Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: A qualitative study research protocol

Michael C Kelly; Jenni Naisby; David J Bell

doi:10.1371/journal.pone.0295382

. 2023 Dec 1;18(12):e0295382. doi: 10.1371/journal.pone.0295382

Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: A qualitative study research protocol

Michael C Kelly ^1,^*,^#, Jenni Naisby ^1,^#, David J Bell ^1,^2,^#

Editor: Sylvester Chidi Chima³

PMCID: PMC10691676 PMID: 38039307

Abstract

Background

Physiotherapists’ play a key role in the management of chronic pain, and as part of the National Institute for Health and Care Excellence (NICE) guidelines, prescribe exercise to support patients with chronic pain. However, there is very limited evidence supporting physiotherapists on what type of exercise or dose of exercise should be prescribed. Physiotherapists’ therefore have more onus on their ability to clinically reason how to prescribe exercise. At present, there is no research investigating how physiotherapists’ working with patients that have chronic pain, clinically reason when prescribing exercise. This study proposes to investigate how physiotherapists experienced in pain management prescribe exercise, to understand what the key influences are on their reasoning, and how these impact on clinical practice.

Methods

This will be a qualitative study, utilising semi-structured individual interviews. Participants will be Health and Care Professions Council registered physiotherapists, working predominantly with patients that have chronic pain. Recruitment will focus on physiotherapists working within the United Kingdom (UK). Up to twenty participants will be recruited. The study, including the interview guide, will be supported by a steering group consisting of academics and physiotherapists experienced in chronic pain. The data will be analysed using framework analysis.

Results

The study will be reported using the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines. The findings of the study will be disseminated through publication in a peer reviewed journal.

Conclusion

This study will provide novel insight into how physiotherapists experienced working with and managing chronic pain patients, prescribe exercise, and will gain new insight into clinical practice to help inform future research and education.

Introduction

Chronic pain, also referred to as persistent pain, is a pain that lasts more than three months [1]. Although there is limited consensus, it is estimated that one-third or up to one-half of the population are affected by chronic pain [1]. A meta-analysis by Fayaz and colleagues [2] reported a prevalence of 35–51.3% within the United Kingdom (UK). Chronic pain is a leading cause of disability, which can affect work, relationships and self-esteem [3]. Patients with chronic pain have described the negative interference it has with physical functioning, professional life, family and relationships, social life, sleep and mood [4]. At present, chronic pain exerts an enormous burden from individual, societal and economic viewpoints [3, 5].

Management of chronic pain is complex, requiring a person-centred assessment [1] and multimodal approach [3]. The use of exercise and physical activity (PA) are two of the recommended approaches to non-pharmacological management of persistent pain [1]. Although the terms exercise and physical activity have been used interchangeably within the literature [6], there is a clear distinction between each term. Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure [7], whereas exercise is a subset of physical activity, that is planned, structured and repetitive and aims to improve or maintain physical fitness [7]. As this study is focused on the prescription of exercise, the term exercise will be used throughout.

Physiotherapists’ play a key role in pain management as part of a multidisciplinary team [8] and are in an ideal position to prescribe exercise and support PA, as they are able to support physical function, provide advice, explanation and encourage activity [9]. Additionally, physiotherapists’ are able to assess risk versus safety in human movement and play a key role in reducing disability in chronic pain [10].

Although exercise and PA are key recommendations for the management of chronic pain and form part of the NICE [1] guidelines, there is little detail about how to put the recommendations into practice. There is an absence of evidence to guide physiotherapists’ on the prescription of the type of exercise, and exercise dose, which is subject to considerable uncertainty [11, 12]. The evidence used to inform the NICE [1] guidelines was predominantly based on female patients with fibromyalgia syndrome (FMS) and patients with neck pain. The guidelines stated that limited evidence was available to compare different types of exercise, making no distinction in which exercise (cardiovascular, mind–body, strength, or a combination of approaches) would be preferential for patients. In their chronic pain update published in the Lancet, Cohen and colleagues [3] also recognised a lack of evidence guiding one type of exercise over another for chronic pain, while highlighting that exercise appears more beneficial for function as opposed to pain relief. A recent network meta-analysis [13], focusing on chronic low back pain, did conclude that Pilates, McKenzie therapy and functional restoration were more effective for reducing pain and functional limitation, compared to other exercise. However, the study did also report that other types of exercise, other than stretching, were more effective for reducing pain and improving functional limitations compared to minimal care, and a highlighted that a higher dose (measured with time) or adding co-interventions for most exercise treatments, was more effective than minimal care.

