Abstract
This study aimed to identify the impact of psychosocial problems on patients successfully or unsuccessfully coping with physical therapy, assessment methods during diagnosis and charting by physiotherapists, psychosocial strategies currently used by physical therapists and current referral systems. patient from one specialist to another. The questionnaire of physiotherapists was published by the Association of Physiotherapists of Albania, and 35 of the physical therapists participated in the study. The questionnaire designed for patients was distributed only to patients who have followed an alternating treatment between physical therapy and psychotherapy to solve their health problems. 48.4% of the physiotherapists who submitted the questionnaire claimed that they did not get the result they expected from the treatment of patients, even though they implemented all the physiotherapeutic protocols approved for the specific pathology. The physical therapists indicated that the factors they identified as obstacles to the success of the treatment were related to the patients’ lack of motivation, their perception of pain, as well as the patients’ stress or anxiety. On the other hand, 64.3% of the patients participating in the study referred to their psycho-emotional state as the main evident obstacle in achieving success after physiotherapeutic treatment. 100% of these patients simultaneously affirmed that their physical pains and emotional concerns have found a final solution after following the psychotherapy sessions. These results show that the impact of the psycho-emotional state on patients directly affects the successful treatment of certain pathologies. However, it is rare for physiotherapists to consider this aspect as crucial in the success of their patients’ treatment. This aspect is largely influenced by their lack of proper training on the identification of psychosocial problems that a patient may present, as well as institutional bottlenecks in the referral system.
Key words: Physiotherapy, psychosocial, psychotherapy, physical pain, stress.
METHODOLOGY
This study was carried out in the period January 15, 2022 – October 15, 2022, in order to discover the psycho-social factors of patients, which influence their physiotherapeutic treatment. From the literature, it was evident that there is a strong connection between a certain psychological state of a patient and the physical pain they experience.
For this study, it was deemed necessary to construct two questionnaires, one designed for professionals and one designed for patients. The sampling of physiotherapists was random and without exclusion criteria. 35 physiotherapists from all over Albania participated in this study. The questionnaire for physiotherapists was distributed by the Association of Physiotherapists of Albania, where the reason for this questionnaire was explained.
Sampling of patients was purposive. All patients who would complete this questionnaire must necessarily have followed the two treatments (physiotherapy and psychotherapy) to treat the health problem they were suffering from. The patient questionnaire was distributed by physiotherapists and psychotherapists to patients who they knew met the main criteria to be part of the study. Only 25 people from all over Albania answered the patient questionnaire.
The data collected from the patient and physiotherapist questionnaires were entered into Excel to then generate the information needed for this study. The secondary purpose of this study is to change the approach of physiotherapists on their clinical reasoning, during the completion and review of physiotherapy cards, making the psycho-social factor of the patient mandatory, part of the assessment during the diagnosis and, consequently, the treatment protocol for these patients.
CONCLUSIONS
1- Patient referral system.
One of the links that does not work in the ideal form, referring European health systems, in Albania, is the system of referring patients from one professional to another, based on the clinical consultations that patients make the first time they show their health problems. 77.4% of the physiotherapists questioned in this study affirm that their patients are referred by the Neurologist/Orthopedic for physiotherapy. This percentage comes against a negligible percentage of referrals by the family doctor with 19.4% and the psychologist with an even lower percentage of referrals, 3.2%. In this aspect, it is worth noting that the majority of patients go to the physiotherapist mainly for orthopedic or neurological treatments. These problems necessarily require physiotherapy, but they are not the only pathologies where physiotherapy plays an essential role in treatment. The connection between the family doctor and the referral to the physiotherapist is very weak. A large part of family doctors do not know the pathologies where physiotherapy intervenes for treatment. From naked eye research or conversations with patients, the family doctor usually suggests pharmacological treatment for 90% of the pathologies that the patient presents with problems. On the other hand, 74.2% of the physiotherapists participating in the study affirm that they have referred patients to the psychologist, but they have not documented who was the reason that prompted them for this referral. This statement is shaken in some way by the fact that the patients questioned in this study affirm in a much smaller percentage that they were referred by the physiotherapist to the psychologist. 50% is the number of patients who claim to have been referred by the physiotherapist to attend psychotherapy sessions. 42.9% of patients were referred to the psychologist by persons who are not part of the health system. Usually, patients visit the psychologist when they themselves feel that something is wrong with them or their family members, the close social circle, advise them to attend psychotherapy sessions for something that seems to be wrong with them. In order to evaluate the general culture of the health system, as regards the referral of the patient to the psychologist, it is enough to mention the fact that only 7.1% of the patients questioned in this study claim that they were referred by the neurologist/neuropsychiatrist to attend psychotherapy sessions. This study proves in its essence a problem that every citizen of the Republic of Albania suffers every time he faces health system in our country. The supporting professions of the health system are not considered to the extent necessary to help the efficient and long-term treatment of the patient, for the pathology from which he suffers.
