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Abstract

Reassuring patients with low back pain to reduce their concerns is important for good clinical practice. However, guidelines provide little information on how physiotherapists should best deliver reassurance. This study explores how “reassurance” is enacted by physiotherapists and back pain patients during an initial consultation. The research setting was primary care. Twenty initial physiotherapy consultations were video-recorded and transcribed. The patient–physiotherapist interactions were analyzed using conversation analysis, a qualitative observational method. These data highlighted how some physiotherapists gave reassurance directed by what they considered to be important but not always grounded in patients’ expressed concerns. We also observed examples where physiotherapists developed a better understanding of patients’ concerns, which provided more patient-focused and targeted reassurance with less interactional “trouble” and greater patient affiliation. These findings suggest that physiotherapists should develop a good understanding of patients’ concerns, and take them into consideration, before delivering their reassurance. This will require that physiotherapists be responsive to patients’ concerns and adapt their communication to the individual needs of the patient.

Keywords

reassurance communication physiotherapy low back pain

Introduction

Reassurance has been defined as the removal of fears and concerns about illness (Traeger et al., 2017). The importance of delivering effective reassurance, to modify patients’ thoughts, reduce their distress, or change behavior (Linton et al., 2008), is reflected in low back pain (LBP) and sciatica guidelines (NICE, 2016; Oliveira et al., 2018), and recent Low Back Pain Clinical Care Standards (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2022). These guidelines/standards recommend that clinicians provide patients with consistent and reassuring messages about the benign nature of LBP, and a favorable prognosis (ACSQHC, 2022). Clarifying patients’ concerns and understanding their agenda is considered a fundamental prerequisite for giving effective and targeted reassurance (ACSQHC, 2022; Pincus et al., 2013). However, health professionals can feel challenged with regard to eliciting patients’ concerns, resulting in a negative impact on the consultation. For example, in medical encounters, it has been demonstrated that clinicians seldom elicit the patient’s agenda (Singh Ospina et al., 2019) and interrupt the patient’s disclosure (Beckman & Frankel, 1984; Coyle et al., 2022; Roberts & Burrow, 2018), reducing the chance of them orienting to a patient’s priorities. Physiotherapy is no exception in this regard with physiotherapists demonstrating similar challenges in balancing their own “professional” agendas with those of the patient (Cowell et al., 2019; Hiller et al., 2015; Josephson et al., 2015). These conflicting professional and patient agendas (Hamilton & Britten, 2006) represent a potential impediment to effective reassurance if the patient’s perspective and concerns have not been successfully solicited (Cowell et al., 2019).

Although clinical guidelines emphasize the importance of reassurance in the consultation, they provide little guidance on how physiotherapists should best deliver and optimize the reassurance they offer patients (NICE, 2016; Oliveira et al., 2018; Wellman et al., 2020). It has been suggested that “good” clinical practice should include a combination of affective reassurance (displaying empathy and building patient rapport) and cognitive reassurance (improving the patient’s knowledge and understanding of their condition through education) (Cheung & Soundy, 2021; Holt et al., 2018). In primary care consultations, it was found that cognitive reassurance was associated with improving patient satisfaction, building patients’ sense of empowerment to self-manage, reducing patients’ concerns, and improvements in patient clinical symptoms, and reduced health care utilization rates (Pincus et al., 2013). However, these findings were from a 2013 systematic literature search and there is currently limited evidence as to why these different components of reassurance are important to clinical practice (Cheung & Soundy, 2021).

Moreover, the best approach to reassure patients with back pain–related fears and concerns remains unclear. This may be partly because the evidence on the effects of reassurance on pain-related problems is limited and inconsistent (Linton et al., 2008; Traeger et al., 2017). While some studies demonstrate lasting positive effects of giving reassurance (Traeger et al., 2015), other studies specify the importance of clear guidance and understanding when the clinician is giving reassurance. Without this, the aim of the reassurance is not clear and this can have potentially negative consequences. These can include increasing patient concern and emotional distress including catastrophization, avoidance behavior, and negative affect (Fantry, 2016; Linton et al., 2008; Traeger et al., 2017) leading to overutilization of health resources (Giroldi et al., 2014).

There are currently no published systematic or scoping reviews that describe the content and methods of delivery of effective reassurance for patients with LBP. Therefore, building a better understanding of how physiotherapists reassure patients and how patients respond to those efforts during an initial consultation is important to optimize how reassurance is delivered effectively to patients with LBP. There are no previous studies that have microanalyzed, in granular detail, how physiotherapists and patients interactionally co-construct reassurance during an initial consultation for patients with LBP.

