Physiotherapists struggle to identify and deal with psychological factors in chronic low back pain

Psychological factors including catastrophizing, fear of movement and psychological distress are predictors of negative outcomes in patients with chronic low back pain (CLBP).[1] Furthermore, patients with CLBP often have comorbid depressive and anxiety disorders.[2] Healthcare professionals involved in managing CLBP are therefore challenged to identify and address such psychological factors.

Qualitative research has shown that musculoskeletal physiotherapists often feel unprepared to integrate treatment for comorbid dominant psychological factors into management of patients with CLBP.[3] Additionally, physiotherapists report uncertainty about the psychosocial assessment in CLBP.[4] It is likely that difficulties in dealing with patients’ negative emotions or thoughts may hinder physiotherapists’ ability to effectively manage patients with CLBP.

In our study,[5] published in Physical Therapy, we investigated how physiotherapists allocate patients, without using patient questionnaires, into risk stratification groups according to the STarT Back Tool, and tested correlations between therapists’ intuitive psychological assessment and patients’ self-reported psychological factors using patient questionnaires for psychological distress, depression, anxiety and fear of movement. The STarT Back Tool is a self-reported questionnaire that allocates patients into low, medium, and high risk of poor outcome according to their psychosocial profile.[6] Furthermore, we explored the influence of patient’s psychological factors on physiotherapist’s self-reported competence to manage each patient with CLBP.

Our findings revealed that physiotherapists were not very accurate at allocating patients into risk stratification groups and further they were poor at assessing psychological factors. Physiotherapists accurately estimated SBT risk allocation in only 41% of patients. Intriguingly, more than half of patients allocated to the low risk by the STarT Back Tool were stratified by the physiotherapist into higher risk groups (medium or high). Correlations between therapists’ perceptions and patient questionnaires were moderate for distress (r = 0.60), but only fair for depression (r = 0.30) and anxiety (r = 0.33). No correlation (r = 0.01) was found between therapists’ perceptions and patient questionnaires for fear of movement. These findings suggest that physiotherapists might be more pessimistic regarding patients’ prognostic risk than screening instruments indicate, and that therapists have difficulties assessing symptoms of depression, anxiety and fear of movement without screening questionnaires.

Interestingly, patient distress measured at treatment baseline was identified as a negative predictor of physiotherapists’ self-reported competence in managing the patient with CLBP. In other words, therapists’ self-reported competence to manage patients was lowest in patients with high levels of psychological distress.

There were some limitations in our study. Most importantly, the study was conducted at only one specific setting, a public hospital in Switzerland, which limits the generalizability of our results. Furthermore, we used the STarT Back Tool to test the accuracy of physiotherapists’ risk stratification, but the predictive validity of the STarT Back Tool is limited.[7] In addition, physiotherapists’ self-reported competence to manage the patient was only measured after the intake session. The study could not evaluate how their perception evolved later in therapy. Notwithstanding these limitations, it was the first study providing evidence for negative relationships between patient-reported distress and physiotherapists’ self-reported competence in CLBP practice.

Our findings support the claim that physiotherapists should receive sufficient psychological training to embed psychological perspectives in their clinical practice.[4,8] It has been widely acknowledged that patients with CLBP and dominant psychological risk factors may benefit from psychology-informed treatments such as cognitive-behavioural strategies. Knowledge about the efficacy of these treatments might be important, but not sufficient for healthcare professionals to effectively treat these patients. It is not only important that physiotherapists know «what» they should do, but rather that they know «how» they should do it. Making physiotherapists ready for managing patients with dominant psychological factors might be one of the main challenges for future musculoskeletal research, education and practice. These patients are not likely to disappear any time soon – so are we going to step up to the challenge?

About the authors

Emanuel Brunner is a physiotherapist who is working at the Kantonsspital Winterthur, in Switzerland, where he consults patients with complex pain problems. Additionally, he is member of the research group Adapted Physical Activity and Psychomotor Rehabilitation at the University of Leuven (Belgium). His research interest is the integration of psychological and psychotherapeutic concepts into physiotherapy for patients with chronic musculoskeletal pain.

Wim Dankaerts is professor in musculoskeletal rehabilitation and member of the Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven (Belgium) where he teaches undergraduate and post graduate musculoskeletal physiotherapy, supervises higher degree research and conducts research in musculoskeletal pain disorders. Wim is a specialist in musculoskeletal physiotherapy, and is both a clinician and a researcher. His extensive clinical experience over a period of more than 25 years generated a major research interest in chronic low back pain. He has published a total of 55 peer-reviewed articles and been a key/invited speaker at more than 30 conferences.

Kieran O’Sullivan is an Irish Specialist Musculoskeletal Physiotherapist. In 2016, he took up a position as Lead Physiotherapist at the new Sports Spine Centre at Aspetar, Qatar, where he remains on a career break from his position at the University of Limerick. His research interest is musculoskeletal pain and injury, particularly persistent spinal pain. He has published one book, six book chapters and over 130 journal articles.

André Meichtry is a physiotherapist and statistician. He works as a lecturer and statistical consultant at the School of Health Professions at the Zurich University of Applied Sciences in Winterthur, Switzerland.

Michel Probst is part-time professor for physiotherapy in mental health and head of the research group Adapted Physical Activity and Psychomotor Rehabilitation at the University of Leuven, in Belgium. Since 1979, he is working with different mental health disorders at the University Psychiatric Centre KU Leuven. Michel has published more than 225 articles on physiotherapy in mental health, psychomotor therapy and eating disorders. Furthermore, he is founder and president of the International Organisation for Physiotherapy in Mental Health (IOPTMH), a recognized subgroup of the World Confederation of Physical Therapy (WCPT).


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[3] Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O’Sullivan P, O’Sullivan K. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of physiotherapy. 2015;61(2):68-76.

[4] Zangoni G, Thomson OP. ‘I need to do another course’ – Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain. Musculoskeletal science & practice. 2017;27:71-77.

[5] Brunner E, Dankaerts W, Meichtry A, O’Sullivan K, Probst M. Physical Therapists’ Ability to Identify Psychological Factors and Their Self-Reported Competence to Manage Chronic Low Back Pain. Physical therapy. 2018;98(6):471-479.

[6] Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis and rheumatism. 2008;59(5):632-641.

[7] Karran EL, McAuley JH, Traeger AC, et al. Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis. BMC medicine. 2017;15(1):13.

[8] Foster NE, Delitto A. Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice–challenges and opportunities. Physical therapy. 2011;91(5):790-803.