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Table 6 Qualitative Thematic Synthesis

From: Barriers and facilitators experienced by osteopaths in implementing a biopsychosocial (BPS) framework of care when managing people with musculoskeletal pain – a mixed methods systematic review

Concept QUAL – (Sub-themes) Concepts (with Themes and subthemes contributing) Supporting quotes from included studies
Barriers Undertrained/underprepared
Lack of clinical reasoning
Threat to professional identity
Intuition based approach to PS factors
Lack of tools to measure PS factors
Avoid/underdiagnose PS Factors
Discordant with osteopathic beliefs
Not within my professional scope
Lack of resources
Listen but still do bio
Lack of contemporary BPS education
Concept 3 - Barriers for implementing a BPS approach
Theme 7: Undertrained to apply BPS model
Lack of contemporary BPS education
Intuition based - lack of clinical reasoning
Lack of resources
Theme 8: Inability to diagnose
Lack of tools
Avoid/underdiagnose PS factors
Theme 9: Threat to professional identity
Discordant with osteopathic philosophy
Not within scope
Listen but still address biomechanical issues
“And I felt my training was very much like that [mechanically focused] I can’t say we weren’t taught these things [BPS model]. We were exposed to them but I think almost too early in the course. So by the time you come to third/fourth year in clinic [exams], it’s all in the background, it’s all gone”
“My undergraduate training paid little attention to this [BPS] model. I feel more comfortable to manage biomechanical and postural aspects of the patient’s pain. I think that BPS model is valid with respect to the chronic pain management, but I have no competence and knowledge to apply this model in my practice”
“Osteopathy is removing barriers to function in the classical osteo-pathic sense … we’ve lost the way trying to be what people expect; respectable, acceptable, payable by the state we don’t put our foot down and stand for the principles of osteopathy”
“I have 4 boxes which I tick one or more of these [pain mechanisms], of which I think is going on with that patient, and by this time I am past the psychosocial, I’m on to bio now”
“I have a little knowledge of this [BPS] model. I have no competence to evaluate other patient’s context. Of course I think that such factors are important in the presentation but I do not have the confidence to manage these situations”
“I leave the assessment for BPS to my own understanding and my own perception of the person as a whole; I don’t think I have any structured way of assessing for BPS factors.”
“you could say the profession is in an identity crisis because we’re told we can be the practitioner we want to be … It’s very broad which makes me excited”
“We have to take into account also the lack of training in pain management and communication inside the undergraduate curricula in Italy. In fact, some aspects are poorly covered and under explored”
“I initially look for those body language cues and how they present themselves, then how they verbalise, what they are feeling in term of what it feels like to them”
“I don’t particularly have a guide, I mean you do have screening tools, which are probably efficient, like STarT Back, which are effective, but I don’t use it”
“the whole structure governs function thing, …, unfortunately that seems to be the one mantra that everyone knows and it’s probably the worst because it’s, it sets everything up to become dualist so that, you know, there’s no room for psychosocial stuff”
I’m really questioning myself about which tools a student or a qualified osteopath has to assess for bio-psychosocial symptoms?”
Enablers Ongoing education
Pain education/ interviewing/mindfulness
Funding and EBP
Adopting a blended approach
CPD opportunities/workshops
Implementing BPS-exemplars
Self-awareness of clients
Superior to GP
Palpation skills
Concept 4: Enabler for implementing a BPS approach
Theme 10: Acknowledging and managing PS factors
Acknowledge PS factors
Management strategies
Self-awareness of clients
Theme 11: Education/CPD
Ongoing education
“Our job is to understand their reality, the patient reality, and find out how they come to that point”
“If we are talking about stress, I might suggest mindfulness, if we are talking about depression, I will push my patient to go out with friends and I will tell the patient to do activities very good for the LBP, to try to engage the patient in the treatment with me in the room, but also engage the patient outside with a personal social life, aiming at doing what the patient likes”
“[on my desk] ‘I’ve got a note which says, ‘tell me your story’”
“Introduce them to pain education, educate them through kind of pain is not equal to tissue damage, and stuff like that, I think it’s a good way of managing it … talk about stress and its effect on the nervous system, kind of using analogy to make in a way this is easy to understand as possible”
“So, for that patient, strongly nociceptive patient, I would probably offer hands-on because there might be some sort of nociceptive input from somewhere, but I would also provide some form of, CBT or motivational interviewing or something for these psychosocial factors to try to decrease the risk of developing chronic pain for that patient”
“I use mindfulness techniques, box breathing techniques, advice on lifestyle, and advice on exercises, anything that is relevant, that can in-fluence the social side or the psychological side, that would then be beneficial, impact on the LBP”
“I’m interested in the crossover between psychotherapy and body work, getting through the layers of the body … working with the mind through that hands-on approach”
“[The course] has changed in some of the language maybe that I would use with patients and just re-emphasizing thought positives and maybe not using quite so much medicalised language”
  1. BM Biomedical, BPS Bio-Psycho-Social, CBT Cognitive Behavioural Therapy, CPD Continuous Professional Development, EBP Evidence Based Practice, GP General Physician, LBP Low Back Pain, PS Psychosocial, UK United Kingdom