The aim of this observational study, employing conversation analysis (CA) (Maynard & Heritage, 2005), was to examine, in forensic detail, actual instances of when and how physiotherapists reassure patients and how patients respond. Our previously published research, based on the same data corpus (Cowell et al., 2019), explored how physiotherapists solicit and explore patients’ concerns, and focused mainly on the spectrum of communication styles (i.e., question formats and the interactional negotiation of agenda setting). This paper utilizes the same data set but with a different focus and examines specifically how physiotherapists formulate reassuring practices to allay patients’ concerns, and the interactional contingencies of these practices by exploring how patients respond to the physiotherapists’ offers of reassurance.

Methods

Setting

The setting for this study was two outpatient physiotherapy departments in primary care in the North-East London Foundation Trust (NELFT), England.

Participants

This observational study was nested in a larger study, conducted over a 3-year duration, examining the training requirements for the implementation of a bio-psychosocially oriented behavioral intervention called cognitive functional therapy (CFT) (Kent et al., 2023; O’Sullivan et al., 2018). These data were collected in 2016 prior to the CFT training program. Twenty initial physiotherapy consultations were video-recorded (10 physiotherapists and 20 patients). To ensure heterogeneity, 12 physiotherapists were purposively sampled based on sex, age, levels of clinical experience, and previous bio-psychosocial training. Two physiotherapists declined to participate due to time commitments. Their clinical experience ranged in years qualified from 4 to >14, with the majority of the experience gained in a musculoskeletal setting (range 3 to >14 years). Previous post-graduate bio-psychosocial training ranged from 0 to 12 days. Twenty-seven patients between the ages of 18–70 years, reporting non-specific chronic LBP >3 months, including a range of risk profiles for predicting non-recovery from LBP (see below for more details), were identified in two NELFT physiotherapy departments from either the triage clinic or the musculoskeletal clinical assessment and treatment service. The patients were contacted by a member of the research team (RP) and the NELFT direct care team. For patients willing to participate, an initial face-to-face meeting was then arranged with the lead researcher (IC) to explain the reasons for the study and the requirement for the interaction to be recorded and for the lead researcher to be present during the consultations. One patient declined to participate, as she did not want to be video-recorded, four withdrew due to resolution of symptoms, and two failed to attend their initial assessment, leaving 20 patients included in the study (11 women and 9 men). The ages of the patients ranged from 26 to 67 years (mean of 47.2 years). The patients completed several questionnaires, which included the Ørebro Musculoskeletal Pain Screening Questionnaire (ØMPSQ) (Boersma & Linton, 2005), Roland and Morris Disability Questionnaire (RMDQ) (Roland & Morris, 1983), the STarTBack Screening Tool (Hill et al., 2008), and a measure of pain intensity on a 0–10 pain numerical rating scale (NRS) (Boersma & Linton, 2005). These questionnaires were administered to understand the risk profile of the patients included in the study in terms of predicting non-recovery from LBP and were consistent with usual practice in the NELFT physiotherapy departments. The ØMPSQ scores ranged from 69 to 163 (mean score of 115.9). The RMDQ scores ranged from 1 to 22 (mean score of 10.8). The patients’ estimated risk profile for developing persistent LBP measured on the STarTBack Screening Tool included 4 patients at low risk, 8 medium, and 8 high. The NRS scores ranged from 2 to 10 (mean score of 6.6). The recorded consultations ranged in duration from 35 minutes to 1 hour. The lead researcher was present at the recorded assessments to adjust the camera as required. Follow-up treatment sessions were not recorded.

