Swedish physical therapists' beliefs on what makes therapy work.

Even though scientific evidence may be lacking, practicing physical therapists have accumulated, through years of experience, a practical and tacit knowledge[1] about what makes physical therapy work. Their beliefs probably reflect how they view their professional practice. Physical therapy can be viewed as an applied biomedical science in which treatment techniques are seen as the cure for the patients' problems. Alternatively, physical therapy can be seen as a caring profession in which the patient-therapist interaction is emphasized more than the treatment method.[2,3] The medical model has dominated the profession, but has been challenged in recent years. For example, the World Health Organization[4] has identified some of the problems inherent in working solely within the medical model and recommends that member nations consider other approaches to health care.

Several Scandinavian writers within the physical therapy profession have discussed alternatives to the traditional medical model. Tyni-Lenne[5] has described how physical therapists may have two different approaches to physical therapy intervention. One approach is to focus on the movement problem and the damaged organ; the other approach is to focus on the patient-therapist relationship as a basis for a learning process whereby the patient achieves health as the goal. The importance of the patient-therapist relationship has been studied by Westman Kumlin and Kroksmark,[6] and the holistic view of physical therapy (focusing on the whole person rather than just body parts) has been emphasized by Roxendal.[7] In addition, Paatero[8] has pointed out that the traditional role of the patient as passive recipient of care is contrary to the goals of physical therapy, which emphasize activity and function. The goals of physical therapy intervention assume a motivated patient, actively participating in therapy.

Physical therapists' beliefs concerning why physical therapy works can be interpreted within the context of attribution theory. According to this theory, there is a universal tendency for people to try to find causal explanations for events.[9] Attribution theory can be traced to Heider's[10] work on the notion of phenomenal causality. Heider assumes that people are motivated to see their social environment as predictable and thus attribute explanations to various events in their social world. A central idea in this theory is that attributions can be external to the behavior or event one is trying to explain or internal, such as referring to a person's ability or personality. Physical therapists can be expected to make causal attributions as to why a treatment succeeded or failed. Such attributions are likely to be founded on knowledge and experience, and to be related to other values and attitudes as well as background variables.

The attributions physical therapists make are probably influenced both by the greater cultural context of the society and its prevailing view of health care and by viewpoints expressed within the professional group. In Sweden, a law regulating health care in 1982[11] makes explicit the view that the patient is not a passive recipient of care, but rather an active participant in charge of his or her own health. The role of the patient has often been the focus of health care discussions in Sweden,[12] and one would expect that most health practitioners believe there is an active role for the patient in treatment.

It seems likely that the current ideas emphasizing patient responsibility, patient-therapist interaction, and holistic views of health care would have some bearing on physical therapists' beliefs as to why physical therapy works. The purpose of this study was to find out (1) what kinds of attributions physical therapists make regarding why physical therapy works and (2) to what extent attributions are related to background variables (eg, gender, age, education, experience, field of work). No attempt was made to determine whether treatments are actually effective. This study examined only belief systems.

We hypothesized that background variables would be correlated to the attributions in the following way: Attributions reflecting a view of physical therapy as a caring profession and a holistic view of health care would be endorsed to a greater extent by women, by those having longer experience working as physical therapists, by those working with patients who have psychiatric problems compared with those working in orthopedic physical therapy, and by those having undergone further education either in physical therapy or in other fields.

Method

Steps in Scale Construction

Qualitative study. To construct an instrument for assessing attributions, a qualitative pilot study was conducted. A strategic sample of six physical therapists were interviewed to explore the kinds of causal attributions physical therapists make to explain successful treatment outcomes. The therapists chosen were a heterogeneous group of physical therapy teachers and practitioners with different specialties, different views about physical therapy practice, different lengths of experience, and so forth. We knew some of the therapists before the study; others were suggested as possible respondents. These therapists were chosen to achieve the purpose of sampling as many different beliefs as possible.

