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Psychologically Informed Practice

Embedding Psychosocial Perspectives


Within Clinical Management of
Low Back Pain: Integration of
Psychosocially Informed Management
Principles Into Physical Therapist
PracticeChallenges and Opportunities
Nadine E. Foster, Anthony Delitto
N.E. Foster, DPhil, BSc(Hons),
MCSP, PGCE, is Professor of Musculoskeletal Health in Primary
Care, Arthritis Research UK Primary Care Centre, Primary Care
Sciences, Keele University, Keele
ST5 5BG, United Kingdom.
Address all correspondence to
Professor Foster at: n.foster@
keele.ac.uk.
A. Delitto, PT, PhD, FAPTA, is Professor and Chair, Department of
Physical Therapy, School of Health
and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh,
Pennsylvania.
[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.
Phys Ther. 2011;91:790 803.]

As the biopsychosocial model of health has become increasingly understood, it has


become clear that there are complex, interdependent relationships between the
physical and biomedical features of low back pain and the psychological and social
factors that present concomitantly. Epidemiological studies have not only highlighted
that psychological and social factors are associated with back pain and disability but
also have shed light on the way in which these factors serve as prognostic indicators,
or obstacles to recovery, predicting which patients will have a poor prognosis.
Integrating the assessment of these obstacles to recovery into physical therapist
practice and using this information to guide clinical decision making have the
potential to improve the quality of care offered by physical therapists by improving
the targeting of treatments to individuals and enhancing the therapist-patient relationship and adherence to management advice and treatment programs. In turn, such
approaches may improve both patients clinical outcomes and the efficiency and
effectiveness of service provision, helping direct interventions to those who need
them. This article summarizes the key challenges to embedding psychosocial perspectives within physical therapist practice for patients with low back pain and the
opportunities that could be realized by doing so, and it highlights new developments
in research, clinical practice, and education that are shaping future directions in this
field.

2011 American Physical Therapy


Association

Post a Rapid Response to


this article at:
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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain

iven that there is some evidence of benefit for interventions that physical therapists
traditionally provide for patients
with low back pain, one may question the added benefit of incorporating psychosocial interventions into
the range of therapeutic options of
this professional group. For example, exercise is one of the key interventions within the scope of physical therapist practice that has been
shown to be effective in the secondary prevention of low back pain and
in the management of chronic low
back pain.1,2 Benefits also have been
shown, for example, using directional preference approaches,3 manual therapy,4 and acupuncture.57
In addition, the interventions that
physical therapists offer have been
shown to be cost-effective at current
levels of willingness to pay.8,9
However, as the biopsychosocial
model of health has become increasingly understood,10 it has become
clear that there are complex, interdependent relationships between
the physical and biomedical features of low back pain and the psychological and social factors that
present concomitantly. Epidemiological studies have not only highlighted that psychological and social
factors are associated with back pain
and disability but also have shed light
on the way in which these factors
serve as prognostic indicators, or
obstacles to recovery, predicting
which patients will have a poor
prognosis.1113 It has been argued
that the transition from recent-onset
pain to chronic pain might be more
strongly associated with psychosocial factors than with physical
factors.10,14
Integrating the assessment of these
obstacles to recovery into physical
therapist practice and using this
information to guide clinical decision making have the potential to
improve the quality of care offered
by physical therapists by improving
May 2011

the targeting of treatments to individuals and enhancing the therapistpatient relationship and adherence
to management advice and treatment
programs. In turn, such approaches
may improve both patients clinical outcomes and the efficiency
and effectiveness of service provision, helping direct more-intensive
interventions to those who need
them. However, there is uncertainty
about how best to integrate psychosocial factors in order to improve
patients outcomes. This article
summarizes the key challenges to
embedding psychosocial perspectives within physical therapist practice for patients with low back pain
and the opportunities that could be
realized by doing so and highlights
new developments in research, clinical practice, and education that are
shaping future directions in this
field.