Analysis

This data corpus of 20 initial consultations was analyzed using conversation analysis (CA), a qualitative data-driven inductive method used to analyze linguistic patterns in “naturally occurring interaction” (Maynard & Heritage, 2005). CA has its theoretical roots in ethnomethodology (ten Have, 2004), reflected in its focus on how social reality is constructed, that is, “what goes on and how is this achieved” (Halkowski & Gill, 2010). One distinctive aspect of CA is that it identifies recurring patterns of verbal and non-verbal communicative practices, with particular regard to their structural and sequential properties within interactions (Drew et al., 2001). There are several “intersecting machineries” (Hoey & Kendrick, 2017) of practice required for conducting the analysis which include: turn-taking (i.e., how turns of talk are taken by the speakers and how this is locally managed within the talk), as well as the sequential implications of each turn, overall organization (overall “map” of the interaction) in terms of analysis of different sections of interaction (e.g., opening—greeting, problem initiation, and closing), sequence organization (how successive turns link up to form coherent courses of action), turn-design (how turns are designed to perform actions, e.g., physiotherapists offers of reassurance), lexical choice (analysis of vocabulary, e.g., the lexical terms used by the physiotherapists in offering reassurance), and forms of asymmetries during the interaction (Heritage, 2004; ten Have, 2004, 2007) (analysis of participation). We focused on the sequential development of the conversational extracts, on a turn-by-turn basis, paying attention to the design of individual turns of talk and of the relationship between turns, or sequence organization (Drew, 2013). Each consultation was initially transcribed in its entirety by a professional transcription service. The entire data was then independently reviewed by two separate authors (IC and RP) to identify all possible cases where physiotherapists offered reassurance to allay, or in some cases to pre-empt, patients’ concerns. These reassurance sequences were then micro-transcribed using the standardized transcription conventions for verbal and non-verbal activity (Jefferson, 2004) to capture how the talk was delivered, including speed, pitch, and turn construction (see Table 1). Non-verbal aspects of communication and their relation to verbal aspects during reassurance sequences were described in brackets (Goodwin, 1981). These shorter “reassurance sequences” were then presented to the research team for repeated viewing to scrutinize and assess the validity of the analytical claims. Given the authors’ clinical and research interest in the management of LBP, and that one of the researchers worked in the research setting, this was an important part of the analysis, and reflected both a commitment to the inductive character of CA and the acknowledged dangers of the researchers importing institutional context of data by making assumptions without support from the data (Perakyla, 2011).

Table 1.

Transcription Convention Used in Extracts.

Like	Underlining denotes accentuated intonation
(1.6)	Indicates a pause timed in seconds and tenths of seconds
(.)	Indicates a pause of less than 0.4 of a second
[Or::][Yeah]	Square brackets indicate the point where overlap begins and ends
again==so	Equals signs indicate that there is no space between utterances
mi-	A dash following a word or part of a word indicates that the last sound has been cut short
or::	Colons indicate stretched sounds
°That (.) I don’t knoh:w.°	Speech contained within degree symbols is notably quieter than the surrounding speech
↑	An upward facing arrow indicates a marked step-up in pitch
↓	A downward facing arrow indicates a step down in pitch
((Writing in chart))	Double brackets contain descriptions of non-verbal actions
> <	Indicates speeding-up
.hhh	In-breath
Hhh	Out-breath
?	Indicates a rising intonation
W (h) ord	Indicates laughing while talking

Ethics

The local research ethics committee approved the study (Reference Number: 2352), and it was successfully reviewed by the East Midlands-Nottingham 2 National Research Ethics Service committee (14/EM/1045). All patients and physiotherapists that agreed to participate in the study were sent an invitation and information sheet and provided written informed consent prior to participation in this study which included authorization to use their transcripts and images in scientific articles.

Results

These findings explicate practices employed by physiotherapists in giving patients reassurance in back pain consultations and illustrate how the reassurance is delivered and responded to. We identified a spectrum of communication practices that ranged from reassurance not targeted to patients’ concerns, and given independent of the patient’s contribution, to reassurance that was clearly “targeted” to the patients’ concerns and dependent on the patient’s active participation. Table 2 provides an overview of the extracts presented in this study. All five extracts presented came from different cases.

Table 2.

Summary of Extracts.

Physiotherapists’ reassurance not targeted to patient’s concerns	Failure to solicit patient’s concerns during a reassurance sequence
	Failure to “pick up” on the patient’s lack of response to concern-seeking question
	Not engaging with patient’s explicit response to concern-seeking question
Physiotherapists’ reassurance targeted to patient’s concerns	Engaging with patient’s response to concern-seeking question
	Disconfirming patient’s fear via a “behavioral experiment”

