Developing an integrated osteopathy and acceptance-informed pain management course for ...

315 Pages·2017·3.11 MB·English

Title : Developing an integrated osteopathy and

acceptance-informed pain management course for
patients with persistent pain

Name : Hilary Amanda Abbey

This is a digitised version of a dissertation submitted to the University of
Bedfordshire.
It is available to view only.
This item is subject to copyright.
DEVELOPING AN INTEGRATED OSTEOPATHY AND
ACCEPTANCE-INFORMED PAIN MANAGEMENT COURSE
FOR PATIENTS WITH PERSISTENT PAIN

Hilary Amanda Abbey

A thesis submitted to the University of Bedfordshire
Institute for Health Research
in fulfilment of the requirements for the degree of
Professional Doctorate in Osteopathy

January 2017
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ABSTRACT

Title: Developing an integrated Osteopathy and Acceptance-informed pain
management course for patients with persistent pain.
Purpose: This study explored therapeutic processes associated with developing a
course for patients with persistent pain which integrated osteopathic treatment
with Acceptance and Commitment Therapy (ACT). This 'third wave’ cognitive
behavioural approach is effective for a range of physical and psychological
problems, including persistent pain, and congruent with osteopathic principles of
holism, function and agency, which provided a theoretical basis for developing
an integrated intervention to promote resilience and well-being. A qualitative
case study was conducted as part of a developmental research programme to
explore how ACT could be integrated with osteopathic treatment for individual
patients, and with what effects on processes and outcomes.
Method: Linguistic ethnography was used to explore links between pain-related
discourses, clinical decisions and responses to pain. Treatments were audio-
recorded, transcribed, and coded. Extracts referring to discourses about pain
experienced during manual therapy were subjected to micro-level conversation
analysis, sociolinguistic analysis of participants’ roles, and macro-level analysis of
links to broader healthcare discourses. A reflective diary was used to explore
experiential learning and integrate auto-ethnographic information.
Results: Two distinctive forms of mechanistic and facilitative pain discourse were
identified. In predominantly mechanistic discourses, agency and expertise were
located with the osteopath, and intention was focused on fixing ‘broken’ parts
and relieving pain using ‘familiar’ osteopathic techniques.
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In facilitative discourses, the osteopath adopted a more collaborative role,
focused on developing the patient's body and self-awareness to promote more
flexible, active pain responses. Practitioner challenges included learning how to
shift intention between mechanistic and facilitative interventions, a process that
was enabled by mindfulness and willingness to tolerate uncertainty.
Conclusions: In this study, ACT-informed osteopathy involved facilitative
discourses, associated with increased patient agency and flexibility in response
to pain. Further research is needed to explore whether this pattern of discourse
is robust in other clinical settings; relationships between mechanistic and
facilitative discourses and therapeutic outcomes; and effects of ACT training on
practitioner mindfulness and attitude towards clinical uncertainty. Findings
suggest that this integrated approach could expand the scope of osteopathic
care for patients with persistent pain, and is worth further investigation.
Keywords: Acceptance and Commitment Therapy, chronic pain, Mindfulness,
Osteopathy
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LIST OF CONTENTS Page

ABSTRACT iii

LIST OF CONTENTS v

LIST OF TABLES AND FIGURES x

ACKNOWLEGEMENTS xii

CHAPTER ONE: INTRODUCTION 1

1.1 Background 1
1.2 Osteopathic relevance 4
1.3 Relevance to patient care 7
1.4 Relevance to healthcare services 8
1.5 Originality and innovation 11
1.6 Personal position 12
1.7 Thesis structure 15
1.8 Related publications and presentations 15

CHAPTER TWO: LITERATURE REVIEW 19

2.1 Introduction 19
2.2 Aetiology of chronic pain 19
2.3 The impact of chronic pain 32
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2.4 Medical interventions 43
2.5 Physiotherapy 46
2.6 Osteopathy 53
2.7 Psychological approaches 60
2.8 Mindfulness 65
2.9 Multidisciplinary pain management programmes 71
2.10 Summary of the literature review 75

CHAPTER THREE: METHODOLOGY 79

3.1 Introduction 79
3.2 Ontology and epistemology 80
3.3 Theoretical perspective 82
3.4 Methodology 85
3.5 Summary 93

CHAPTER FOUR: METHOD 94

4.1 Introduction 94
4.2 Study 1: Group-based pain management course 96
4.3 Study 2: Individual pain management course 99
4.4 Participants 99
4.5 Intervention 102
4.6 Research process 105
4.7 Equipment 107
4.8 Data collection 108
4.9 Ethical considerations 109
4.10 Data analysis methods 113
4.11 Stage 1A: Quantitative content analysis 115
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4.12 Stage 1B: Quantitative linguistic analysis 116
4.13 Stage 1C: Quantitative ethnographic analysis 117
4.14 Stage 2A: Micro Discourse Analysis 118
4.15 Stage 2B: Interactional Sociolinguistic Analysis 119
4.16 Stage 2C: Macro Discourse Analysis 119
4.17 Summary of data analysis methods 120

CHAPTER FIVE: RESULTS 121

5.1 Introduction 121
5.2 Stage 1A: Patterns in ACT-related interventions 121
5.3 Stage 1B: Patterns of communication and participation 122
5.4 Stage 1C: Ethnographic influences 123
5.5 Stage 2A: Talking about pain 124
5.6 Stage 2B: Changing the response to pain 131
5.7 Stage 2C: Broadening the discourse about pain 139

CHAPTER SIX: DISCUSSION 148

6.1 Introduction 148
6.2 Summary of the key findings 148
6.3 Strengths of the study 151
6.4 Limitations of the study 154
6.5 Comparison of the findings with existing literature 156
6.6 Implications for osteopathic research 172
6.7 Implications for osteopathic practice and education 180

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CHAPTER SEVEN: CONCLUSIONS 185

7.1 Introduction 185
7.2 Study context 185
7.3 Skill development 186
7.4 Patient outcomes 187
7.5 The osteopathic model of biopsychosocial healthcare 187
7.6 Conclusions 188

CHAPTER EIGHT: THE RESEARCH JOURNEY 190

8.1 Introduction 190
8.2 Home is where we start from 191
8.3 Whose journey is it anyway? 193
8.4 The limits of language 194
8.5 What am I supposed to be doing? 195
8.6 Right here, right now 197
8.7 What would I have done differently? 198
8.8 What next? 198

REFERENCES 200

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APPENDICES Page

Appendix 1: Literature searching strategy 238
Appendix 2: Participant Information Sheet 240
Appendix 3: Patient Workbook 243
Appendix 4: Patient Application Form 278
Appendix 5: Interview Recording Consent Form 279
Appendix 6: Pre-course Interview Questions 280
Appendix 7: Study Consent Form 281
Appendix 8: Post-course Interview Questions 282
Appendix 9: Reflective Field Note Questions 283
Appendix 10: Example of a field note transcription 284
Appendix 11: Example of a research diary entry 285
Appendix 12: Overview of other data analysis methods 286
Appendix 13: Colour coding tables 287
Appendix 14: Linguistic coding tables 290
Appendix 15: Ethnographic coding tables 292
Appendix 16: Extracts selected for qualitative analysis 294
Appendix 17: Conversation Analysis transcript notations 295
Appendix 18: Differences in linguistic form 296
Appendix 19: Coding of expert or collaborative extracts 297
Appendix 20: Discourse Analysis Framework 298
Appendix 21: Summary of MDA for extract A4.1 299
Appendix 22: MDA transcript for extract A2.1 300
Appendix 23: MDA transcript for extract A7.7 301
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