The therapists were asked to think about patients they believed they had treated successfully and to talk about what they thought had made physical therapy work. The interviews lasted 1 to 2 hours and were tape-recorded. The interviews were then transcribed and subjected to a qualitative analysis by the first author (LS). Several readings of these interviews revealed three categories of attributions:

1. Physical therapists attributed success to themselves, to their own role as experts, and to their knowledge and techniques.

2. Physical therapists attributed the success to the patient. The patient's own resources, capacity for healing, and motivation to change were seen as the cause.

3. Attributions were made to the interaction between physical therapist and patient; their relationship was seen as the cause for the success.

Questionnaire. A questionnaire was constructed specifically for the purposes of this study. The first part included background information about respondents: gender, age, year of graduation, number of years of practice, further education, major area of work, and areas of interest in physical therapy.

The second part of the questionnaire was an attitude scale consisting of 22 statements to which respondents were asked to express their degree of agreement on a five-point Likert-type scale.[13] Nine attribution statements were mixed in with 13 other statements concerning attitudes toward physical therapy. The attribution statements were based on the three categories identified in the qualitative study. Three statements attributed the cause for successful outcome to the physical therapist's knowledge and treatment techniques, 3 statements attributed the cause to the patient, and 3 statements attributed the cause to the patient-therapist relationship. Some of the statements used in this scale were paraphrasings of what physical therapists had actually said in the qualitative study. We constructed other statements as reflecting the meanings of the categories.

The other 13 statements expressed various attitudes toward physical therapy. These statements were based on a review of the literature.[5-8] Three statements were concerned with a holistic view about the treatment and the patient. The remaining 10 statements were used to increase the credibility of the questionnaire and dealt with issues such as patient responsibility and therapeutic approaches as described in the literature.

An initial version of this instrument consisted of 28 statements. Ten colleagues (teachers of physical therapy and practicing physical therapists) completed this version. They were also asked to comment on the items with respect to content, choice of words, and so on. Some items were found to be ambiguously phrased, too controversial,[14] or "double-barreled"[14] (eg, comments reflected the respondents reacted emotionally), and as a result 6 statements were excluded and others rephrased. The final instrument consisted of 22 statements (Appendix).

Scoring. Three different scores were computed, reflecting the three different kinds of attributions. Statements 1, 6, and 17 were combined by adding the responses, forming a variable reflecting attributions to the physical therapist's knowledge and treatment techniques (called technique attributions). Similarly, statements 3, 9, and 16 were combined into a score named client attributions, and statements 4, 12, and 18 were combined to form a score named interaction attributions. These three scores served as dependent variables. The items were scored such that a score of 5 indicated agreement with the attribution and a score of 1 indicated disagreement. Negatively phrased items were reversed according to the Likert procedure. The possible range of scores for each variable was 3 to 15, where 3 indicates total disagreement with the attribution and 15 indicates total agreement. In addition, three statements (7, 3, 22) reflecting a holistic attitude were combined to form an attitudinal score named holistic attitude. The range of scores for this variable was also 3 to 15, where the higher score reflects a stronger endorsement of a holistic viewpoint.

Main sample. The respondents were randomly sampled from the members of the Swedish Physiotherapy Association, to which 94% of Swedish physical therapists belong. A multistage sampling procedure was used, whereby first a cluster sampling of regions in Sweden was carried out by randomly choosing 4 regions from the total of 17 regions. Within each region, a 25% sample was randomly selected stratified by gender. The sample thus chosen consisted of 187 physical therapists (83% women and 17% men). The size of the sample was determined by two considerations: an adequate number of subjects to perform statistical analyses and limited funding.

Questionnaires with accompanying cover letters and stamped return envelopes were mailed to the 187 physical therapists. Envelopes were coded to facilitate reminders. The code was removed on receipt of the questionnaires so that respondents could be assured of confidentiality. A reminder was sent after 10 weeks. The final response rate was 76% (142 responses). Two questionnaires were less than half completed and had to be excluded, leaving 140 for analysis.