A recent meta-analysis [14], systematic review with a meta-analysis [15], and Cochrane Review [16] have highlighted that while evidence supports the use of exercise for chronic pain, there is virtually no knowledge of the appropriate dose [14], and there is a scarcity of evidence supporting physiotherapists’ on the parameters of exercise prescription, and how they may change prescription, when faced with the predominance of nociplastic pain [15]. Although daily recommended exercise guidelines exist [17], it has been postulated that these may be an excessive dose for patients with chronic pain [14]. Whilst the NICE [1] guidelines are unable to direct physiotherapists’ on the most effective type of exercise, they do state that patients would be more likely to exercise if they were provided with programmes that suited their lifestyle, physical ability and addressed their health needs. Individualising treatment is important [12], but doing so complicates the ability to establish definitive exercise prescription guidelines [11].

Despite the lack of evidence and recommendations for physiotherapists’ to prescribe exercise, daily, physiotherapists’ are required to prescribe exercise and support physical activity for patients with chronic pain. Clinical reasoning is a key component for physiotherapists’, defined as a “context dependent way of thinking and decision making in professional practice to guide practice actions” [18] and a foundation of physiotherapy practice. Although studies have investigated how physiotherapists’ clinically reason in the assessment of pain [19] or how ready they are to manage chronic pain [20], there appears to be no research investigating how physiotherapists’ clinically reason to prescribe exercise for patients with chronic pain. Ultimately, the guidance to prescribe exercise is variable and generic for patients with chronic pain, the result of which is a reliance on individual physiotherapists’ preferences and abilities to prescribe exercise [15].

Considering the very limited guidance to prescribe exercise for pain, it is important to understand how physiotherapists’ who are experienced in pain management clinically reason to prescribe exercise and support rehabilitation. Rehabilitation is based upon social interaction and dependent upon attitudes, thoughts, and motivations [21] and qualitative research is well placed to help gain insight into what is important for those involved in the research [21]. Therefore, investigating how physiotherapists’ experienced in pain management prescribe exercise, will help understand what the key influences are on their reasoning, and how these impact on clinical practice. Doing so, will help guide other physiotherapists or health care professionals to consider what may support their own clinical reasoning, to help prescribe exercise for patients with chronic pain. This work will highlight key opportunities for physiotherapists, physiotherapy education and further research to understand the key aspects of clinical reasoning when prescribing exercise for patients with chronic pain, but also provide a starting point to improve how exercise is prescribed for patients with chronic pain.

Methods

Study design and type

In this study, following a generic qualitative approach [22], semi-structured individual interviews will be used to gather qualitative data, with the aim of investigating the clinical reasoning of physiotherapists’ prescribing exercise for patients with chronic pain. The interview guide (see S1 File) has been developing through a scope of the literature and the research team experiences. The research teams experiences were deemed important, due to limited extant literature. The research team piloted the questions using a steering group of physiotherapists’ and academics that were experienced in working with patients that have chronic pain. This steering group were consulted regarding the interview content guide, as well as the research concept. The research team are all musculoskeletal physiotherapists from different career backgrounds. There is one clinical pain specialist working within the NHS (DB) and two Assistant Professor physiotherapists, experienced in research in the areas of pain (JN) and exercise (MK). The guide includes topics such as engagement with the guidelines, influences on reasoning (such as prior experience, education, patient viewpoints/expectations), influence of type of pain/pain mechanisms, service agreements and therapist experience.

Study place and population

Recruitment will begin in summer 2023, lasting up to one year. A purposive sample of Health and Care Profession Council (HCPC) registered physiotherapists, working predominantly or exclusively with chronic pain patients (such as within pain services or pain clinics) that present with chronic primary pain (such as, but not exclusively fibromyalgia syndrome) [23] or chronic secondary pain (such as, but not exclusively osteoarthritis) [24] will be recruited.

Recruitment will not take place directly within health services (such as the National Health Service), but through adverts circulated via social media, the Physiotherapy Pain Association, the Physiotherapy Research Society as well as using a snowballing approach using clinical experts within physiotherapy networks to support recruitment. Potential participants will contact the principal researcher via email, and be provided (via email) with an electronic participant information sheet and consent form. Participants will provide consent by emailing a completed consent form to the principal researcher. Following consent, a date and time will be agreed for the interview to take place.