Physiotherapists’ Reassurance Not Targeted to Patient’s Concerns

Failure to Solicit Patient’s Concerns During a Reassurance Sequence

Description of Key Features

Extract 1 comes at the end of the consultation, in the explanation and planning phase. It starts with the physiotherapist’s empathic statement recognizing the impact that the LBP has had on the patient: “I can see …. is .. really affectin- you.” This is acknowledged by the patient with a simple nod of the head. What follows in the next turn is the physiotherapist’s attempt to reassure the patient, which is initially constructed as a broad reassuring statement (lines 07–08): “don’t be too concerned.” The physiotherapist then specifically targets the patient’s scan findings (lines 09–10 and 12–14), presuming that this is the patient’s focus of concern. The physiotherapist frames the patient’s findings as minimal: “it’s not it’s not a [major thing].” We observed similar examples in these data of physiotherapists minimizing the patient’s condition in this way to communicate more positive perceptions about patients’ scans (see also extract 2, lines 40–45; extract 3, line 16; extract 4, lines 49–52). However, the patient’s overlapping response (lines 15–16) and the interactional features of that response indicate some resistance to this. The cut-offs on “[Yeah that’s]- that's,” and the quiet downward intonation of “^o↓yeah ^o ,” as the patient looks despondently to the floor, suggest that he is reluctant to accept the reassurance being offered. The overlapping speech (lines 14 and 15) is picked up by the physiotherapist in line 18 with her question, “What what were you going to say,” which provides an opportunity for the patient to make explicit that the scan findings were not his “main worry,” and that he is more concerned about returning to work. Rather than develop a better understanding of the patient’s concerns about returning to work, the physiotherapist immediately attempts to offer the patient reassurance suggesting she is “confident …. we can help you do that.” Extract 1 highlights how patients can communicate, verbally and non-verbally, their resistance to reassurance that does not align with their concerns.

Failure to “Pick Up” on the Patient’s Lack of Response to Concern-Seeking Question

Description of Key Features

Extract 2 is positioned early in the interview and starts with the physiotherapist’s reference to the patient’s MRI report of her cervical spine. The physiotherapist’s concern-seeking question is a polar/closed question that invites a constrained yes/no response: “Is [that] a concern” … “is that why you brought it in,” (lines 06–07 and 09). The question appears to reflect his presumption that the patient has brought the scan report to the consultation due to concerns that similar “wear and tear” changes have developed in her back. The patient’s response in line 10 is “well” prefaced and operates here as an indication that the answer is unlikely to be straightforward. The patient does not answer the physiotherapist’s question but instead launches a narrative over multiple turns describing how she has learned to live with neck pain and is now more concerned about developing LBP. Although the patient does not directly answer the question about the report, the physiotherapist still attempts to offer the patient reassurance about the scan findings over multiple turns (lines 34–36, 38–45, 49–51, 53–61, 64–67, 69–70, and 72). This “normalizing,” which continues over multiple turns, fits a typical structure in these data (see also extract 3 lines 21 and 25; extract 4 lines 49–50)—that ageing is a normal process and that these findings are common in the asymptomatic population. The physiotherapist also speculates that the patient may harbor some fear about the diagnosis: “fearful for us sometimes.” Despite receiving only simple acknowledgments from the patient throughout this sequence: “[Uhum]” and “Yeah,” the physiotherapist signals to the patient that her concerns about the report will be discussed further during the course of the examination: “we’ll come back to it a bit.” The physiotherapist’s reassurance statement in line 72: “=don’t be concerned [about that]” ((points to scan)), makes clear his assumption about the patient’s concerns, and prompts an overlapping disaffiliative¹ response from the patient: “[See I’m not((points to scan)).” Over the next few turns, the patient accounts for why she has brought the report to the consultation, explaining that she thought the physiotherapist would want to see it. In lines 89–91, she makes it clear that she is more concerned about her “mobility issue” than the report: “not bothered about the [diagnosis].” This prompts the physiotherapist’s open-ended Wh-Qs² in lines 93–94, which include: “what are you re:ally keen to get out of coming here today.” This question is more typical of an “up-front” agenda pursuing question (Robinson et al., 2016). Its placement here may reflect the physiotherapist’s recognition of his presumptive stance and a desire to more broadly understand what the patient wants from the consultation.

Extract 2 provides further illustration of the difficulty some physiotherapists have in establishing the patient’s main concern and the importance of picking up on the patient’s responses to concern-seeking questions (in this case a lack of response). Part of the issue lies in the fact that the cues that patients give may be misleading and dissonant from their actual concerns. As in extract 1, this extract illustrates how the physiotherapist handles/mishandles the patient’s concerns, presuming the patient is concerned about the MRI report of her cervical spine and so directs reassurance to this end. This presumptive approach results in misalignment between patient and physiotherapist. It also highlights how physiotherapists can risk wasting considerable time by providing generic evidence-based information largely irrelevant to the patient’s specific agenda of concerns.

