Trust, humor, and the balance of involvement – Patients with musculoskeletal conditions and comorbidities and their expectations towards physiotherapists

Abstract

Background

Understanding patients’ expectations of health care is central to providing patient-centered care and improving patient satisfaction. However, the current literature is primarily focused on single disease-specific patient expectations.

Aim

To develop an in-depth understanding of the expectations patients with musculoskeletal conditions and comorbidities have towards physiotherapists working in private physiotherapy practice.

Methods

35 observations with patients with musculoskeletal conditions and comorbidities receiving treatment in a Danish private physiotherapy setting were conducted. Of these, nine patients participated in interviews. A Grounded Theory analysis was undertaken, and categories were formed and agreed upon through an inductive approach grounded in the data.

Results

Three major themes emerged from the data 1) Professional expertise is needed but will not be enough if enthusiasm fades in a long treatment course 2) Being able to laugh about life when you have many health problems 3) The balance of involvement and the sharing of power and responsibility. Patients express a desire for a strong bond with their physiotherapists, fostering intimacy and mutual understanding. They seek light-hearted interactions and wish to share personal aspects like family dynamics and hobbies. The study also underscores their expectations for sharing power and care tailored to their specific needs.

Conclusion

Our findings reveal that patients with musculoskeletal conditions and comorbidities have clear expectations of treatment and collaboration with their physiotherapists in private physiotherapy practice. Underscoring personal relationships over physical results and demonstrating that this patient group has resources to support treatment and is clear about levels of involvement and collaboration.

Background

Patients who present with multiple chronic conditions constitute 78% of primary care consultations in European health settings. ¹ The prevalence of these concurrent chronic conditions is anticipated to rise, particularly since over half of those affected are 65 years of age or younger. ² In contrast to patients with only one chronic condition, those contending with multiple chronic conditions face an elevated risk of functional deterioration, ³ premature mortality, and hospitalization, often accompanied by an extended length of stay.^4,5 The assessment of such patients is intricate and necessitates a multidimensional approach encompassing physiological, functional, social, environmental, and personal aspects contributing to their multiple health issues. ⁶

A diverse array of patients, predominantly those afflicted by chronic conditions such as musculoskeletal conditions, partake in physiotherapy interventions. ⁷ The nature of these treatments is contingent upon specific conditions afflicting the patients, with general practitioners having the authority to provide referrals either free of charge or at a reduced fee. ⁸ The most common chronic conditions affecting the musculoskeletal system are treated in private physiotherapy practice. ⁹ While the overarching aim of physiotherapy is often to enhance physical function, particularly in the context of chronic conditions, the focus may shift towards preserving or slowing down the decline in physical function. Many individuals living with chronic conditions undergo prolonged periods of physiotherapy treatment, some requiring assistance for years or even the entirety of their lives following diagnosis. ⁸

Patients grappling with multiple chronic conditions are confronted with an increased risk of unemployment, ¹⁰ prompting some to view physiotherapy as a significant source of social interaction in their daily lives. As patients often require extensive and ongoing treatment, and the efficacy of these interventions may be limited, physiotherapists may encounter challenges in sustaining patients’ motivation and engagement with their treatment regimens. ¹¹ It has been advocated that each clinical encounter should commence with an evaluation of the patient’s expectations, ¹² as comprehending these expectations holds pivotal importance in enhancing patient satisfaction, motivation, and the delivery of patient-centered care. ¹³ It is worth noting that expectations can exert influence over health outcomes, ¹⁴ including the effects of medical interventions. ¹⁵ An extensive survey demonstrated a strong correlation between patient satisfaction and the fulfillment of healthcare expectations, ¹⁶ thereby underscoring the significance of understanding patient expectations, even within the realm of physiotherapy.^17,18

A comprehensive review of the literature concerning patients’ expectations unveiled that these expectations are constructed based on the encounter and outcomes of physiotherapeutic interventions. ¹⁹ This exploration encompassed diverse patient cohorts, ranging from those seeking assistance for musculoskeletal concerns to those contending with neurological and psychiatric disorders. The review discerned those patients desired comprehensive assessments, accurate diagnoses, elucidations of their conditions, treatments, strategies for self-management, and relief or resolution of symptoms. ¹⁹ Nonetheless, these findings predominantly centered on expectations specific to individual diseases. A considerable amount of the existing literature shares this disease-specific focus.^19,20 For instance, Lynch et al. ²⁰ identified a quest for education and self-management among patients with spinal stenosis, while Bishop et al. ²¹ ascertained those patients with neck issues expected symptom alleviation, disability prevention, and the capacity to engage in enhanced physical activity and improved sleep. However, explicit expectations pertaining to patients dealing with multiple concurrent conditions have yet to be delineated.