Statistical Analyses

Means, standard deviations, ranges, and confidence intervals were calculated for the dependent variables. Stepwise multiple regression was used to test the hypotheses about relationships between background variables and dependent variables. Pearson Product-Moment Correlation Coefficients were calculated to describe the strength of relationship between the dependent variables as well as between dependent variables and background variables. A t test for independent means was used to test the hypothesis that psychiatric physical therapists differed in attributions from orthopedic physical therapists. All analyses were performed by computer using the SAS program.[15]

Results

Description of the Sample

The 140 physical therapists (116 women and 24 men) ranged in age from 21 to 78 years (X=37.89, SD=9.45). They had graduated from Swedish school of physical therapy between 1934 and 1990; 44.3% had completed their basic physical therapy education prior to 1981, and 55.7% completed their basic education during the period 1981 to 1990. The group averaged 10.28 years of clinical practice (SD=8.86, range=1-50). Seventeen percent of the physical therapists had more than 20 years of work practice, and 10% of the therapists had less than 1 year of work practice. Thirty-two percent of the physical therapists had attended courses in physical therapy corresponding to at least 5 weeks of full-time study, and 38% of the therapists had attended courses in other fields of the same duration. The physical therapists' major area of work included 27% in hospital clinics, 29% in primary health care, 6% in occupational health, and 5% in private practice. The remaining 33% had various combinations of these areas of work.

Dependent Variables

Descriptive statistics on the four dependent variables are presented in Table 1. As a check on the reliability of the instrument, Cronbach's alpha reliability coefficients were also calculated and found to be .50 for technique attributions, .75 for client attributions, .65 for interaction attributions, and .57 for holistic attitude. Because each variable is based on only three items, the reliability coefficients are understandably somewhat low. The total instrument, however, had a Cronbach's alpha of .81.[16]

Table 1. Means, Standard Deviations, Ranges and 95% Confidence
Intervals for
the Four Dependent Variables

Dependent Variable         X      SD     Range    95% CI

Technique attributions     9.47   2.19   3-14      9.11-9.83
Client attributions       12.87   2.30   3-15     12.49-13.25
Interaction attributions  12.99   2.14   3-15     12.63-13.35
Holistic attitude         11.67   2.42   3-15     11.27-12.07

Relationships among the dependent variables were explored by correlations (Tab. 2). We found that three of the dependent variables - client attributions, interaction attributions, and holistic attitude - were positively interrelated. The variable technique attributions, however, was not significantly related to the other three dependent variables.

[TABULAR DATA OMITTED]

Relationships Between

Background Variables and

Dependent Variables

To test hypotheses about relationships to background variables, four different stepwise multiple regression analyses were performed with gender, age, years of work experience, further education in physical therapy, and other education as the predictor variables and each of the four dependent variables as the criterion variable. The variables gender, further education in physical therapy (yes/no), and other education (yes/no) were entered as dummy variables. For the dependent variables client attributions and interaction attributions, no predictor variables met the .15 significance level for entry into the regression model. Thus, no predictor variables correlated significantly with these two dependent variables (Tab. 2). The results for the other two dependent variables - technique attributions and holistic attitude - are presented in Table 3.

[TABULAR DATA OMITTED]

As shown in Tables 2 and 3, gender was a significant predictor of holistic attitude. Women had more holistic attitudes (X=11.91, SD=2.25) compared with men (X=10.54, SD=2.92). No other background variables, however, correlated significantly with the dependent variables.

The variable professional work area could not be included in the multiple regression. To determine whether this variable was related to the dependent variables, an attempt was made to categorize the participants on the basis of their answers to questions about work areas and work interests. Most therapists had listed several areas of work and several interests. It was possible, however, to delineate two distinct groups: physical therapists who worked exclusively with patients with orthopedic problems and who indicated this as their area of interest (n=26) and physical therapists who worked exclusively with patients with psychiatric problems and who indicated this as their area of interest (n=17). These two groups were named orthopedic physical therapists and psychiatric physical therapists, respectively, and were compared using t tests for independent groups (Tab. 4).