Not Engaging With the Patient’s Explicit Response to Concern-Seeking Question

Description of Key Features

Extract 3 is positioned halfway through the interview and starts with the physiotherapist asking whether the patient has had previous imaging for his LBP. The patient reports that he had had an x-ray which had revealed “nothing” or possibly a “slight ↑curvature.” In lines 12–13, the physiotherapist’s concern-seeking question is designed to solicit any concerns that the patient may have about these findings: “how do you feel about that is it something that’s bothered you at all.” The patient’s response in line 14 rather emphatically conveys that this is not of concern to him: “No ((shakes head)) no it ain’t bothered me.” Despite the patient’s response, the physiotherapist provides a reassurance sequence over the next two turns minimizing the patient’s x-ray findings as minor and common. This receives only minimal acknowledgment from the patient (“Yeah,” “Uhum,” “Okay”). Extract 3 provides further illustration of the importance of “actively” listening and engaging with patients’ responses to concern-seeking questions in order to target reassurance more effectively to patients’ actual concerns.

Reassurance Targeted to Patient’s Concerns

Engaging With Patient’s Responses to Concern-Seeking Questions

Description of Key Features

Extract 4 is positioned toward the end of the interview. The extract starts with the physiotherapist and patient discussing the patient’s recent x-ray findings, which had revealed “a bit of arthritis.” As similarly observed in extracts 2 and 3, the physiotherapist employs a concern-seeking question (lines 25–26): “Have you got any concerns about what was on (.) the x-ray or.” In this extract, the patient voices his concern that working outdoors might exacerbate the arthritic changes observed on the x-ray (lines 28–35). The physiotherapist’s follow-up question seeks to fully understand the patient’s perspective and to clarify whether the patient attributes his current stiffness symptoms to the arthritic changes on the x-ray. The patient’s response is typical of how patients offer their perspectives on symptom attribution in these data with the use of weak evidential markers³: “Quite possibly yeah,” “contributes to it,” and “whether it is or not,” which seem to be used to downgrade assertions and indicate uncertainty about their knowledge. Although the physiotherapist acknowledges the patient’s perspective, he suspends judgment about the specific association of the x-ray findings to the patient’s symptoms at this point in the examination: “We’ll look into that.” However, in the next two turns, the physiotherapist does attempt to offer the patient some reassurance by providing evidence-based information about x-ray findings. This reassurance sequence casts doubt on the relevance of these findings to the patient’s symptoms. The “mixed message,” “we all have some,” and “normal process” communicate to the patient that the findings are “normal” and not significant. The physiotherapist’s assessment of the patient’s x-ray (lines 52 and 55): “doesn’t look horrific or anything we need to worry about,” includes the lexical choice of “horrific” which, although semantically extreme, is designed here to reassure the patient by providing a non-literal reference to more extreme cases. The physiotherapist emphasizes that his reassurance is based on the report and suspends a full assessment until further data gathering has been completed: “we’ll see if that’s [contributing] to what you’re having there.”

Extract 4 provides further illustration of how physiotherapists commonly offer reassurance through normalizing imaging findings. However, in contrast to extracts 1–3, the physiotherapist first solicits the patient’s concerns about the x-ray findings and engages more appropriately with the patient’s responses before offering reassurance clearly tailored to the patient’s concerns. This collaborative communication approach allows the patient to participate more in the interaction and helps to accurately establish the patients’ concerns as a platform for targeted reassurance.

Disconfirming Patient’s Fear via a “Behavioral Experiment”