Challenges
There are many and varied challenges to embedding psychosocial
perspectives within physical therapist clinical practice. Here, we shed
light on select key challenges for
entry-level (professional) physical
therapy training and current physical
therapist practice, which are summarized in Figure 1.
Entry-Level Physical
Therapy Training
The focus and priorities of entrylevel training. Physical therapist
students choose their career based
on their own perception of physical therapy, often informed by
work experience or placements
within sports settings or through
their own experience of physical
therapy from personal injuries. The
initial focus of entry-level training
tends to firmly consolidate biomedical models of health and illness
and, thus, a fledgling professional
culture starts to develop, to be further influenced by the opinions of
respected teachers and clinicians.

Early learning often focuses on musculoskeletal problems that student


and junior physical therapists will
assess and treat, reinforcing notions
of clear anatomical and pathological links with pain and disability.
The physical assessment and treatment emphasis within early training
starts physical therapists off on a
biomedical perspective of musculoskeletal pain, which then is difficult to challenge as learning and
experience progresses. Definitions
of physical therapy rely heavily on
disease and injury models of pain,
body structure, the application of
physical agents and modalities, and
the focus on strength (forcegenerating capacity), movement,
balance, and functional abilities.
Even at training institutions that
introduce a biopsychosocial model
of health to students and follow
national and international guidance
on rheumatology and pain curricula,15,16 the majority of time and
attention often is spent on the biomedical assessment and treatment of
musculoskeletal problems.
There is much competition for space
within entry-level training programs,
and priorities are influenced by vari-

Available With
This Article at
ptjournal.apta.org
Symposium Podcast: Download
an audio or video podcast of the
Enhancing Clinical Practice
Through Psychosocial Perspectives
in the Management of Low Back
Pain symposium at CSM 2011
with speakers Julie Fritz, Steven Z.
George, Chris J. Main, and
William Shaw. The symposium
was sponsored by APTAs
Orthopaedic Section.
Audio Abstracts Podcast
This article was published ahead of
print on March 30, 2011, at
ptjournal.apta.org.

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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


Entry-Level Physical Therapy Training

Current Physical Therapist Practice

The focus and priorities of entry-level training


emphasize anatomical, biomechanical, and
biomedical models.

Physical therapy culture and current physical


therapist practice propagate anatomical,
biomechanical, and biomedical models.

The lack of cohesion across entry-level clinical


education environments means that
opportunities to reinforce application of key
psychological informed management
principles are lost.

The focus of continuing education for physical


therapists reinforces the biomedical emphasis
from entry-level training.

Patients expectations of low back pain and


physical therapy can raise challenges, such as
their expectations about diagnostic certainty
and hands-on treatment approaches.
There is uncertainty about the key psychosocial
factors and how to assess and manage them in
ways that fit into busy clinical practice.
Reimbursement systems and service priorities do
not value management of psychosocial factors.

Figure 1.
Key challenges to integrating psychosocial perspectives in clinical practice.

ous professional organizations and


regulatory bodies. A recent survey of
Canadian universities17 showed that
undergraduate pain education was
generally inadequate and that veterinary scientists received more pain
education than health care professionals. A comprehensive survey of
the curricula of 8 health care professions across the United Kingdom
highlighted that current pain education is inadequate preparation
for professional practice.16 Teaching on pain was often found to be
delivered piecemeal as part of other
topics, and despite the management of pain often requiring multidisciplinary approaches, students
tend to learn about pain management in narrow professional groups.
Physical therapist students received
the highest input, with an average of
37 contact hours dedicated to pain,
but there was a bewildering variation (ranging from 5 to 158 hours),
and in only one physical therapy
training institution was the International Association for the Study of
Pain curriculum fully implemented.
The amount of time devoted to specific topic areas within programs varied widely, and instruction was most
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frequently delivered through lectures and written patient case examples, with little attention to development of skills or the learning
techniques that might best support
such skill development.16
The American Physical Therapy
Associations (APTAs) Normative
Model of Physical Therapist Professional Education18 provides a
consensus-based vision for professional education in the United States
and serves as the primary resource
for the Commission on Accreditation
in Physical Therapy Education when
individual programs are reviewed. A
review of this document for curricular content in the foundation and
clinical science sections reveals little, if any, emphasis on pain education. In foundational sciences, pain
is mentioned only as primary content when considering physiologic
responses to physical agents. There
is no mention of pain in other relevant primary content areas, including neurophysiology, plasticity, neurological function, and psychology.
Areas where psychology is considered as primary content in the normative model include emotional