Sample size

Providing an a-priori sample size within qualitative research has been subject to criticism, based upon the premise that it is illogical to suggest a specific number of participants based upon a subject or topic with which the key themes cannot be identified in advance, or create understanding about what is as of yet known [25].

This study will recruit participants using the concept of information power [26], whereby the more information a sample holds, relevant for the study, the lower the amount of participants are required. This approach allows researchers to approximate the number of participants required for analysis. Appraisal of information power should be repeated as stepwise approach [26] and will be following each interview in this study.

Although using information power to guide sample size provides guidance, it is not without criticism and as with all qualitative research, justifying a sample size is a genuine challenge [25]. Therefore, as opposed to stipulating a specific number of participants, this study will impose an upper limit of 20 participants, following the guidance of Sim [25]. This guidance, which also mirrors that of Malterud [26], recommends ongoing interpretation of the data by the research team, using an inductive approach, with a focused research agenda, to increase the potential for saturation [27], or in this case information power, with the aim to understand how physiotherapists’ experienced in pain management prescribe exercise, and understand what the key influences are on their reasoning, and how this impacts on clinical practice.

Data collection

All interviews will be conducted by the first author (MK)The study will take place face to face with participants on the university grounds, or via teleconferencing. All interviews will take place in a private space. All interviews will be audio recorded using two digital voice recorders. If interviews are undertaken via teleconferencing, no screen footage will be recorded, only an audio recording. The interviews will last up to two hours to allow exploration on the participants’ clinical reasoning. Field notes made during the interviews may also be taken, to record key insight or aspects of the interviewer’s experience. Prompting and probing questions will be used to support the interview guide. Following each interview, the interview questions will be reviewed, adapted or refined by MK and JN, as part of a reflexive approach.

The age, level of entry qualification, highest level of qualification, number of years qualified and number of years working with chronic pain will be collected. This will enhance the transferability of study findings. No other data will be collected, other than the contents of the interviews, which will be audio recorded.

Data management and analysis

Audio recordings will be transcribed, and participants will be allocated a numeric code at the beginning of the study, which will be used to identify any data which they provide within the study. None of the participants’ personal details will be associated with any participant data. Informed consent forms containing both name and code will be stored separately from the recorded data in the study. Framework analysis [28] will be used to analyse the data. Framework analysis, consisting of seven stages (Transcription, familiarisation, coding, developing and analytical framework, applying the analytical framework, charting data into framework matrix and interpretation), is a form of thematic analysis, and thematic analysis is not tied to a specific discipline or construct [29], which helps to provide theoretical freedom and flexibility, while providing rich, detailed and complex accounts of data [30]. The analysis will be conducted by members of the research team independently, therefore providing the benefit of multiple coding, independent verification of analysis [31] and code refinement [32]. Trustworthiness will also be enhanced using guidance by Shenton [33], which includes the use of frequent debriefing sessions between the research team, peer scrutiny, and the use of reflexive diaries as the research develops.

Ethical considerations

The study has been approved by Northumbria University Ethics Committee (11^th July 2022, Ref 51228). Following completion of the study, participants will receive an electronic participant de-brief, informing them of the lead researcher contact details, ethics officer details and information about what the information from the study will be used for.

Dissemination of results

The study will be reported using the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines [34]. The findings of the study will be disseminated by sharing at a national conference and publication in a peer reviewed journal. In addition, a summary will be shared with professional networks who have supported recruitment.

Discussion

To the best of our knowledge, this will be the first study seeking to understand the clinical reasoning processes of physiotherapists’ when prescribing exercise or PA for patients with chronic pain. There is a paucity of evidence guiding physiotherapists’ about the type or dose of exercise for patients with chronic pain. Therefore, investigating how physiotherapists’ experienced working with and managing chronic pain patients, prescribe exercise or PA, will gain new insight into clinical practice. In order to improve research within healthcare, it should be designed, disseminated and implemented with stakeholder input, such as clinical staff and patients [35]. Therefore, using the support of a steering group of physiotherapists’ and academics, we will seek to understand what the key influences are on the physiotherapists’ clinical reasoning processes. This will include how much importance is placed on exercise and, how they may gain a baseline for exercise to start with, and how they progress and monitor patients. This study will also consider the range of influences on their clinical reasoning, including the patient presentation, the patients’ views and goals, the current evidence base, as well as the physiotherapists’ backgrounds and experiences of managing patients with chronic pain. This research will also consider what concerns physiotherapists’ have regarding exercise prescription and highlight what questions they may pose when looking forward to improving their understanding of exercise prescription for their patients.