Consequently, a crucial need exists to ascertain the expectations harbored by patients grappling with multiple chronic conditions in relation to physiotherapy. This study’s overarching objective was to cultivate an intricate understanding of the expectations harbored by patients affected with musculoskeletal conditions and comorbidities towards physiotherapists operating within the domain of private physiotherapy practice. Additionally, the study sought to shed light on how these expectations influence the collaboration between the patients and the physiotherapists. Consequently, we ask: How are expectations from patients with musculoskeletal conditions and comorbidities expressed and motivated, and how do they feed into clinical communication and collaborative efforts?

Methods

Design

35 participant observations with patients with musculoskeletal conditions and comorbidities participating in physiotherapy practice were conducted. Of these, nine patients agreed to participate in individual semi-structured qualitative interviews. This study was reported according to the COREQ guidelines. ²²

Patient characteristics and recruitment

In this study, we focused on patients with neck or low back pain or knee or hip osteoarthritis plus a minimum of one of the following conditions: stroke, depression, heart disorder that required treatment, and type-2 diabetes. These conditions are among the leading causes of global disability, affect hundreds of millions of people around the world, and often coexist linked via systemic inflammation and physical inactivity. ²³ An initial consultation at a physiotherapy clinic normally lasts 60 minutes and afterward, a regular consultation lasts 25 minutes.

The lead researcher, Anna Lyhnebeck (AL), sampled three distinct private physiotherapy clinics and 13 physiotherapists working there, in Zealand Denmark. The 13 physiotherapists (7 men and 6 women, aged 26-60 years) had between 1 and 29 years of experience working in private physiotherapy practice. They had treated the patients participating in the study for periods ranging from 6 months to 5 years. The detailed methods, e.g. sampling strategy and the results on physiotherapists’ treatment strategies can be found in a forthcoming article. ²⁴ As part of that study, all 13 physiotherapists provided their consent to be observed throughout a full day of work. Similarly, 35 patients provided their consent for the observations. Subsequent to the day of observations AL sent an email to the physiotherapists containing the inclusion criteria that aligned with the study’s inclusion criteria, for identifying potential patients to be interviewed individually. The physiotherapists contacted patients who had already participated in observations, and were deemed suitable according to the inclusion criteria, utilizing either phone calls or face-to-face interactions. If the patients expressed their consent to participate, AL obtained the patient’s contact information. Following this, AL initiated contact with the patients via phone to arrange a suitable date and time for the interviews, accommodating the patients’ preferences. Sampling stopped with nine patients, partly as a pragmatic choice but also based on attempts to ensure diversity. Throughout the recruiting process of patients, the research team made concerted efforts to ensure a diverse representation of patients, considering factors such as age, gender, geographical location, and distribution of diseases. This was achieved through a stepwise recruitment approach, where the research team reviewed the diversity of each newly included patient before including the next to ensure variation. If needed, we could have enlarged the sample, however, we deemed the diversity within nine patients satisfying, see also Strengths and Limitations.

Individual interviews

Individual interviews were conducted using a semi-structured interview guide comprising open-ended questions. ²⁵ The duration of patient interviews varied from 30 to 57 minutes, with an average of 44 minutes, depending on the extent of the patient’s elaboration on the subject. These interviews were audiotaped and transcribed verbatim. The interview guide encompassed inquiries concerning the patient’s expectations of their physiotherapists, their level of involvement in decision-making, physical and mental strain, consistency of treatment across different settings, and cost-related matters. The complete interview guide is available in Appendix 1. AL, a female physiotherapist working as a research assistant with qualitative research experience, conducted the interviews. The interviews were conducted within the patients’ homes, and only the interviewer (AL) and the patient were present during these sessions. Field notes from the participant observations, together with existing literature, enriched the development of the interview guide for the individual interviews. However, the participant observations themselves are not included in the study’s data.

