Do physiotherapists effectively deliver psychological interventions?

Many of you will be asking why this topic? I had an accident in 2012 where I was diagnosed with whiplash/fibromyalgia. I tried physiotherapy and conventional medicine, all the while my health deteriorated. After two years, I added meditation to my physical therapy routine, and by 2015, I had fully recovered physically and mentally. This experience inspired me to start a PhD investigating physiotherapy-delivered psychological interventions for pain-related conditions.

While there is evidence that psychological treatments can to assist recovery in a range of conditions, there are often barriers preventing patients from obtaining this type of treatment. These barriers can include perceived social stigma[1-3], financial hardship and the complexity of multiple health providers[4]. Pain clinics are an option for patients who require interdisciplinary management, however, access to these clinics is often difficult with long waiting lists and generally low availability[5]. The idea of a single professional (e.g. physiotherapist) integrating more than one type of treatment within their service provides another possible way forward[4,6-8].

The treatment effects of physiotherapy delivered psychological interventions combined with physiotherapy were compared with physiotherapy alone or usual care using meta-analysis. Subgroup analyses were conducted by testing pooled differences in pain, disability, self-efficacy, fear of movement between low back pain, WAD & neck pain, and osteoarthritis at short and long term follow-up. In summary, the most clinically relevant effects of physiotherapy-delivered psychological interventions were found in measures of depression, while small effects were shown in greater improvements pain, self-efficacy, catastrophizing and fear of movement.

A number of aspects of the review were quite astonishing to us. Firstly, the high number of full texts obtained for detailed evaluation (200) was impressive, and seems to reflect the great interest of physiotherapists in including psychological interventions in their practice. Secondly, the oldest RCT was published in 1998, suggesting that physiotherapists’ consideration of psychosocial factors is far from new – with special mention of the work of Louis Gifford, Gordon Waddell and David Butler. This RCT shows that physiotherapists were trained and prepared to deliver these psychological intervention by themselves for LBP at that time. Thirdly, as our definition of psychological interventions was broad it was useful to further examine studies included in our review that did show clinically important effects. What did they have in common? Although it was not possible to clearly identify the features of effective interventions form our review. It was noted  that studies reporting clinically meaningful effects tended to use individually tailored interventions, shared decision making around goals and treatment plans, and addressed patients’ maladaptive cognitions through the use of various cognitive techniques. They also increased the level of activities using a range of behavioural strategies (e.g., breathing and relaxing techniques, goal setting, and graded activities).

To wrap up: Whilst the effect sizes were small for most outcomes, results universally favoured the physiotherapy that combined physical and psychological strategies. This supports the inclusion of psychological training in physiotherapy courses, and the inclusion of psychological strategies into physiotherapy biopsychosocial practice.

About the Alma Viviana

Alma completed her BPhty Hons at The National University of Colombia in 2000. She worked for over 10 years in clinical practice and research in Colombia, before moving to Australia to continue postgraduate studies in 2010. Currently she is completing her PhD: An Investigation of Physiotherapists Delivered Psychological Interventions for Musculoskeletal Pain Conditions- Reassurance for Neck Pain and WAD conditions at Recover Injury Research Centre and teaching at The University of Queensland. She is part of the executive committee for the Critical Physiotherapy Network (CPN). Volunteering has also been a part of her life. She has offered her time and skills in community programs in Colombia (i.e. Organising holiday trips for children with cerebral palsy that gives a deserved day-off to their careers), USA (Thubten Chondron organisation) and here in Australia (Permablitz).

References

[1] Vogel DL, Wade NG, Haake S. Measuring the self-stigma associated with seeking psychological help. J Couns Psychol. 2006;53(3):325-337.

[2] Corrigan P. How stigma interferes with mental health care. Am Psychol. 2004;59(7):614-625.

[3] Frantsve LE, Kerns RD. Patient–provider interactions in the management of chronic pain: current findings within the context of shared medical decision making. Pain Med. 2007;8(1):25-35.

[4] Nielsen M, Keefe FJ, Bennell K, Jull GA. Physical therapist-delivered cognitive-behavioral therapy: a qualitative study of physical therapists’ perceptions and experiences. Phys Ther. 2014;94(2):197-209.

[5] Hogg MN, Gibson S, Helou A, DeGabriele J, Farrell MJ. Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia. Med J Aust. 2012;196(6):386-390.

[6] Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1-9.

[7] Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909-1914.

[8] Bennell KL, Ahamed Y, Jull G, et al. Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2016;68(5):590-602.