Understanding the reasoning processes of physiotherapists’ will help provide new insight about how patients with chronic pain are supported using exercise. Additionally, this study will help inform future research, other health care professionals involved with patients that have chronic pain, and undergraduate education, for this important, but poorly understood topic.

Study limitations

This study will investigate the views of HCPC registered physiotherapists’ only, therefore specific contextual influences (for example, individual service provision) will be unique to physiotherapists’ working within the United Kingdom. This study will also be specific to physiotherapists’ who work predominantly with patients that have chronic pain. Therefore, this study will not reflect the experiences or reasoning of other physiotherapists’ that may encounter patients with chronic pain, as part of a typical caseload. Although the geographical reach of the research may be limited, and specific to a small proportion of physiotherapists that specialise in chronic pain, and therefore limiting transferability, this study will provide important contextual insight into how physiotherapists’ working in the UK, prescribe exercise for patients with chronic pain. To enhance transferability, it will be ensured that detailed contextual information will be provided about the sample.

Understanding context within research and clinical practice is important. Patient preferences and concerns are shaped by contextual factors which impact on applicability of clinical guidelines [36], while studies that do not consider context, risk being unable to articulate the “how” and the “why” [37]. Due to the paucity of evidence guiding physiotherapists’ in exercise prescription for chronic pain, developing research that can capture the contextual factors that impact on physiotherapists’ clinical reasoning is important to furthering our understanding of this topic.

Supporting information

S1 File. This is the semi structured interview guide to investigate physiotherapists’ clinical reasoning to prescribe exercise for patients with chronic pain.

(DOCX)

Click here for additional data file.^{(19.2KB, docx)}

Data Availability

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0295382.r001

Decision Letter 0

Claudio Di Lorito

14 Apr 2023

PONE-D-23-00756Physiotherapists clinical reasoning to prescribe exercise for patients with persistent pain: a qualitative study research protocol.PLOS ONE

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Reviewer 1 comments:

INTRODUCTION

• You are using exercise and physical activity interchangeably. I suggest you stick to exercise and not physical activity since physical activity cannot be prescribed (line 150, 155). It is exercise that can be prescribed.

METHODS

A lot of information has been mixed up in the methods section. Authors are providing information that is not necessary for a publication. For example, some details (lines 215 to 252) can be summarized in a single sentence and then just referenced. Authors are writing the methodology section as if this is a thesis, yet this is a manuscript for publication. I suggest you cut down any unnecessary details in the methods section and write the methodology section concisely with the following subheadings:

• Study design and type

• Study place

• Study population

• Sample size/ sampling

• Data collection

• Data management and analysis

• Ethical considerations

• Dissemination of results

Some further comments in the methods section are below:

Study design

• Information under study is largely describing the data collection process and the tools used for data collection. Authors need to indicate what study design will be used as this has not been described under the study design section.

• Some information in lines 181 to 187 is misplaced. This information should come the ethical consideration. In addition, this section (ethical considerations) is missing and needs to be included.

Study population

• Information on sample size has been misplaced (lines 253 to 263) under data collection. This information should be under a sub heading sample size which follows the study population sub section.

• Under sample size, authors should be specific on how participants will be sampled. What sampling frame will be used?

Data analysis

• Provide information on how data trustworthiness will be ensured.

DISCUSSION

Study limitations

• Since this is a protocol, indicate how you intend to mitigate the limitations that you foresee.

Reviewer 2 comments:

Thank you for submitting this protocol for review. It is certainly a useful piece of work to understand the clinical reasoning of clinicians and something that has been poorly explored previously. I have outlined a few questions and amendments to strengthen the protocol

Abstract

Background – uses NICE abbreviation, suggest no abbreviations on an abstract, spell out in full for international readers. Can we avoid using the word patients as many service users do not view themselves as patients, particularly in the outpatient setting

Methods – again using UK abbreviation Write out in full

Ethics statement – needs more detail. Please explain why NHS IRAS/HRA ethics will not be required. What do you mean consent will be gained in the written format. Please give further details. Has ethics already been obtained?