Ethics and data security

AL communicated that participation was entirely voluntary. Prior to commencing patient observations and interviews, the principal researcher (AL) provided patients and physiotherapists with comprehensive information regarding the study’s objective and the assurance of anonymity. Patients were explicitly assured that choosing not to participate would have no bearing on their treatment within the healthcare system, and they were informed of their right to withdraw consent at any point. Written consent was obtained from all physiotherapists and patients who participated.

The study received approval from the Danish Data Protection Agency (file number: 514-0606/21-3000). According to the public Danish National Center for Ethics interview research projects are exempted from formal ethical approval if they do not include human biological material, in accordance with §14 of the Act on Research Ethics Committees paragraph 2. To ensure confidentiality, participant names were substituted with unique IDs, all names used in the study are pseudonyms. All these aspects collectively signify the adherence of the research to the Danish regulations for General Data Protection Regulations (GDPR).

Data analysis

The study of social processes pertaining to how clinical encounters take place, how the interaction between parties is performed, and what it is based on, makes symbolic interactionism and Grounded Theory (GT) a suitable choice as a basic methodological approach for this study. In this study, we have applied Kathy Charmaz’s interpretation of GT, which involves a nuanced and constructivist approach to qualitative research methodology. She emphasizes the role of the researcher’s reflexivity and focuses on understanding the subjective experience and perspectives. She advocates for a flexible, iterative process where data collection, coding, and analysis occur simultaneously. This approach allows for the emergence of themes and categories that are grounded in participants’ narratives. An active role by the researcher is also emphasized, allowing the researchers to actively engage with the data, using constant comparison to refine concepts and theories. ²⁶

During transcript analysis, Charmaz’s interpretation of GT was employed. Initially, all transcripts were read to gain a comprehensive impression of the collected data. Subsequently, analytic codes were generated from the data, leading to the creation and organization of categories aligned with the codes. The categories included barriers to treatment, the patient’s rapport with the physiotherapist, the patient’s self-perception, collaboration and communication, and adapting treatment to other concerns. For instance, the codes included in “barriers to treatment” encompassed economy, self-motivation, actual treatment time, the physiotherapist’s competencies, and the referral. Extracted from the codes, focal points were abstracted for each category, culminating in the development of themes.

Throughout the analysis, memos were created to clarify and elaborate the categories. The analytic process involved constant comparisons between data and data, and data and category, and category and category with each other.

AL received guidance from experienced qualitative researchers within the research group (AG and MR). Unlike the traditional GT approach and Charmaz’s interpretation of GT where the analytic process typically commences after the first interview, AL began the analytic process after conducting observations and individual interviews, motivated by practical considerations.

Results

Nine patients (five females and four men, aged between 44-80 years) participated in individual interviews (Table 1). The patients had between two and eight chronic conditions. Six patients received physiotherapy free of charge, one had private health insurance that covered the cost of care and two patients paid themselves with a reduced fee. Three major themes emerged from the analysis: Professional expertise is needed but will not be enough if enthusiasm fades in a long treatment course, Being able to laugh about life when you have many health problems, and The balance of involvement and the sharing of power and responsibility.

Table 1.

Patient characteristics.

ID	Name	Sex	Age	Diseases	Type of payment model
#1	Kate	F	73	Apoplexy Epilepsy Osteoporosis Knee osteoarthritis Anxiety	Free-of-charge
#2	Arthur	M	65	Knee osteoarthritis Type 2 diabetes	Healthcare insurance
#3	Gracie	F	59	Frozen shoulder Fibromyalgia Type 2 diabetes Low back pain	Paid by herself with a reduced fee
#4	Harry	M	80	Apoplexy Herniated disc Glaucoma Type 2 diabetes Heart problems	Free-of-charge
#5	David	M	55	Cerebral hemorrhage Morbus Scheuermann Depression	Free-of-charge
#6	Mia	F	44	Neck pain Low back pain Metabolic disease Rheumatoid arthritis Headache Allergy Plantar fasciitis	Paid by herself with a reduced fee
#7	Susan	F	61	Hypertension Polycystic ovarian disease Fibromyalgia Metabolic syndrome Rheumatoid arthritis Low back pain Paralysis of the legs Herniated disc	Free-of-charge
#8	George	M	71	Spinal stenosis Cerebral hemorrhage Epilepsy	Free-of-charge
#9	Sara	F	66	Headache Neck pain Shoulder pain Low back pain Cancer (gastrointestinal stromal tumor) Neurofibromatosis Recklinghausen type 1	Free-of-charge