2- Factors that hinder treatment. A treatment does not always meet the expectation of the professional or the patient. It usually happens that the precise implementation of treatment protocols, in different patients, gives different results, for the same pathology. From the literature, it is explained that this result is not always related to the professional skills of the professional but, sometimes, there are hindering factors that affect the treatment. Physiotherapists questioned in this study listed, according to the request of the questionnaire, the factors identified as hindering the success of the treatment. Non-adherence to advice, the patient’s psychological state, the pathology from which he suffers, the patient’s economic aspect, the patient’s motivation, the patient’s education, the patient’s lack of cooperation, patients in a bad mood and those who do not believe in physiotherapy treatment and not following the advice on the part of the patient, were the points that were mentioned the most by them. What stands out in this listing is that all physiotherapists “consider the patient guilty” for the lack of success in the treatment. Based on the main purpose of this study, what impresses is the clash of data generated by the participating physiotherapists. Only 2 physiotherapists have identified the psychological factor as an obstacle to the success of the treatment, meanwhile, the same physiotherapists have answered that they have referred patients to the psychologist in 74.2%. and 83.9% of them affirm that they have in their clinical records, questions that evaluate the psycho-social aspect of the patient. Even in this aspect, a fluctuation in the veracity of the responses of the physiotherapists themselves in this questionnaire is observed. This fluctuation, in the judgment of information and conversations with professionals from different fields of treatment, comes because physiotherapists do not have the appropriate level of information regarding the influence of the psychological factor in physiotherapy treatment, as well as the areas in which they should evaluate this factor. This fluctuation, born as a question and from the literature, is noticed in the data generated by the questionnaire, when the physiotherapists were asked if physiotherapy was enough in the treatment of patients who referred certain psychological traumas or psychosocial disorders, only 35.7% of them claimed that there was used physiotherapy in their treatment, 32.1% admit that physiotherapy was not enough to treat patients successfully and 32.1% referred that it was enough sometimes physical therapy for treatment. These percentages do not come close to any of the percentages achieved in the other questions regarding the referral of patients to the psychologist or the factors that have not allowed the successful treatment of the patient with physiotherapy. What stands out after analyzing the data is the patients’ approach to evaluating the factors that have hindered the success of their physiotherapy treatment. 64.3% of the patients questioned in this study refer to their psychological condition as the main obstacle in the success of the treatment. This percentage, compared to the responses of physiotherapists where only 2 of them have identified the psychological aspect of the patient as an obstacle to success, shows us the neglect of physiotherapists on one of the most important aspects, during the clinical judgment of the cases they treat in the work of their daily life.
3- PERCEPTION OF THE EFFECTIVENESS OF THE TREATMENT.