Data section (page 5). I am confused as you state that no data sets were produced or analysed as part of the study but this study is generating a new data set (qualitative data from interviews). Please clarify and amend

Full manuscript

Background

- You state that chronic pain and persistent pain are more or less the same. Why have you chosen to call it persistent pain throughout the manuscript as this could be confusing for your reader?

- Chronic/persistent pain is complex. Are you focusing on clinical reason in certain conditions/populations (i.e MSK related, organ related, multi-morbidity, fibromyalgia)? Clarifying this would help focus the mind of your readers.

- Please define exercise and physical activity (as they are two distinct, though related terms)

- Although you have focused on physiotherapists as the main prescribers of exercise, I think you could expand the final paragraph of this section (page 14) to consider how other professionals could learn from these findings. For example exercise physiologists etc

Method

- You state that the interview guide has been developing using literature. Can you elaborate? Have you completed a systematic/mapping review to identify literature? How can you be sure there isn’t any available evidence?

- Please confirm if consent will be written or electronic

- Robust qualitative research includes reflexive diaries. I note you have said that you will keep field notes but reflexive diaries are also needed and should be incorporated into the analytical framework

- I am unclear why you need two people to complete a semi-structured interview. Why would JN observe and make notes? This is unsual for this method so please explain the rationale. The bias of two interviewers to one participant could potentially introduce bias into the method through social power. This needs to be explained further

- If you are using data saturation to determine your sample size please define your working definition of saturation

- There is limited detail on the analysis section. I note that you are suing the framework method which has seven stages of analysis (linked to the Gale reference). The authors have not followed this nor provided enough detail on their analytical method. For this to be published the seven stages need to be outlined.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: Yes: Dr. Enock Chisati

**********

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PLoS One. 2023 Dec 1;18(12):e0295382. doi: 10.1371/journal.pone.0295382.r002

Author response to Decision Letter 0

18 May 2023

Dear reviewers,

Thank you for taking the time to review our manuscript, and for providing clear and detailed feedback to help improve the submission. Below, we have provided a table with reviewer comments in one column and responses in another, to help provide a clear audit of the changes made. We have responded to each reviewers points separately, though some points made by the reviewers highlight the same issue (such as terminology relating to exercise and physical activity).

Reviewer 1

INTRODUCTION

Response: Agreed, exercise will be utilised throughout. Reviewer 2 requested that exercise and physical activity should be defined, which has been added (lines 96-104) and is followed by why exercise will be used throughout the manuscript.

METHODS

• Study design and type

• Study place

• Study population

• Sample size/ sampling

• Data collection

• Data management and analysis

• Ethical considerations

• Dissemination of results

Response: An effort was made to be more succinct in reporting of the methods in lines 207-227. However, reviewer two commented that a definition was required relating to information power/saturation, therefore this has remained in the script. We have amended the script and used the titles and order of titles as suggested. However, we have combined study place/population as a sub heading, as each section in isolation would have limited detail. We have added a sub heading for ethical considerations (lines 263-268) and dissemination of results respectively (270-273)

Some further comments in the methods section are below:

Study design

• Some information in lines 181 to 187 is misplaced. This information should come the ethical consideration. In addition, this section (ethical considerations) is missing and needs to be included

Response: We have clarified that this will be a qualitative study, following a generic qualitative approach as described by Kahlke (2014) on lines 172-175. Ethics information has been moved to the “ethical considerations” section (lines 263-268)

Study population

• Information on sample size has been misplaced (lines 253 to 263) under data collection. This information should be under a sub heading sample size which follows the study population sub section.

• Under sample size, authors should be specific on how participants will be sampled. What sampling frame will be used?

Response: We have moved the information on sample size to the appropriate sub heading of sample size (lines 206-227). As described in lines 190, a purposive sample will be used from the recruitment method outlined in lines 196-199. We felt that this approach was most appropriate, due to the nature of the physiotherapists linked to these associations.

Data analysis

• Provide information on how data trustworthiness will be ensured

Response: This has been added in lines 259-261

DISCUSSION

Study limitations

• Since this is a protocol, indicate how you intend to mitigate the limitations that you foresee.

Response: We have highlighted that the main limitation is the transferability of the study, due to the specific type of clinicians to be recruited, and highlighted how this could be mitigated in lines 313-314

Reviewer 2

Background – uses NICE abbreviation, suggest no abbreviations on an abstract, spell out in full for international readers.

Response: Agreed, this has been amended accordingly.