Description of Key Features

Earlier in physical examination (prior to this sequence and not shown in this extract 5), the physiotherapist had solicited the patient’s concerns about bending, which he avoids as he is concerned “[That it’s] going to hurt my back.” Extract 5 starts with the physiotherapist returning to the patient’s concern by asking him to bend to the floor from the sitting position. The physiotherapist’s positive assessment of the patient’s movement, “It’s alright isn’t [it],” which is synchronized with a nonchalant shrug of the shoulders, appears to highlight disconfirming evidence to the patient about his worries that bending will “hurt.” In lines 08–09 the physiotherapist amplifies the patient’s concern by asking him to bend from a standing position, a position the patient had previously indicated (prior to this sequence and not shown in this data) as particularly worrying for him (“I think it’s the distance”). The patient cautiously performs the bend a couple of times, his anxiety audible with a large in-breath and embodied by a worried facial expression and nervously oscillating his hands. The physiotherapist’s evaluation of the movement, “That looks NI:CE,” is designed to reassure the patient. However, the physiotherapist detects that the patient is still worried, which prompts a concern-seeking question (lines 17–18 and 20) about the tightness the patient is experiencing: “have you got any worries about that?”. This gives the patient space to elaborate on his concerns fearing that his back might “[jus:: go],” an idiomatic expression for his back going into painful spasm. The physiotherapist’s supplementary and open question (lines 28–29) attempts to develop further the patient’s concerns and provides opportunity for the patient to reiterate that he is worried that his back “might just start to seize up.” Line 36 marks the start of a multi-turn reassurance sequence in which the physiotherapist begins to gradually expose the patient to his pain-related fear of bending. The initial position is side lying with the patient’s knees bent to his chest. The physiotherapist’s question: “Do you feel anything,” guides the patient toward an appreciation of his bodily responses. The patient’s response: “No it’s really actually very comfortable,” is the start of developing patient insight and allowing him to experience disconfirming evidence to challenge his expectation and concern of developing pain. The physiotherapist then emphasizes that in this position, the patient’s back is actually “fully flexed” (i.e., the position the patient fears), which implicitly challenges the basis of the patient’s concern. In lines 48–49, the physiotherapist proposes to the patient that the problem is not bending per se but how he bends: “it’s the process of how you get into these positions,” and that he is guarding his back due to a lack of confidence to move. In lines 55–56, the patient strongly affiliates to the physiotherapist’s representation of his back pain: “Yeah that’s that’s a lot of (0.2) lot of the problem I’ve had.” Over the next few turns, the physiotherapist progresses the start position to kneeling and attempts to modify the patient’s guarding responses by using breathing techniques and again guiding the patient to his bodily responses and to recognizing that the feared outcome has not occurred: “tell me what it feels like now” and “do you feel anything at all now here.” The patient responds with a positive assessment: “A lot better actually” and “it’s better than it was.” The physiotherapist’s follow-up Wh-Q: “Why is that?”, orients to the importance of developing the patient’s awareness and insights into his back pain. The patient’s developing understanding is clearly displayed in lines 99–100 where he recognizes his protective responses: “Yeah I suppose it’s the guard .. mechanisms.” This receives a strong agreement from the physiotherapist: “I totally agree with you,” who positively frames the patient’s “bending” as “a lovely (0.2) flexed position” without “any discomfort.” Having elicited the patient’s perspectives, the physiotherapist offers a more direct assertion, “I think that key is that your your back can [go into this position],” in lines 105–106. The patient responds with a simple acknowledgment and then reveals his insights by offering an account explaining that his back has tightened due to the length of time he has experienced back pain.

Extract 5 provides further illustration (similar to extract 4) of the importance of physiotherapists first eliciting the patient’s perspective and engaging in collaborative dialogue to establish what the patient is worried about before giving targeted reassurance. It also illustrates how some physiotherapists go beyond simply providing reassuring information and employ behavioral experiments in the physical examination as a reassurance strategy to test and disconfirm patients’ movement-related fears. We observed how the reassuring potential of these experiments was augmented by the physiotherapist’s simultaneous assessment commentary: “That looks NI:CE,” and a style of communication that encouraged patient reflection and insight into the disorder.

Discussion

Reassurance is considered patient supporting (Pinto et al., 2012) and in the context of LBP is perceived by patients to be an important part of a “good back consultation” (Holopainen et al., 2020; Laerum et al., 2006), which is reflected in recent Low Back Pain Clinical Care Standards (ACSQHC, 2022). Although patients value patient-focused communication where clinicians actively listen to their “thoughts, worries/feelings” (Laerum et al., 2006), these data suggest a need for physiotherapists to more adequately explore patients’ concerns and “actively” listen to patient responses before attempting to give reassurance.

Reassurance is recognized as a complex intervention (Giroldi et al., 2014), and simple “knee-jerk platitudes and messages of hope” (Traeger et al., 2017) are considered ineffective and risk increasing emotional distress. However, the best way to allay patients’ concerns and worries remains elusive (Karran et al., 2018). These data provide interesting insights into physiotherapists’ reassurance practices, which typically focused around educating patients and providing them with positive information about their scan findings, framing the findings as normal or minimal (see extracts 1–4). Biomedical beliefs are pervasive in western society (O’Sullivan, 2012), which are often influenced by unhelpful interpretations of normal age-related scan findings that are poorly associated with pain (Traeger et al., 2015). Providing explanations about normal image findings has clear reassuring potential (Karran et al., 2018) and aligns with guidelines for recommended practice (ACSQHC, 2022; NICE, 2016). However, evidence-based education individually tailored and relevant to patients’ concerns is likely to be more effective than generic educational messages (Cowell et al., 2019; Maguire & Pitceathly, 2002; Traeger et al., 2017). In these data, some physiotherapists assumed that all patients would benefit and feel reassured from receiving such generic evidence-based information, irrespective of their concerns (see extracts 1–3). These data reveal the interactional consequences of this presumptive approach and the implications for the consultation when physiotherapists provide reassuring information about spinal imaging without first establishing the patient’s concerns (see extracts 1–3). This could be characterized as a more paternalistic (Thomson et al., 2013) and, albeit benign, physiotherapist-directed (Cowell et al., 2019; Hiller et al., 2015) style of communication where the physiotherapist delivers evidence-based information that they regard as important rather than offering reassurance responsive to the patient’s actual concerns and information needs. Although the judicious use of current evidence-based education is important to standardize patient care, these data highlight that for such education to be received as reassuring, efforts should be made to target the information to patients’ individual concerns.