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responses to exercise, sport, illness,


and disability, but not pain. In clinical sciences, pain is not explicitly
addressed; instead, it is inferred
from diseases, injuries, or conditions that require physical therapy
intervention.
The lack of cohesion across entrylevel clinical education. In parallel, when entry-level students spend
time in clinical placements or practice environments, as they must do
to consolidate their learning and
develop their skills, a cohesive
approach that spans the training
institutions and associated clinical
placements is largely missing. The
knowledge and skills that are being
developed within entry-level training
institutions on integration of psychosocial perspectives may well fail to
be consolidated by their clinical educators, many of whom continue to
operate in the biomedical model, losing the opportunity for powerful and
deeper learning on this topic. These
often highly respected clinical role
models may heavily influence students perceptions of the relative
importance of biomedical versus
psychosocial factors within patient
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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


assessment and management. Thus,
even when students develop knowledge and competencies in the assessment and management of psychosocial obstacles to recovery from their
training institutions, failure to consolidate this knowledge and these
competencies within clinical environments essentially halts their
development.
Most clinical education is carried
out in clinical environments where
adherence to evidence-based standards, in many cases, is less than
optimal. The students then are
exposed, sooner or later, to situations where they are being asked
or expected to practice in ways
that are incongruent with the ways
in which they were taught. This is
perhaps the major entry-level challenge to embedding psychosocial
perspectives into physical therapy,
that of integration into everyday clinical practice.
Current Physical Therapist
Practice
Physical therapy culture and
current
practice. Traditionally
there has been inadequate attention
to psychosocial factors in the physical therapy literature. For example,
the most recent online edition of the
widely regarded Guide to Physical
Therapist Practice19 only superficially includes psychosocial factors,
stating that they may have an influence on the complexity of the case,
number of visits, and the decisionmaking process in choosing interventions. Specific to the purposes of
this perspective, the Guide to Physical Therapist Practice makes no
recommendation on which specific
psychosocial factors to measure for
patients with low back pain, despite
consistent
evidence
indicating
which candidate psychosocial factors might be most appropriate for
routine assessment for that particular practice pattern. Other factors
influencing decision making include
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the clinicians own beliefs about the


effectiveness of treatments, his or
her prior clinical experience, and
the pre-eminence of his or her relationship with the patient.20,21
Physical therapy culture and current
physical therapist practice for low
back pain have been explored in
research studies using qualitative
interviews20,22 and survey questionnaires.2328 These studies have highlighted wide practice variation, an
emphasis on the assessment of physical impairments and pain, a lack of
knowledge about the content of clinical guidelines and the way in which
physical therapists pain beliefs influence their behavior within therapeutic encounters with patients. Interviews and observations22 highlight
therapists beliefs regarding the
development of craft knowledge
needed to manage low back pain and
their beliefs regarding the clinical
characteristics of patients they consider as good to treat and the challenge of patients who are seen as
difficult to treat. Daykin and Richardson22 proposed that the physical
therapists biomedically oriented
pain beliefs influenced their clinical
reasoning processes, including the
explanations given to patients. Smart
and Doodys29 interviews with experienced physical therapists showed
their clinical reasoning to reflect an
integration of diverse models and
theories of pain, which the authors
termed mechanisms-based reasoning of pain.
Survey research has shown that a
substantial proportion of physical
therapists are unfamiliar with the
content of clinical guidelines for low
back pain.23 In a large UK survey
using patient vignettes, Bishop and
Foster26 found that although most
physical therapists recognized when
patients with low back pain are at
high risk of developing chronicity,
many paradoxically recommended
limitations in patients activity levels

and advised them not to work.