Can we avoid using the word patients as many service users do not view themselves as patients, particularly in the outpatient setting

Response: We have elected to keep the word patient, this is to keep aligned with the terminology used by National Institute for Health and Care Excellence (NICE), and the International Association for the Study of Pain (IASP).

Methods – again using UK abbreviation Write out in full

Response: Agreed, this has been amended accordingly.

Response: Yes, ethics has been obtained. This was stated in lines 187-188 (in the original submission), detailing the ethics committee, reference number, and the date ethics was obtained. With the amendments to the manuscript, this is now on lines 263-268. Consent will be electronic, via email. This has been clarified in lines 200-204. As recruitment is not taking place directly within the NHS, but via social media, the Physiotherapy pain association and the Physiotherapy research society and can include participants that are not working in the NHS, NHS IRAS/HRA ethics is not required. We have highlighted in the manuscript that recruitment will not be directly within the NHS (lines 196-199)

Response: The data collection has not started. For clarity, we have amended the date of the recruitment to summer 2023 (line 190). We did not want to/have not started data collection, as we wanted this protocol paper to be accepted first as per the PLOS one guidelines.

Full manuscript

Background

You state that chronic pain and persistent pain are more or less the same. Why have you chosen to call it persistent pain throughout the manuscript as this could be confusing for your reader?

Response: We have amended this to chronic throughout the script, which includes the title

Chronic/persistent pain is complex. Are you focusing on clinical reason in certain conditions/populations (i.e MSK related, organ related, multi-morbidity, fibromyalgia)? Clarifying this would help focus the mind of your readers.

Response: This has been clarified in the participants section (lines 190-195) and uses IASP references to support

Please define exercise and physical activity (as they are two distinct, though related terms)

Response: We have defined both terms (lines 96-104), as physical activity is discussed in the NICE guidelines, but also highlight why exercise will be used throughout the manuscript

Although you have focused on physiotherapists as the main prescribers of exercise, I think you could expand the final paragraph of this section (page 14) to consider how other professionals could learn from these findings. For example exercise physiologists etc

Response: We have added to the final paragraph, but opened this up to health care professionals (line 298)

Method

You state that the interview guide has been developing using literature. Can you elaborate? Have you completed a systematic/mapping review to identify literature? How can you be sure there isn’t any available evidence?

Please confirm if consent will be written or electronic

Response: A systematic review/mapping review was not undertaken. However, the scope of the literature, as far as the research team was aware was used, due to the limited exploration of this subject. We had highlighted in the script that the scope of the literature as far as the research team was aware was utilised (lines 175-177) . Consent is electronic (lines 200-204)

Robust qualitative research includes reflexive diaries. I note you have said that you will keep field notes but reflexive diaries are also needed and should be incorporated into the analytical framework

Response: This has been added in lines 260-261

Response: We have removed JN from attending the interviews.

If you are using data saturation to determine your sample size please define your working definition of saturation.

Response: We are not using data saturation, but information power, which is covered in lines 211-216

There is limited detail on the analysis section. I note that you are suing the framework method which has seven stages of analysis (linked to the Gale reference). The authors have not followed this nor provided enough detail on their analytical method. For this to be published the seven stages need to be outlined.

Response: We have added the seven stages of framework analysis to this section (lines 251-253) but have not discussed each, as the study has not yet been conducted.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(21.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0295382.r003

Decision Letter 1

Claudio Di Lorito

7 Aug 2023

PONE-D-23-00756R1Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: a qualitative study research protocol.PLOS ONE

Dear Dr. Kelly,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but a few minor comments need addressing to fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 25 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Claudio Di Lorito

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Authors

Thank you for the revisions. Two reviewers have checked your re-submission and they are happy to proceed with publication if you addressed the minor comments included. Please carefully addressed these reminaing comments, so we can proceed with publication of your manuscript.

Best Wishes

Claudio Di Lorito

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I would like to congratulate the work done previously by the authors and very concise help and valuable help by the reviewers, in the presentation of the manuscript.

I have 2 minor additions which I suggest be added to the manuscript.

Line 95: What is your understanding/theoretical stand point in relation to complex pain, you state which approach is needed but not how you define and understand complex pain. This could be clarified.

95: “Management of chronic pain is complex, requiring a person-centred assessment [1]and multimodal approach [3].”