Research in other contexts has shown that a failure to fit advice to the advisee’s “problem” creates resistance (Heritage & Sefi, 1992; Park, 2014). Similarly, in these data, we observed how patients displayed their resistance explicitly when physiotherapists failed to tailor their reassurance to their concerns: “I’m not bothered about the [diagnosis] (0.2) it’s the mobility issue that [causes me] more of a concern” (see extract 2 lines 89–91). Their disaffiliative stance was also embodied “((looks to the floor))” (see extract 1, lines 15–16) and facially expressed “((despondent look)” (see extract 1, line 16).

We observed in these data how physiotherapists can invest considerable interactional effort and time, often over multiple turns of talk, delivering ineffective reassurance due to a failure to ascertain patients’ actual worries and fears (see extract 2). It has been recommended that the health care system must place greater value and investment on innovations that create the time required to deliver patient-centered approaches (Pieterse et al., 2019). However, it is also important for physiotherapists, with the acknowledged time constraints in primary care, to reflect on individual practice and to use the time they have more judiciously (Cowell et al., 2018), through a collaborative style of communication, where patients are encouraged to actively participate. Active patient participation contributes to improved health outcomes and quality of care, but is heavily dependent on the practitioners’ communicative style (Street et al., 2005).

We observed in these data a few examples of more patient-focused sequences where the physiotherapist’s reassurance was more targeted to the patient’s concerns. In these more collaborative exchanges, the physiotherapists actively engaged with the patient’s responses to their concern-seeking questions and typically employed secondary prompts/questions to build a better understanding of patients’ concerns. These concern-seeking sequences then provided the basis for more appropriately targeted reassurance (see extracts 4 and 5) with less interactional “trouble” in terms of patient resistance.

In these more targeted sequences (extract 5), the physiotherapist, when addressing the patient’s fear of movement, went beyond just providing reassuring information and employed behavioral testing in the physical examination to allay the patient’s concerns. In this more elaborate sequence, the physiotherapist gradually exposed the patient to the bending movement he feared while attempting to modify his protective responses. This use of guided behavioral experiments to disconfirm patients’ fear of movement has been advocated as an effective model of reassurance and may be more effective than simply providing information (Linton, 2005; Linton et al., 2008). Behavioral experiments are planned in the physical examination and attempt to achieve pain control through graded exposure to movements and activities that are nominated by the patient in the interview as painful, feared, or avoided (Kent et al., 2023; O’Sullivan et al., 2018). An interesting communication feature in this extract was the physiotherapist’s contemporaneous evaluation of the movement that appeared to have a reassuring function: “That looks NI:CE,” “a lovely (0.2) flexed position.” A similar type of communication approach designed to reassure patients, termed “online commentary,” has been observed in medical interaction, where physicians describe what they are seeing, feeling, or hearing during physical examination (Heritage & Stivers, 1999). The physiotherapist’s communicative practices employed in this sequence, including eliciting the patient’s perspective, reflective questioning, and guiding patients toward their bodily sensations, speak to the importance of developing patient’s understanding of their disorder. Rather than reassurance being imposed on the patient, as we observed in extracts 1–3, the reassurance we observed in extract 5 was grounded in a collaborative process in which the patient was helped to “play a part” in understanding why the feared outcome had not occurred. Extract 5 provided the strongest illustration of patient affiliation⁴ to reassurance, and it would appear that integrating behavioral testing to dethreaten pain experience may offer promise in reassuring and directing patients toward “active” behavior change.