The analysis clearly revealed that all patients held robust expectations and perspectives concerning the nature of their treatment within a private physiotherapy practice. Numerous patients reflected upon their rapport with their physiotherapist, particularly emphasizing the degree of trust established therein. While the patients indeed valued professional trust in the physiotherapist’s expertise and clinical insights, the analysis underscored that this aspect alone did not suffice to foster positive treatment experiences. The patients expressed a desire for a deeper, more personal connection. Moreover, the analysis demonstrated the significance of patients feeling at ease and relaxed during their interaction with physiotherapists. This environment enabled them to engage in light-hearted exchanges, even regarding the more profound aspects of their intricate lives. Additionally, a notable finding was the patients’ contemplation of achieving a harmonious balance in their participation, involving communication, decision-making, and the execution of their treatment plans.

Professional expertise is needed but will not be enough if enthusiasm fades in a long treatment course

Numerous patients highlighted the significance of professional trust when articulating their treatment priorities. A female patient, who had been receiving treatment for an extensive span of 11 years at a consistent physiotherapy clinic, articulated her perspectives as follows:

“Well, I think he is very qualified. Well, he knows what he is doing and he knows what is good.” (Kate)

For Kate, her professional rapport with her physiotherapist was firmly rooted in a profound trust in the physiotherapist’s actions and a genuine belief in his adept professional competence to discern the best course of action for her specific conditions. Kate explained that this dynamic became evident in her treatment course, particularly when her physiotherapist adeptly customized her therapy to accommodate her specific chronic conditions. Kate recounted instances where certain exercises tailored for her osteoarthritis posed challenges due to her post-stroke balance difficulties. Her physiotherapist, possessing an awareness of her multifaceted health conditions, foresaw these potential challenges and skillfully adjusted her exercises. The adaptation allowed her to perform the exercises with the support of a chair, thus facilitating balance and rendering completion possible through a slightly modified approach. Such perspective anticipations underscored the physiotherapist’s well-informed expertise, effectively bolstering the patient’s confidence in his capabilities and reinforcing the basis of their professional relationship.

In certain instances, professional trust alone did not suffice to ensure a fruitful treatment course. They also sought a dimension of familiarity with their physiotherapist beyond the confines of a purely professional connection. Arthur, a construction worker in his 60s, contemplated this aspect in the following manner:

”She does it professionally and nicely, it is not that at all. But you can feel if there is heart involved, and maybe there is, but then I just cannot feel it.” (Arthur)

While Arthur held complete confidence in the physiotherapist’s expertise and her ability to administer appropriate treatment, he sensed a void in their relationship – a lack of human dimension. Arthur, who once held the role of a handball instructor, drew from his own experience of being spirited and engaged in instructional roles. He yearned for a similar level of engagement from his physiotherapist throughout his treatment course. He noticed subtle cues in her posture, energy, and level of engagement, which led him to believe that he did not appear to be an interesting patient for her. In his eyes, he seemed to be just another elderly patient, and much of his treatment seemed automated.

Several patients, including Arthur, emphasized the importance of establishing a strong rapport that extended beyond the clinical context. For them, a fulfilling therapeutic relationship involved gaining insight into the person they were spending time with. Even seemingly trivial details, such as knowledge about families and everyday lives, played a significant role. Some patients expressed a sense of disappointment, feeling that their physiotherapists did not engage in enough casual conversation or exchange of personal information, which in turn weakened the overall rapport. This illustrates that a professional association with a physiotherapist is not solely determined by their clinical expertise, it is also influenced by the degree to which they invest themselves personally in the relationship.