Clinical reasoning is a key component

Line 146-147 you define clinical reasoning for physiotherapists as a “context dependent way of thinking and decision making in professional practice to guide practice actions” [18]

Even though you describe an inductive approach in your framework analysis it seems unrealistic and maybe critical, that you do not have an informed starting point by having a model/theoretical understanding of clinical reasoning. This should be elaborated and clarified in the analysis section in Methods as this will influence the future analysis.

Reviewer #3: Thank you for your work. I feel that you managed to respond well to previous comments from colleague reviewers. There is no need for extra reviews after that.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

**********

Attachment

Submitted filename: PONE-D-23-00756R1 Reviewer 1.docx

Click here for additional data file.^{(12.6KB, docx)}

PLoS One. 2023 Dec 1;18(12):e0295382. doi: 10.1371/journal.pone.0295382.r004

Author response to Decision Letter 1

10 Aug 2023

Reviewer comment

95: “Management of chronic pain is complex, requiring a person-centred assessment [1]and multimodal approach [3].”

Response: Within the script, we have used the term chronic pain, supported by the NICE guidelines definition. We have not used the term complex pain, as we are stating that the management of chronic pain is in itself complex (and requires person-centred assessment and multimodal approach). The focus of the study is clinical reasoning within chronic pain, as opposed to within complex pain, which may be a separate entity.

As we are not focusing on complex pain (which we are unaware if an accepted definition exists, or is an accepted term), we feel that discussing complex pain, or introducing this term to the paper adds unnecessary deviation from the focus of the study, namely chronic pain.

Reviewer comment: Clinical reasoning is a key component

Line 146-147 you define clinical reasoning for physiotherapists as a “context dependent way of thinking and decision making in professional practice to guide practice actions” [18]

Response: Within the analysis section of the methods section (line 256), we have highlighted that relevant clinical reasoning frameworks will inform analysis where appropriate, using an inductive approach to allow themes to emerge.

As different clinicians may utilise different clinical reasoning models (such as hypothetico-deductive, pattern recognition, biopsychosocial etc), we do not want to have a specific reasoning model as a starting point of analysis.

Attachment

Submitted filename: RESPON~1.DOC

Click here for additional data file.^{(17.7KB, DOC)}

PLoS One. doi: 10.1371/journal.pone.0295382.r005

Decision Letter 2

Sylvester Chidi Chima

21 Sep 2023

PONE-D-23-00756R2Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: a qualitative study research protocol.PLOS ONE

Dear Dr. Kelly,

Thank you for submitting your revised manuscript to PLOS ONE. After careful consideration, we feel that it has fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Kindly modify your abstract as previous into a structured abstract as follows with the following sub-headings, as recommended by the peer-reviewer:

1. Background (here include the purpose /aim of the study with a brief background).

2. Methods (summary of methods)

3. Results (summary of results/expected outcomes)

4. Conclusion.

Also address any other observations or comments by the peer- reviewers.

Please submit your revised manuscript by Nov 05 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Sylvester Chidi Chima, M.D., L.L.M, LLD.

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: No

Reviewer #2: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors should re organize the abstract to be logical with the following sub headings:

1. Background (which should also include the purpose /aim of the study).I advise they cut down and provide just a summary of the background.

2. Methods (summary of methods)

3. Results (summary of results)

4. Conclusion.

There is no need to provide a discussion in the abstract.

Reviewer #2: I can accept the arguments provided by the authors No further comments. Good luck with the coming project.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. 2023 Dec 1;18(12):e0295382. doi: 10.1371/journal.pone.0295382.r006

Author response to Decision Letter 2

3 Nov 2023

Kindly modify your abstract as previous into a structured abstract as follows with the following sub-headings, as recommended by the peer-reviewer:

1. Background (here include the purpose /aim of the study with a brief background).

2. Methods (summary of methods)

3. Results (summary of results/expected outcomes)

4. Conclusion

1) We have added the aim of the study into the background.

2) The method has remained the same

3) As this is a protocol, we do not have any results. Therefore, we have included here what the outcome will be with the results.

4) We have removed the subtitle discussion and replaced with conclusion, and provided a conclusion.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(17KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0295382.r007

Decision Letter 3

Sylvester Chidi Chima

22 Nov 2023

Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: a qualitative study research protocol.

PONE-D-23-00756R3

Dear Dr. Kelly,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sylvester Chidi Chima, M.D., L.L.M, LLD.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

We have received 3 Accept recommendations from previous peer reviewers for this study protocol. The fourth review appears to duplication of previous reports and may be considered by the authors during their full study

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #4: Partly

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #1: Yes

Reviewer #4: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #4: No

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #1: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors of the manuscript have appropriately addressed all the comments. I have no further comments.