Advice to not work was associated
with more-severe perceived spinal
pathology, again suggesting persistence of the biomedical model for
low back pain within the culture of
physical therapy. A survey 3 years
later of both UK family physicians
(general practitioners) and physical
therapists showed that advice about
work was significantly related to the
clinicians treatment orientations, as
measured using the Pain Attitudes
and Beliefs Scale (PABS).27 Physicians and physical therapists with
high biomedical and low behavioral
orientations were much more likely
to advise continued work absence
(44.9%) than those with high behavioral scores and low biomedical
scores (11.9%). Several studies have
shown that the attitudes, beliefs, and
treatment orientations of health care
professionals are associated with the
advice they give to patients as well as
the choice of interventions,30 34 begging the question of whether, and to
what extent, these attitudes, beliefs,
and behaviors of professionalsin
this case, physical therapistsare
modifiable.
The focus of continuing education for physical therapists. Following graduation, physical therapists pursue continuing education
in order to maintain competency,
raise awareness of new developments, and meet the requirements of
national or state relicensure. Perusal
of available post-qualifying education for physical therapists highlights a plethora of mostly didactic
continuing education opportunities
such as conferences, short courses,
and workshops that reinforce the
biomedical emphasis from entrylevel training. In the United Kingdom,
for example, courses on specific
physical assessment and treatment
approaches for low back pain are
commonly advertised and attended,
yet a physical therapist wanting to
develop confidence and skills in the

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psychosocial assessment and management of patients with musculoskeletal problems will struggle to
find such educational opportunities.
In the United Kingdom, there are
very few interactive educational
opportunities that focus on supporting changes in practice toward biopsychosocial models. In the United
States, different states have different
continuing education requirements,
but based on our anecdotal experiences, few of these offerings are
related to psychosocial models and
how to integrate psychosocial principles into routine management of
patients with low back pain.
Patients expectations of low
back pain and physical therapy.
Other potential challenges to embedding psychosocial perspectives within
physical therapist practice include
patients preferences and expectations. Patients and, indeed, the general population have specific beliefs
and expectations about low back
pain and physical therapy treatments.35 The public expects health
care professionals to be able to tell
them exactly what is wrong with
their back, and 10 years ago most
expected to have a radiograph.36
More recent data show that patients
expect a physical examination and
the right diagnosis.37 Patients with
chronic low back pain continue to
expect symptomatic improvements
and can have very clear ideas of
what treatment will entail.35 Some
of these patients may be seen as
difficult or problem patients by
physical therapists, given their more
complex health care needs and
perceived resistance to self-care
approaches.35 Anecdotally, physical
therapists want to deliver credible
treatments to their patients; thus,
meeting patients expectations may
be a key driver in the selection of
both assessment and management
approaches. For example, if a new
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cessful intervention, a physical therapist may decide to offer similar


treatment for this back pain episode,
irrespective of best practice recommendations, in order to try to meet
the patients treatment expectations. Several studies have reported
higher patient satisfaction with handson treatment approaches,38 40 and
this finding may influence physical
therapists decision making about
treatments.
Uncertainty about the key psychosocial factors and how to
assess or manage them. There
has been much uncertainty by physical therapists about which psychosocial obstacles to recovery in
patients with low back pain are the
most important to identify, assess,
or focus on within clinical management. Even physical therapists who
have been eager to integrate psychosocial perspectives into practice
for some time have been somewhat
undermined by the ambiguity surrounding how best to do this in
ways that can be easily embedded
in routine practice. Many psychosocial factors are reported to be
important obstacles to recovery, such
as patients fear avoidance,41 44 catastrophizing,45 47 perceptions about
risk of persistence,48 depression,45,48
self-efficacy,49 expectations,10,44,49,50
beliefs about the future,51 and illness
perceptions regarding their back
problem.52 Clearly, the assessment
and management of all of these factors cannot be integrated into everyday practice.
Even for those factors that appear to
have a relatively consistent evidence
base, there is only limited evidence
about specific measurement properties. For example, the diagnostic
accuracy of brief screening questions has only been established for a
few factors.53 Rather, the screening
tools that have been available are
lengthy and not suited for routine
use in busy clinical practice, and