Being able to laugh about life when you have many health problems

Certain participants conveyed the significance of having a relaxed and genuine connection with their physiotherapists, one that allowed for informal discussion and shared moments of humor. Harry, a man in his 80s, who had been receiving treatment at the same clinic for nearly two decades, articulated his reflections on it like this:

“As we usually say to Marianne, (..), sometimes she says “Yes, why do you come here really, is it not to get better?”. Then we say “No, it is because you still need some patients and can make some money”. And you have to say that that is open communication, right? That you take it with humor and things like that.” (Harry)

Harry felt comfortable in the relationship when there was open and honest communication, where he felt like they trusted each other enough to joke with one another. This meant that he could be himself and that the relationship he had built with his physiotherapist had moved beyond the professional barriers and into a more familiar interaction. Other participants also mentioned that being able to have humorous interactions with their physiotherapists was important for them, and indicated that they had a connection, showing trust and closeness in the relationship to do this. Susan a woman in her 60s with multiple complex conditions and a very complex disease history expressed that she appreciated the ability to joke and talk candidly about her disease situation. Due to her complex disease history and conditions, she was challenged in walking and was often in a lot of pain. Several of the patients expressed that being able to exchange humorous comments about their declining physical function was important to them and a way for them to cope with their situation. They needed that intimacy and relationship with their physiotherapist. Since many patients with complex chronic conditions did not observe significant improvements in their physical function during their treatment, it could be discouraging to continue with physiotherapy. Therefore, it became essential for them to find alternative sources of motivation to sustain their physiotherapy regime. For many patients, this motivation stemmed from enjoyable and meaningful relationships and interactions with their physiotherapists, where they could share jokes, and derive pleasure from social interaction and exercise, rather than solely focusing on substantial physical improvements.

The balance of involvement and the sharing of power and responsibility

Involvement in one’s treatment was a subject that caused reflection among the patients. A patient named David, a man in his 40s, reflected on his wish for involvement in his treatment like this:

”In practice, they are quite eager to answer questions and accommodate that I am very interested in my treatment, also in new exercises. And they might have read about what new exercises it could be. So, I feel taken very seriously.” (David)

It was important for David that his physiotherapist was willing to answer questions David might have about his treatment. By doing this David experienced a feeling of being involved and being taken seriously in the involvement of his treatment. David had suffered a massive stroke leaving him with severe impairments. Before David became impaired, he had been a very active athlete in badminton, biking, and triathlon. David had now, and before his stroke, a profound curiosity about knowledge of the human body and how everything is connected. This wish for knowledge was also present in his rehabilitation in physiotherapy practice. It was essential for David having a successful treatment course that the physiotherapists acknowledged David’s interest in his treatment and that the physiotherapists allowed time for them to share information and knowledge. A number of the patients were very serious about their treatment in physiotherapy and spent time at home gaining knowledge about their treatment and conditions. It was essential for these patients that their knowledge and experiences were respected in the communication of their treatment course. For these patients, it was necessary to have a high level of personal involvement.

Other patients had different expectations regarding their level of involvement. The patient Susan reflected on the balance of responsibility in the treatment course like this:

“And they will start by saying, “Well, what do you think we should do today?”, “I do not know”. But then all of a sudden it is me who has to play the professional, and I think that is wrong.” (Susan)

This quote illustrates that Susan sometimes felt like she was the professional in the relationship between herself and her physiotherapist. Susan described that she used to work in the pharmaceutical industry and therefore had in-depth knowledge about her different diseases, their treatment course, and medicine. Because of her extensive knowledge and insight into her conditions, she sometimes felt that the physiotherapists put the responsibility of the treatment course on her. She appreciated that they respected her and the knowledge she had due to her prior workplace, but she still wanted the physiotherapists to be the healthcare professionals and feel that they took responsibility for her treatment. Susan described that her treatment course and disease history could be so complex that the physiotherapists could not keep an overview and could be overwhelmed with her as a patient. Some of the patients described that in complex and overwhelming situations they experienced that the physiotherapists would instead ask them what they felt was right, thereby leaving them with a feeling of being too involved with their own treatment and being left in charge. Overall, these varied perspectives highlight the importance of striking the right balance between patient involvement and professional guidance to ensure effective and respectful communication and balance of power between the patient and the physiotherapist was essential throughout the treatment process. This demonstrated that many of the patients with multiple complex illnesses were very resourceful in certain aspects of their treatment and desired collaboration with their physiotherapists. However, they did not want the physiotherapists to relinquish all control. Instead, they preferred a collaborative approach that showcased their strengths while ensuring the physiotherapists’ responsibility remained evident.