Giving reassurance is common practice for physiotherapists when treating patients with LBP and is consistent with best practice for treating people with musculoskeletal pain (Lin et al., 2020). It is intuitive for clinicians to want to allay/reassure patients’ concerns (Kathol, 1997). However, providing patients with reassurance unrelated to their expressed concerns has been described as “worthless” (Balint, 2000). In these data, we have observed that despite physiotherapists’ eagerness to provide reassurance, it was not always effective or efficient. The interactional difficulties observed in these data (extracts 1–3) might point to physiotherapists feeling more comfortable with information giving and “reciting” evidence-based messages than engaging in the more skilled communication practice required to better understand patients’ concerns. Encouragingly, we also observed in extracts 4 and 5 how a more collaborative style of communication, where the physiotherapists encouraged patients to actively contribute to the interaction, allowed for a better understanding of their concerns and the delivery of more targeted reassurance.

Practice Implications

Delivering reassurance and addressing patients’ biomedical misconceptions about the cause of their back pain are clear evidence-based messages. Although we did not measure patient outcomes, our analysis suggests that for these key evidence-based messages to be effective and perceived as reassuring by patients, they need to be aligned to patients’ concerns. It is therefore important for physiotherapists not to make assumptions about concerns that patients might have and encourage a dialogue with patients, listen to their concerns, and take them into consideration before delivering their reassurance. Giving patients the opportunity to provide a full account of what concerns them is likely to contribute to patient satisfaction and enhance the therapeutic relationship. The use of behavioral experiments during the physical examination has been previously described as a central component of physiotherapy-led CFT (O’Sullivan et al., 2018) and may offer promise in providing active reassurance. Training physiotherapists to carefully explore patients’ concerns and adapt their communication to the individual needs of the patient, both within the interview and physical examination, is likely to be important.

Limitations

This relatively small corpus of interactions, undertaken in the United Kingdom in two settings in primary care only, does not claim to represent a comprehensive description of reassurance practice, and therefore there can be no claim to generalizability. However, these data do illustrate the possible practices through which physiotherapists can better align reassurance to the specific patient concerns (Perakyla, 2011). Future research capturing a wider data set with greater representation of physiotherapists and patients would further enhance knowledge in the field. It is also recognized that using video recording might have influenced how participants behave (Parry, 2010) and that the presence of the lead author may have disrupted natural interaction. Future studies also need to examine whether physiotherapists’ style of communication can be modified with training and whether this is associated with better clinical outcomes.

Conclusion

These data illustrate that giving reassurance in a physiotherapy context is common and typically involves some form of information giving. We observed how some physiotherapists give reassurance directed by what they considered to be important or what they assumed the patient was concerned about. This more physiotherapist-focused style of communication appeared ineffective and was often resisted by patients. We also observed examples where the physiotherapists more actively engaged with the patient’s responses to build collaboratively a better understanding of patients’ concerns, which provided the basis for more tailored and patient-focused reassurance with less interactional “trouble” and greater patient affiliation.

Footnotes

Acknowledgments

The authors would like to thank the NELFT physiotherapy service for their support.

Author Contributions

All authors have made substantial contributions to all of the following: (1) The conception and design of the study,acquisition of data,and analysis and interpretation of data;(2) drafting the article;and (3) final approval of the version submitted.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research,authorship,and/or publication of this article: P.O.,K.O.,and I.C. receive fees for speaking at conferences and providing clinical workshops for health care professionals in the management of musculoskeletal disorders.

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: The authors would like to acknowledge funding from the Private Physiotherapy Educational Foundation and the Musculoskeletal Association of Chartered Physiotherapists.

Ethical Statement

ORCID iDs

Ian Cowell

Ged Murtagh

Notes

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A Detailed Analysis of How Physiotherapists “Give” Reassurance for Patients’ Concerns in Back Pain Consultations

Abstract

Keywords

Introduction

Methods

Setting

Participants

Analysis

Ethics

Results

Physiotherapists’ Reassurance Not Targeted to Patient’s Concerns

Failure to Solicit Patient’s Concerns During a Reassurance Sequence

Description of Key Features

Failure to “Pick Up” on the Patient’s Lack of Response to Concern-Seeking Question

Description of Key Features

Not Engaging With the Patient’s Explicit Response to Concern-Seeking Question

Description of Key Features

Reassurance Targeted to Patient’s Concerns

Engaging With Patient’s Responses to Concern-Seeking Questions

Description of Key Features

Disconfirming Patient’s Fear via a “Behavioral Experiment”

Description of Key Features

Discussion

Practice Implications

Limitations

Conclusion

Footnotes

Acknowledgments

Author Contributions

Declaration of Conflicting Interests

Funding

Ethical Statement

ORCID iDs

Notes

References