Data analysis
This was a lengthy and time consuming process due to the quantity and quality of the
data collected. Interpretation was the sole responsibility of the researcher and had to
be her interpretation alone. The experience of the survey analysis proved helpful
when it came to analysing the interview data. Longer interviews, although desirable
for richer data, may have impeded completion to date and the analyst was learning
the job. A personalised method proved more productive and expansive. Adhering to
established approaches (Finlay, 1999) would have impeded the researcher’s
process. The results emerged systematically, reflecting the perceptions of the
participants (Bowman, 1994), emulating a phenomenological trait (Polit & Hungler,
1997). Contrary to expectation the author was not aware of engaging in self-
57
discussion or opining during the process, but focussed on the written data, which was
absorbing and demanded a disciplined approach.
Intuiting (Grbich, 1999, Polit & Hungler, 1997) was about being open to the
participants’ point of view, but the reader has to rely on the interpretation of the
analyst (Polit & Hungler). Objectivity during analysis was questioned (Lowes,
Prowse, 2001), as the author wanted to work with the written data without distortion
(Grbich, 1999). The early data came from the survey, and the phenomenological
principles did not directly apply, but the compilation of the results was an individual
interpretation and reduction of all the responses. In alternative circumstances the
researcher would have emulated Foulder-Hughes (1998) and invited a colleague to
explore the response categories independently, to improve rigour.
Limitations
The interview sample was a small group of senior grades only and was drawn from a
small rural area. Although the participants had a varied clinical background they were
not necessarily representative of the general population of occupational therapists
working with chronic low back pain in primary care. Access to a larger potential
sample and a more experienced interviewer may have elicited broader data. The
participants verified the text, but the results relied on their reflections and accounts,
as telephone interviews prevented observation of participants in action. Another
researcher may have interpreted the themes differently (Henare et al., 2003), and the
interpretations were dependent on the personal and professional integrity of the
researcher to give as true an interpretation as possible. The account was somewhat
reductionist (Finlay, 1997), as the analysis followed the same formula for survey and
interview. The time constraints were always in consideration, but there was also the
unfulfilled desire to further explore methodological discussion within the study.
58
Initially expectations of the outcome may have been biased and cautious, but
acknowledging the qualitative clinical input of the participants dismissed this.
Recording early expectations in the reflective diary at the outset and debriefing with
peers facilitated objectivity, separating any personal expectations of the study from
the experiences of the participants. This researcher acknowledged that there were
inconsistencies in her study whilst recognising the experience she was gaining.
Honest evaluation of her methods helped create a reflective learning process about
the methodology and research design employed.
Conclusions
This study demonstrated a small competent experience of occupational therapists
working in primary care with low back pain and identification of their expertise and
interest is encouraging. The study found that there was no specialist occupational
therapy input for this condition but there was:
1. Competent assessment and intervention for patients.
2. No knowledge of clinical guidelines.
3. A strong probability that therapists contributed to disability prevention
4. Multi-disciplinary working, but that did not discredit lone intervention.
Those who were working with the client group were able to identify the debilitating
effects of the condition and had the knowledge to facilitate patients to live with the
pain, by adopting physical and emotional strategies. Their input was often limited
because of the demands of their more general caseload. Due to the statistical
evidence on the prevalence of low back pain there would seem to be a need for more
specific services to reduce the statistics. Based on the findings of this initial study it
would seem that occupational therapists are qualified to intervene with these
patients, employing their holistic and occupational performance expertise, and that
full use should be made of their expertise. Occupational therapists are requested to
59
reflect on this small study to consider the future of occupational therapy and low back
pain in primary care.
Recommendations
Further exploration is required to explore the wider experiences and perspectives of
occupational therapists to support these findings, and alert occupational therapists to
their potential individual clinical input with chronic low back pain. Interviewing reliable
patients with low back pain about their experiences of occupational therapy in
primary care would provide the consumers’ point of view, and provide evidence to
improve services to the increasing patient group. There is evidence that occupational
therapists are particularly qualified to assess the effects of low back pain at an early
stage, to prevent future disability and chronicity. Inclusion of occupational therapists
in the working parties of clinical guidelines would exploit occupational therapy to a
higher level, as it is already recognised by the Pain Society as an integral contributor
of a multi-disciplinary pain management programme. Knowledge of clinical
guidelines, would enable occupational therapists to recognise their skills to identify
that low back pain can be alleviated through the practical problem solving
approaches that demonstrate the full philosophy of occupational therapy. Most
additional training had been at the therapists’ own instigation. Further opportunities
and provision would heighten interest as well as improve basic skills. This study has
heightened the researcher’s awareness, but more evidence is needed to heighten
interest and enable occupational therapy practice with chronic low back pain in
primary care. The provision of a National Framework for Pain, planned for the future,
may go some way to heightening the awareness of not only occupational therapists,
but other members of multi-disciplinary teams, and contribute to reducing the
unnecessary effects of chronic low back pain.
60
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