Discussion

Our study revealed that patients with musculoskeletal conditions and comorbidities harbored substantial, overarching expectations concerning both their well-being and the role of physiotherapists in the realm of private physiotherapy practice.

Patients’ multifaceted expectations included trust, humor, and calibrated participation. They desired an intimate alliance with their physiotherapist, rooted in professional competence and mutual trust, yet allowing for deeper personal connection. Patients also sought moments of levity and wit, highlighting the importance of a collaborative approach in their interactions.

In the context of patient-centered care, particularly for patients managing multiple chronic conditions, our findings resonate with existing literature. ²⁷ Wijma et al. ²⁷ conducted a systematic review in 2017, delving into physiotherapists’ utilization of patient-centeredness. Their study uncovered several interconnected themes, one of which centered on “getting to know the patient”. This theme underscored the mutual belief among patients and physiotherapists that developing a personal understanding of the patient was essential for tailoring physiotherapy to the individual’s needs. This included facets such as identifying patient expectations. These findings align with our own, emphasizing the critical importance of comprehending patients’ expectations, such as fostering light-hearted interactions and discussing outside the confines of physiotherapy sessions.

These findings highlight that for patients with multiple complex illnesses, the relationship with physiotherapists becomes as important as, or even more important than, the improvement of physical function, which is often the primary goal for other patient groups receiving physiotherapy. Given that this patient group has chronic conditions that are for some are progressive and may require lifelong physiotherapy, maintaining motivation for continued treatment can be challenging. This study emphasizes that to keep motivation levels high, it is crucial for patients and physiotherapists to establish a strong and comfortable relationship, which can help sustain the patient’s commitment to physiotherapy. The importance of prioritizing relationships over results in treatment for patients with multiple conditions is further confirmed by a qualitative systemic review of general practitioners’ strategies for managing patients with multimorbidity from 2020. ²⁸ This review illustrates that GPs prioritize above all long-term relationships with their patients with multimorbidity due to the numerous benefits these relationships provide. ²⁸

In a 2019 systematic review, Langberg, Dyhr, and Davidsen sought to establish a comprehensive framework for the concept of patient-centeredness, encompassing five dimensions: 1) the biopsychosocial perspective, 2) patient-as-person, 3) Sharing power and responsibility, 4) the therapeutic alliance, and 5) doctor-as-person. ²⁹ Some participants within our study contended that having faith solely in their physiotherapist’s professional expertise was insufficient, they also desired a personal connection. This aligns with Langberg, Dyhr, and Davidsen’s emphasis on the therapeutic alliance, the relationship between healthcare provider and patient. They posit that this cooperative alliance can enhance adherence, while a distant or negative relationship might hinder successful treatment. ²⁹ In our study, certain patients expressed dissatisfaction with the therapeutic alliance, feeling a lack of personal rapport with their physiotherapist. This sentiment impacted both their treatment progress and their relationship with their physiotherapist adversely. Conversely, other patients asserted that broadening their relationship to encompass aspects beyond physiotherapy, such as humor-filled exchanges, contributed to a stronger rapport.

The significance of a robust patient-healthcare professional relationship was similarly highlighted in a 2012 qualitative study investigating general practitioners' consideration when treating patients with multiple chronic conditions. ³⁰ The study revealed that a personal patient-doctor connection emerged as a pivotal factor positively influencing care for individuals with multiple chronic conditions. Analogous to our study’s findings, the general practitioners recognized that showing genuine interest in patients on a personal level fostered trust and established a resilient relationship. ³⁰

Patient participation and involvement have been firmly established as integral components for achieving high-quality care and favorable outcomes among patients with multiple chronic conditions.^15,18,29,31 Nonetheless, our study underscores the importance of a balanced approach to involving patients and sharing power and responsibility within their treatment course. This involvement should not stem from physiotherapists feeling overwhelmed or lacking a comprehensive overview of patient’s medical history and treatment trajectory. Rather, it necessitates an implementation that grants physiotherapists a sense of control while affording willing patients the opportunity to engage. Moreover, it should be a delicate equilibrium to avoid patients feeling solely burdened with overseeing every facet of their care.