[TABULAR DATA OMITTED]

Table 4 shows that these two groups differed only in the extent to which they attributed the cause of success to treatment techniques. Physical therapists working in orthopedics were more likely to attribute success to their treatment techniques than were physical therapists working with patients with psychiatric problems. Interestingly, the two groups did not differ in their client attribution or interaction attributions, nor was there any evidence of difference in holistic attitude.

Discussion

This study showed that Swedish physical therapists are more likely to attribute perceived treatment success to the patient-therapist relationship and to the patients themselves, rather than to their treatment techniques. One possible interpretation of these findings is that physical therapists have learned through experience that what they do (ie, which treatment technique they choose) is less important than bow they do it (ie, focusing on the quality of the patient-therapist relationship and the motivation of the patient).

These findings are somewhat surprising because according to attribution theory, one would expect people to attribute success to their own efforts,9 and thus technique attributions would predominate. Because the therapist is obviously involved in the patient-therapist interaction, however, endorsement of these attributions is also an endorsement of the therapist's role in successful treatment.

The findings of a study are only as credible as the methods and instruments used in the data collection. One limitation of this work is the question of validity. Does the instrument actually measure the attitudes and attributions acclaimed? For the purposes of internal validity of the items, further development of the instrument is planned. The somewhat low reliability of the subscales can probably be addressed by including more items in these subscales. We suggest that further instrument development is needed before other researchers use this instrument.

The mean score on the dependent-variable technique attributions indicated a somewhat uncertain endorsement of physical therapists' knowledge and treatment techniques as the determinants of the successful treatment outcome. This result may be interpreted as a lack of faith in or uncertainty about treatment techniques. Many treatment methods have not received support in scientific studies and many have never been the subject of evaluation. Peat[17] discussed both art and science in physical therapy, and perhaps physical therapists feel unsure about the "science" and more at home with the "art." Our interpretation of the physical therapists' reluctance to attribute the cause to treatment techniques is that the treatment technique is probably not perceived as sufficient for a successful outcome. The respondents emphasized the patient-therapist interaction and the patient's own resources and motivation. This finding suggests some important questions: Is it possible to isolate the treatment method (eg, ultrasound, exercise) from the context of the patient-therapist relationship? Is the therapist part of the treatment? Is the patient-therapist relationship more important than the various components of the treatment technique? What is the nature of the "placebo" effect in physical therapy?

As was shown in this study, patient attributions and interaction attributions had fairly strong correlations to holistic attitudes. The group as a whole endorsed to a great extent the items expressing a holistic view of physical therapy. Thus, these data can also be used to support a new physical therapy paradigm,[18,19] which contains competences, ideals, and actions relevant to the practice of physical therapy as a caring profession, as well as attitudes toward health, illness, and disablility.

The medical model of physical therapy does not seem to appeal to this sample of Swedish physical therapists. Although the orthopedic physical therapists were more inclined to make treatment technique attributions than the psychiatric physical therapists, these two "extreme" groups did not differ on the other dependent variables. The degree of homogeneity with respect to the dependent variables in this statistically random and otherwise quite varied sample is noteworthy. We feel confident about this conclusion on the basis of the high return rate (76%).

Conclusion

Our study has shown that a majority of Swedish physical therapists endorse a holistic view of treatment and think that the patient's own resources and the patient-therapist relationship are the most important factors in explaining why physical therapy works.