Reviewer #4: Introduction

I understand the work claims to be the first study (line 274) seeking to under standing clinical reasoning processes of physiotherapists when describing exercise. When such a claim is made I think it is important that other articles around experience of PTs and clinical reasoning article more generally are acknowledged to give a context and a better focus on the gap so for the introduction and discussion I have had a quick search of articles (I am not an expert in this area so forgive me if these are not bang on) but I would think some of them need to be acknowledge so the context of this statement can be fully understood and acknowledgement to past work and the gaps are identified.

Frontiers | The Needs and Experiences of Patients on Pain Education and the Clinical Reasoning of Physical Therapists Regarding Cancer-Related Pain. A Qualitative Study (frontiersin.org)

Exercise prescription for patients with non-specific chronic low back pain: a qualitative exploration of decision making in physiotherapy practice - ScienceDirect

Full article: Clinical reasoning and critical reflection in physiotherapists’ examinations of patients with low back pain in its early phase: a qualitative study from physiotherapists’ point of view (tandfonline.com)

The clinical reasoning of pain by experienced musculoskeletal physiotherapists - ScienceDirect

Articles that contain some information

Physiotherapists’ beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies - ScienceDirect - this review cites 5 past articles

Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare - ScienceDirect

Self‐management and chronic low back pain: a qualitative study - Crowe - 2010 - Journal of Advanced Nursing - Wiley Online Library

Self-management support for people with non-specific low back pain: A qualitative survey among physiotherapists and exercise therapists - ScienceDirect

Full article: The suitability and utility of the pain and movement reasoning model for physiotherapy: A qualitative study (tandfonline.com)

Context articles

Full article: Factors influencing physical therapists’ clinical reasoning: qualitative systematic review and meta-synthesis (tandfonline.com)

Full article: Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study (tandfonline.com)

Promoting Participation in Physical Activity and Exercise Among People Living with Chronic Pain: A Qualitative Study of Strategies Used by People with Pain and Their Recommendations for Health Care Providers | Pain Medicine | Oxford Academic (oup.com)

Methods

Lines 169-177

You call the research you are planning a generic qualitative study. The reference you use states this:

One research approach that falls under this broad category is known as generic qualitative research, which is subsequently subdivided into genres of interpretive description and descriptive qualitative research (Caelli et al., 2003).

Later on the author give a perspective on a philosophical stance – e.g.,

generic studies seek to understand how people interpret, construct, or make meaning from their world and their experiences. Furthermore, she writes that generic studies are epistemologically social constructivist, theoretically interpretive studies that focus on “(1) how people interpret their experiences, (2) how they construct their worlds, and (3) what meaning they attribute to their experiences” (Merriam, 2009, p. 23).

Given the above do you need to be more specific as to whether you work will be a descriptive or interpretive description approach? If so, there may be a better reference to use also do you need to mention something about social constructivism?

You mention interviews here but this is methods so can go later on?

Do you want to separate out aspects of setting, context and reflexivity?

Lines 178-184

The development of the guide could be expanded and include if you will do pilot interviews?

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #4: No

**********

PLoS One. doi: 10.1371/journal.pone.0295382.r008

Acceptance letter

Sylvester Chidi Chima

24 Nov 2023

PONE-D-23-00756R3

Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: a qualitative study research protocol.

Dear Dr. Kelly:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Sylvester Chidi Chima

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. This is the semi structured interview guide to investigate physiotherapists’ clinical reasoning to prescribe exercise for patients with chronic pain.

(DOCX)

Click here for additional data file.^{(19.2KB, docx)}

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Data Availability Statement

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

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PERMALINK

Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: A qualitative study research protocol

Michael C Kelly

Jenni Naisby

David J Bell

Roles

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Study design and type

Study place and population

Sample size

Data collection

Data management and analysis

Ethical considerations

Dissemination of results

Discussion

Study limitations

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Claudio Di Lorito

Roles

Author response to Decision Letter 0

Decision Letter 1

Claudio Di Lorito

Roles

Author response to Decision Letter 1

Decision Letter 2

Sylvester Chidi Chima

Roles

Author response to Decision Letter 2

Decision Letter 3

Sylvester Chidi Chima

Roles

Acceptance letter

Sylvester Chidi Chima

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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