Our study also reveals that patients with multiple complex conditions are, in many ways, a strong and empowered group. They were clear about their treatment preferences and how they wanted to receive it. This did not mean they wanted complete control, but rather that they wished to actively contribute to collaborating with the physiotherapist and the overall treatment plan whenever possible. This demonstrates a new dimension of this patient group, which is often portrayed in the literature as both vulnerable ³² and fragile. ³³

Langberg, Dyhr, and Davidsen’s dimension of “sharing power and responsibility” within patient-centered care resounds deeply in our study. This dimension, characterized by adequately informing patients and fostering their participation in medical decisions, is poised to bolster adherence and treatment success. ²⁹ Our findings illuminate the intricate complexity of realizing this dimension in practice. We uncover the diversity of patient expectations for involvement, reinforcing the notion that no two patients hold identical demands for engagement. Mood et al.’s 2022 ³⁴ integrative review, exploring the patient perspective on primary care for multimorbidity, echoes our results. They emphasize the patient group’s aspiration for meaningful inclusion within their healthcare team, a sentiment encompassing being heard and valued for their expertise. ³⁴ This mirrors our study’s findings, emphasizing patients’ yearning for inclusion tailored to their unique requirements and resources. Our study reveals a spectrum of preferences, from intense patient involvement to a preference for healthcare professionals taking the lead.

This dimension further beckons for differentiation. A Dutch study categorizing patients with multiple chronic conditions identified three distinct profiles: the prepared proactive patient, the everyday patient, and the vulnerable patient. ³¹ The perspective of Frank in our study aligns with the prepared and proactive category, demonstrating a strong desire for active inclusion in his care. Conversely, Susan’s perspective reflects a more vulnerable position, facing challenges in communication with healthcare professionals and relying on them to establish treatment goals. This underscores the heterogeneous needs within the musculoskeletal conditions and comorbidities patient population. It underscores the importance for healthcare professionals to attentively discern the individual they are working with, as not all individuals require the same type of care.

Our study not only underscores the centrality of patient participation but also emphasizes the necessity of tailoring involvement to diverse patient needs. By striking a careful balance, healthcare professionals can foster effective partnerships that transcend the complexities of multiple chronic conditions. This tailored approach is pivotal in ensuring high-quality care that is truly patient-centered and recognizes the uniqueness of everyone’s journey.

Strengths and limitations

A strength of our study is the diverse background of the research group, which included two medical doctors, two physiotherapists with private practice experience, and a medical anthropologist. The entire team has extensive experience researching patients with multiple illnesses. This diverse expertise allowed for a more comprehensive understanding of the patient’s conditions from multiple perspectives. The multidisciplinary approach enriched the research process and analysis, enabling the research team to address the complexities of the patient group more effectively.

A limitation of our study is the limited number of participants in the individual interviews. The research team attempted to mitigate this by ensuring a diverse inclusion of patients, securing a wide range in age, geographical location, lengths of participation in physiotherapy, and variations in chronic conditions. This diversity makes the findings transferable to patients with similar combinations of diseases in similar treatment settings, supported by Malterud’s concept of information power ³⁵ . Another strength of the study is the extensive amount of participant observations, which provided a solid foundation for developing the interview guide.

Conclusions

The findings of our study underscore that patients with musculoskeletal conditions and comorbidities have strong expectations of trust, humor, and personal connection with their physiotherapists. Due to the patient’s complex health, the relationship with the physiotherapists is often more crucial than the physical results of treatment. The study reveals that patients, who have multiple complex chronic conditions, are not only strong and empowered in some respects but also clear about their expectations regarding treatment preferences, and levels of involvement and collaboration with the physiotherapist grounded in professional competencies and personal rapport.

Ethical statement

Ethical approval

According to the public Danish National Center for Ethics interview research projects are exempted from formal ethical approval if they do not include biological material. All participants gave written informed consent before data collection began.

ORCID iDs

Anna Bernhardt Lyhnebeck https://orcid.org/0000-0003-0371-2962

Søren T. Skou https://orcid.org/0000-0003-4336-7059

Mette Bech Risør https://orcid.org/0000-0002-7912-5804