References

[1] Molander B. Tacit knowledge and silenced knowledge: an atempt at an overview. Nordisk Pedagogik. 1990;10:99-114. [2] Engelsrud G. Kroppen: glemt eller anerkjent? In: Jensen K, ed. Moderne Omsorgsbilder. Oslo, Norway: Gyldendal Norsk Forlag A/S; 1990. [3] Parry A How do you think about physiotherapy? Physiotherapy. 1990;76:197. [4] The Work of WHO 1984-1985 Biennial Report of the Director-General to the World Health Assembly and to the United Nations Geneva, Switzerland: World Health Organization; 1986. [5] Tyni-Lenne R. Fysioterapins Kunskapsomrade. Ur: Veten-skaplig Utveckling av Sjukgymnastik. FOU Rapport no. 1. Goteborg, Sweden: Vardhogskolan i Goteborg; 1987. [6] Westman Kumlin I, Kroksmark T. The first encounter: Physiotherapists' conceptions of establishing therapeutic relationships. Scandinavian Journal of Caring Sciences 1992;6:37-44. [7] Roxendal G. Ett Helhetspektiv: Sjukgymnastik Infor Framtiden. Lund, Sweden: Studentlitteratur; 1987. [8] Paatero H. Om fysioterapiprocessen. Laakin-tavoimistelija. 1980;6:19-22. [9] Eiser JR. Social Psychology: Attitudes, Cognition and Social Behaviour. Cambridge, England: Cambridge University Press; 1986. [10] Heider F. Social perception and phenomenal causality. Psychol Rev. 1944:51;358-374. [11] Landstingsforbundet. Ny Halso-och Sjukvardslag for Utveckling av Halso-och Sjukvarden, Solna, Sweden: Utbildnings-produktion AB; 1982. [12] Hermeren G. Hur paverkar manniskosynen varden? Lakartidningen. 1988;85:3956-3960. [13] Likert R. A technique for the measurement of attitudes. Archives of psychology. 1932;140:44-53. [14] Oppenheim AN. Questionnaire Design and Attitude Measurement London, England: William Heinemann Ltd; 1966. [15] SAS Institute Inc Release 6.03 Edition. Cary, NC: SAS Institute Inc; 1988. [16] Nunnally JC. Introduction to Psychological Measurement. New York, NY: McGraw-Hill Inc; 1970. [17] Peat M. Physiotherapy: art or science? Physiotherapy Canada. 1981;33:170-176. [18] Tyni-Lenne R. To identify the physiotherapy pardigm: a challenge for the future. Physiotherapy Practice. 1989;5:169-170. [19] Tyni-Lenne R. Toward a physical therapy paradigm. In: Proceedings of the 11th International Congress of the World Confederation of Physical Therapy, London, England. 1991:238-240.

Appendix. List of Attitude Statements as They Appeared to the Respondents (American Translation of Swedish)

1. A physical therapist's treatment method is the most decisive factor responsible for the client's recovery. 2. A physical therapist should not become too concerned with the client's personal problems. 3. For physical therapy to succeed, the most important component is that the client is motivated. 4. It is the interaction between client and therapist that is most important in physical therapy. 5. Physical therapy should promote the health of the client and not emphasize the diagnosis. 6. The physical therapist's knowledge and technique are what make physical therapy work. 7. The physical therapist should not treat just part of a person or body part but must be interested in the whole person. 8. Physical therapy should be oriented toward the client's resources, rather than the client's problems. 9. it is the client's own capacity for recovery that makes physical therapy work. 10. Physical therapy is above all an aid to self-help. 11. The client's social problems should be the concern of another allied health professional such as a social worker or counselor. 12. During the first therapy session, the interaction between physical therapist and client starts a process that will make physical therapy work. 13. Physical therapists should work with both the body and the mind of the client. 14. The physical therapist should place less emphasis on the client's diagnosis and more emphasis on enhancing the client's coping skills. 15. The psychological problems of the client should be of concern to the psychologist, not the physical therapist. 16. Physical therapy works through eliciting the client's own ability to change and improve. 17. The client's problem can be cured by physical therapy techniques. 18. The interaction that occurs between client and physical therapist has no bearing upon a successful treatment outcome. 19. The most important factor in physical therapy is the client's own coping abilities. 20. Physical therapy can cure tendinitis. 21. The client's diagnosis should be the central focus of attention in physical therapy. 22. Many clients can be successfully treated without the physical therapist necessarily having a holistic view of the client.