Embedding psychology into physiotherapy for low back pain – why is it so difficult to change our minds?

“The way I look back at physio now, was that it was just the hell I had to go through in order to eventually get to pain services”.

Those were the words a patient with chronic low back pain (LBP) used to describe their experience of musculoskeletal physiotherapy in a patient involvement group I’d been invited to speak at. I was stunned. As a passionate musculoskeletal physiotherapist, clinical academic and psychologically-informed practice enthusiast, it was incredibly saddening to hear that a patient could have such a negative experience of physiotherapy.

Despite the evolving evidence base supporting psychologically informed approaches [3, 5, 6, 7, 9, 11] and their adoption in various clinical guidelines, research suggests that there are still significant challenges to embedding combined psychological and physical programmes into the management of LBP. Difficulties in uptake, delivery and implementation have all been reported within physiotherapy [1, 2, 6, 8, 9, 12].

Hold on, the evidence tells us it adds benefit, physiotherapists know it is important, so why aren’t we all doing it?

First, although physiotherapists delivering psychological interventions isn’t new, much of the current evidence is centred around multidisciplinary Cognitive Behavioural Therapy [3, 5, 6, 7, 8, 10]. There are well-established clinical decision-making tools e.g. STarT back, to identify patients likely to benefit from combined psychological and physical programmes [7,11].  There is emerging evidence considering the use of alternative psychological approaches such as cognitive functional therapy and compassion focused, mindfulness-based therapies [3, 4, 6, 7, 11]  The overlap between more complex interventions and lack of a uniform definition, leave psychologically informed physiotherapy open to personal interpretation by individual physiotherapists [12]. Whilst attempts have been made to classify and refine this, there is still a lack of clarity and specific implementation guidance [3, 6, 7, 11,12].  Exactly which psychological techniques, or combinations are most effective in each clinical setting and population is still under debate. [3, 6, 7, 11, 12].

Secondly, the face of musculoskeletal physiotherapy is evolving. The development of advanced practice roles, first contact practitioners and an increased presence in emergency settings, means LBP may be managed by musculoskeletal physiotherapists at many points of care [3]. Although some of these clinical environments might not be ‘ideal’ to deliver a psychological intervention, patients may still choose local, accessible services in their community. An established combined psychological and physical model proven to be effective in one setting or population, may simply not be feasible or successful in another.

The context of environment is not just restricted to the physiotherapy setting itself. Challenges may arise from an organisational perspective, as priorities are often target and time driven, with strict financial performance indicators.  Limited time, resources and a high-pressure, busy environment, can be a source of stress for physiotherapists. Subsequently, this may act as a barrier to both service and personal development [1, 2, 3, 4, 8, 12].

Thirdly, it could be debated that there is now an expectation for physiotherapists to have the necessary knowledge and skills to use psychological approaches, whilst remaining within their scope of practice. It has been highlighted that physiotherapists may overestimate their perceived competence and understanding [2,12]. Therefore, specific competencies and communication skills are key for the patient-physiotherapist therapeutic alliance and effective delivery [ 6, 8, 9, 10]. Physiotherapists may not have been taught these at undergraduate level, with limited post graduate options being raised as an obstacle [2, 6, 12 ]. Studies report that whilst physiotherapists may have a biopsychosocial treatment bias and recognise the importance of these skills, it is a lack of confidence which acts as a barrier to their use [2, 3, 8, 9, 12].

Patient-centred care, we’ve got this! What about physiotherapist-centred training?

With so many factors to consider, it’s hardly surprising that embedding psychologically informed approaches is still a challenge. It seems unlikely that a one size fits all approach to training will be ‘ideal’ in developing the necessary competence and confidence [12]. Physiotherapists themselves are individuals with different professional and personal attitudes, beliefs and perceptions [1, 2, 6, 8, 9, 12]. Factors such as self-awareness, a biomedical orientation, social influences and learning style, may all influence a physiotherapists’ individual needs and optimal learning experience [1, 2, 8, 12]. In addition to the learning needs of each physiotherapist, considering their clinical setting and demographic may be beneficial in shaping effective psychologically informed practice training.

If our aim is to bridge the evidence to practice gap; recognising that optimising the clinical environment, alongside a shift in workplace culture to promote acceptability is vital.  Mutually reinforcing personal, professional and organisational dynamics which support the delivery of a biopsychosocial model of care is paramount. Tailoring individualised and contextual psychologically informed training may be the key to nurturing compassionate, competent and confident physiotherapists.

About Doré Young

Doré is as a highly specialised musculoskeletal (MSK) physiotherapist working for Manchester Local Health Organisation. She is the clinical lead for the adult community services back pain team and has a special interest in the use of psychologically informed approaches in the management of chronic low back pain. Her current academic role is a Manchester University NHS Foundation Trust doctoral clinical academic bridging fellow.

Email: dore.young@mft.nhs.uk | Twitter @reallyDeeDee

References

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[3] Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018 Mar 21.

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[5] Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J. E. M., Ostelo, R. W. J. G., Guzman, J., & Van Tulder, M. W. . Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta‐analysis. BMJ. 2015

[6] Keefe FJ, Main CJ, George SZ. Advancing psychologically informed practice for patients with persistent musculoskeletal pain: promise, pitfalls, and solutions. Physical therapy. 2018 Apr 16;98(5):398-407.

[7] National Institute for Health and Clinical Excellence. Low back pain and sciatica in over 16s: Assessment and management. NICE guideline [NG59]. 2016 Retrieved from: https://www.nice.org.uk/guidance/ng59

[8] Richmond H, Hall AM, Hansen Z, Williamson E, Davies D, Lamb SE. Exploring physiotherapists’ experiences of implementing a cognitive behavioural approach for managing low back pain and identifying barriers to long-term implementation. Physiotherapy. 2018 Mar 1;104(1):107-15.

[9] 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 Apr 1;61(2):68-76.

[10] Wilson S, Chaloner N, Osborn M, Gauntlett-Gilbert J. Psychologically informed physiotherapy for chronic pain: patient experiences of treatment and therapeutic process. Physiotherapy. 2017 Mar 1;103(1):98-105.

[11] Whitehurst DG, Bryan S, Lewis M, Hay EM, Mullis R, Foster NE. Implementing stratified primary care management for low back pain: cost-utility analysis alongside a prospective, population-based, sequential comparison study. Spine. 2015 Mar 15;40(6):405-14.

[12] Young D, Callaghan M, Hunt C,. Briggs M, Griffiths J. Psychologically informed approaches to chronic low back pain: Exploring musculoskeletal physiotherapists’ attitudes and beliefs. Musculoskeletal Care. 2019;1–5. https://doi.org/10.1002/msc.1384