Eleven respondents, characterised in Table 3, completed the survey with one question missing a response. All participants were female and clinical experience ranged between 1 and 38 years. Of the respondents, n = 9 (82%) worked in community, outpatient, or private practice neurology settings and n = 2 (18%) worked in other areas but had experience in neurology. Five respondents (45%) had postgraduate training in psychological interventions. Of those, n = 3 (60%) had training in motivational interviewing (MI), n = 1 (20%) in cognitive behavioural therapy (CBT), and n = 1 (20%) had informal training.
How people with RRMS present
Respondents reported that stress (63%), depression (59%) and sadness (57%) were most frequently encountered in PwMS however, anxiety and depression were prioritised as most important to manage during physiotherapy interventions (Fig. 1). Trouble concentrating (56%) and worry (53%) were common emotional symptoms observed, followed by avoidance (41%). To understand the impact of anxiety in relation to rehabilitation, physiotherapists were asked to consider negative patterns associated with anxiety and the extent to which they arose in PwMS clinically. High expectations of others (80%), dwelling on the past (70%), over generalising (70%) and labelling (70%) were most frequently observed.
Managing anxiety in clinical practice
Respondents identified anxiety in PwMS through informal conversations with other members of the team (91%), however Multidisciplinary Team meetings were not selected by any participants. Self-reporting from patients constituted 91% of the responses and most participants (82%) felt clinical experience was a significant factor for identifying anxiety. All participants felt confident asking about mental health problems, however responses were widely spread in relation to acting on, or dealing with a disclosure (Fig. 2). Table 4 details treatment approaches for anxiety used by the respondents. Goal setting (91%) was most common, followed by relaxation (82%) and reflective listening (73%). Despite only 3 participants receiving training in motivational interviewing, it was a treatment approach selected by 7 participants (64%).
Skills and training required to manage anxiety in patients
Effective communication (89%) and listening skills (88%) were deemed most important to managing anxiety. However clinical experience (61%) and working towards goals (59%) were less important, despite goal setting being the most frequently used treatment technique for anxiety. Involving the Multidisciplinary Team (55%) and offering advice (39%) was least important. Figure 3 details participants responses to identifying interventions useful for managing anxiety and indicating those where additional training would be useful. Interestingly, motivational interviewing scored similarly in its value as an intervention in clinical practice (57%) and additional training (58%). Similar incidence was found for mindfulness, scoring 53 and 57% respectively. Most participants (82%) agreed psychology was an important part of physiotherapy training. However, responses were skewed regarding effectiveness of undergraduate training in providing skills to successfully navigate patient psychological wellbeing.
Five physiotherapists, characterised in Table 5, participated in semi-structured interviews. All participants worked in neurology with a greater proportion having experience in MS therapy centres (n = 3). Three participants worked in community and outpatient settings whilst two worked in clinic settings. Three participants received informal psychological training. Figure 4 displays a visual representation of the overarching themes, themes and subthemes. A single direction arrow establishes hierarchical relationships; bi-directional arrows indicate close lateral relationships; a dashed line signals a tentative relationship.
Theme1: understanding the MS journey
A common idea was understanding the MS journey significantly differs to other neurological conditions. Within this theme participants discussed their role when treating PwMS, patient expectations and the challenges they face.
Subtheme: physiotherapist role
In addition to facilitating movement and function, physiotherapists are required to support acceptance and adjustment following a life-altering health event or diagnosis. This requires understanding the MS illness experience, the impact on social, family and life roles and manage anxieties related to these factors. Despite being well placed to take an active role in managing anxiety in clinical interactions, they recognised the importance of working within their scope of practice and seeking support elsewhere in more challenging situations.
Subtheme: Patient’s expectations
A significant challenge was the importance placed on physiotherapy, from patients and other professionals, to manage symptoms in the absence of any curative treatment. Misconceptions around physiotherapy necessitating hands-on treatment challenged productive self-management discussions. As the measure of success is inherently different in progressive neurological conditions, physiotherapists often felt like they were not helping their patients therefore not meeting patient expectations.
Theme 2: modifying assessment and treatment
Participants acknowledged the many layers of anxiety that PwMS can face and recognised it exists within physiotherapy treatment sessions. In identifying the impact of these anxieties, participants reflected on how they manage it as it presents, reflected in the following subthemes.
Subtheme: impact of anxiety
All participants reflected anxiety blocked treatment progression, particularly through greater time discussing anxiety related issues and the implications of this on physical progression. Participants felt physiotherapy itself contributed towards anxiety, referencing challenges to physical ability, indicating the importance of exploring the source and reflexively modifying treatment. Anxiety was detrimental to self-efficacy, affecting concentration and retention of information, therefore impeding self-management. An interesting insight was the impact of anxiety on physiotherapists, with clinicians feeling less competent in their clinical skills and noting feelings of inefficacy.
Subtheme: management strategies
All participants used treatment planning as an anxiety management strategy, ranging from task specific training and goal setting, to changing the layout of the room. Education strategies varied between education relating to the physiotherapy process and psychoeducation to normalise anxiety symptoms. There were mixed views around using psychological interventions as part of physiotherapy treatment. Signposting and onward referrals were emphasised, with MS nurses being a more valuable resource than General Practitioner’s. All participants adopted anxiety management strategies within their clinical practice, however expressed difficulty meeting the psychological needs of their patients.
Theme 3: anxiety management toolbox
Themes two and three are closely related as the process of managing anxiety does not solely rely on interventions and clinical approaches, but the skills required to employ them. The subthemes ‘Skills and attributes’ and ‘barriers and facilitators’ build upon what is required for physiotherapists to create an anxiety management toolbox.
Subtheme: skills and attributes
Interpersonal skills such as communication skills, active listening, and empathy to form stronger therapeutic relationships, underpinned the anxiety management toolbox. Strong therapeutic relationships allow patients to open up about their worries allowing physiotherapists to alleviate concern, signpost accordingly and set specific rehabilitation goals. Clinical reasoning was important to evaluate the success of interventions, providing opportunity to question why progress may not as expected and address underlying issues, such as anxiety, posing as barriers.
Subtheme: barriers and facilitators
All participants felt strongly that undergraduate training did little to prepare new graduates for the challenges they are likely to face managing psychological wellbeing. Barriers included a lack of confidence and skills, inadequate undergraduate and postgraduate training opportunities, and clinical supervision. Facilitators included clinical setting and team support, having access to psychology input, and opportunity to build a therapeutic relationship.
Theme 4: lagging behind MSK
Participants felt neurological physiotherapy may be behind, in both research and practice, when looking at the link between physical and mental health. Reference was made to evidence supporting the psychosocial management of chronic pain within physiotherapy and how these principles could be applied to the neuro setting. Using patient narrative over gold standard research methods to understand the patient story was also deemed important in the context of neuro-research.
Theme 5: gaining knowledge and skills
Suggestions to gain knowledge and skills to effectively manage anxiety in PwMS were detailed in the following subthemes.
Subtheme: Interprofessional working
Interprofessional working was strongly woven through all of the interviews. This included working with psychology, MS nurses and occupational therapists, and the recommendation of a network for therapists interested in MS. Despite recognising that interprofessional working was important, it was noted that this opportunity may not be available to all therapists.
Subtheme: physiotherapy training
Several suggestions to support physiotherapy training at undergraduate and postgraduate level were made. These included training in the use of psychologically informed physiotherapy and opportunities to enhance communication and listening, joint training with psychology and MS nurses, and utilising interactive, online training platforms through the Chartered Society of Physiotherapy.