When it comes to a certain state of the individual, its interpretation is mostly subjective. A professional, in any field of medicine, at the moment he starts the treatment of a case, also creates the expectation for the final result. Well yes, this result does not always coincide with reality. 48.4% of the physiotherapists who participated in this study claim that they have applied all the treatment protocols for a certain case, but did not get the result they expected. The way they mainly evaluated the “failure” in the treatment of these cases was the way the patients interpreted the result at the end of the treatment. Judging by this data, there was a need to see from the patient’s point of view, how he perceives the success of a treatment. Inaccurate or unclear information given at the beginning of the treatment, by the professionals, about the procedures followed according to the protocols and the expected result, creates confusion and dissatisfaction among the patients. 78.6% of the patients questioned in this study affirm that they were aware of the procedures followed by the physiotherapist during their treatment and 7.1% of them do not remember this detail from the physiotherapeutic treatment they followed. What is noticeable is that if we add the sum of these percentages, it exactly coincides with the percentage generated by the questionnaire for the question of how patients evaluate the approach of their physiotherapist on the concerns they have referred. Accordingly, 85.7% of the patients reported that their physiotherapist was very careful about the concerns they mentioned during the treatment. This is an indication of the fact that communication throughout treatment makes the patient feel more heard and understood by
his therapist. Generally, based on our culture, family members have an attitude of indifference towards concerns that a person may express. This causes them to withdraw and stop voicing their concerns as they feel unsupported or understood by others. If this also happens to the professionals, who have an obligation to consider every concern that the patient refers to, the latter experience it even worse, passing through experiences of guilt as to why they feel that concern and no one understands them. . An exact compliance, which supports what was said above in the patients’ responses, is also observed in the response of those patients who referred that they did not have information about the protocol followed by 14.3% of them. Yes, 14.3% of the patients questioned affirmed that their physiotherapist did not pay attention to the concerns they referred to during the treatment. As for the perception of pain on the part of the patient, 42.9% of them referred that their pain after the physiotherapeutic treatment has decreased to the extent of 5-8, on a measuring scale from 0-10 (VAS scale). 35.7% of patients reported that the pain decreased 8-10. These percentages indicate an above-average pain reduction. If we add these percentages again, we arrive at the sum of 78.6%, which exactly coincides with the number of patients who refer that they are aware of the procedure followed by the physiotherapist during their treatment. These data show exactly the fact that the key to successful treatments is the information given to the patient as well as the importance with which he is treated during therapy by professionals. Many other patients would have found optimal solutions for the treatment of their pain if physiotherapists were more careful to identify their needs and to understand the importance or weight of the influence of the patient’s psychological aspect in their treatment . 100% of the patients questioned in this study affirm that psychotherapy has influenced the reduction of physical and emotional pain they experienced. This is the main scientific fact that proves the hypothesis of this study.
4- PAIN CONCENTRATION AND PSYCHOEMOTIONAL STATE.
Since above we emphasized the fact that the experiences of certain conditions are completely individual, there was a need to evaluate a concrete connection between physical pain and psychosocial problems experienced by the patient, through their perception translated into data to be analyzed. 50% of the people questioned in this study refer to anxiety as the problem for which they went to the psychologist, and the rest are divided between strong traumas and emotional disorders. To make the connection between emotional disorders and pain
physical, the patients participating in the study were also asked about the concentration of their physical pain. What stands out is the fact that 50% of the patients reported that their pain was concentrated in the neck. This percentage is totally compatible with the percentage of patients who answered that the reason for which they attend psychotherapy sessions is anxiety. If we dig a little into the information about what anxiety is and what causes it, this compatibility of percentages is confirmed. People who suffer from anxiety, one of the characteristics of the symptoms they have is precisely the loss of concentration or the difficulty to focus even on the simplest daily activities. The positioning we take to increase focus creates an arch in the neck, which is not similar to its physiological arch. Automatically, this action also imposes the contraction of the neck muscles. If this strained positioning lasts over time, it also creates pain in the neck muscles and then deviation of the vertebrae from C1 to C7. Difficulty in breathing is also one of the problems experienced by people suffering from anxiety disorder. In this case, all the accessory muscles that participate in the breathing process are affected, causing their contraction and automatically pain. The lack of breathing normally according to physiology also causes a lack of oxygen supply to the muscles. Fear, yet one of the aspects that these patients suffer from, is a factor that affects the physical condition. When a person experiences fear, they usually assume a position like a baby in the mother’s womb (the fetal position), this position makes breathing difficult, does not help the typical postural positioning of the human body, and is a contracted state of almost every muscle in the body. . All this analysis made on the data generated in this study, in addition to the relationship analyzed so far between the patient’s psychosocial condition and physical pain, shows us that there is a very strong relationship between anxiety disorders and neck problems (pain). .