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some have complicated scoring systems.53 The current variation in practice in the psychosocial factors that
are assessed or addressed28 could be
largely a consequence of this dearth
of easy-to-use assessment and screening tools. Long54 has already identified that practice style differences
flourish in environments of professional uncertainty.
A further challenge is the dearth of
knowledge and confidence about
what to do with patients for whom
key psychosocial obstacles to recovery are identified. Kent and colleagues28 pointed out that the uncertainty about effective interventions
for patients who have psychosocial
obstacles to recovery may well mean
that clinicians do not see the value in
routine assessment of these factors.
Some of these psychosocial obstacles to recovery (eg, pain-related
distress, perceptions of poor personal control, catastrophizing, fear
of movement) are likely to be modifiable using physical therapy treatment approaches. Other factors,
such as unemployment, low levels
of perceived job control, and social
isolation, may be much more challenging to address within the context of physical therapy services
alone. Many physical therapists work
in settings where there are no, or
limited, patient pathways to, for
example, mental health specialists.
This situation may serve to further
inhibit physical therapists from
opening the black box of patients
cognitive appraisals and emotional
consequences of their pain. They
fear they are ill-equipped to manage
these problems and may well have
little or no support from other specialists in pain management teams.55
There are many pain management
courses of varying quality and specific relevance to low back pain
available; thus, the current picture in
physical therapy is one of highly variable levels of competence and confidence in the assessment and manMay 2011

Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


Entry-Level Physical Therapy Training

Current Physical Therapist Practice

Change the focus and priorities of entry-level training to


emphasize integrated biopsychosocial models and
consider the value of benchmarking standards in pain
education and interprofessional education.

Gather more evidence from clinical trials about the


outcomes of patients managed through biopsychosocial
management approaches and from implementation
studies about how to facilitate tangible shifts in physical
therapist practice.

Facilitate cohesion across entry-level clinical education


using, for example, interprofessional clinical education,
different educational methods, and innovative academic
and clinical partnerships.

Enhance the role of physical therapists in educating


patients and the public, using all available media.

Identify and target key psychosocial factors more


systematically and use them in decision making about
treatment and advice about work.
Change the reimbursement system and service priorities
to include patient-reported outcome measures and
optimal standards of care to positively influence
improvements in practice.

Figure 2.
Key opportunities to integrating psychosocial perspectives in clinical practice.

agement of patients with low back


pain in whom key psychosocial
obstacles to recovery are important.
Reimbursement systems and service priorities. In some health
care systems, physical therapist practice is heavily influenced by the reimbursement systems in place. This situation is problematic given that
these reimbursement systems look
to standards of practice rather than
best or optimal practice. For example, a study of practice in the Netherlands showed that the mean number of treatment sessions (X10)
was similar to the number eligible
for reimbursement by their public
health insurance funds.25 The fee-forservice model that dominates reimbursement in the United States rarely
includes reimbursement codes for
psychosocial interventions in physical therapy. In other health care systems, such as the National Health
Service in the United Kingdom, there
are increasing pressures on waiting
times and access to physical therapy
services. Service managers are constantly looking at ways to deliver
more efficient and more accessible
services, using routinely collected
data on waiting times and patient
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numbers to justify service changes


without supporting systematically
collected clinical or cost outcome
data. New service initiatives in the
United Kingdom include, for example, physical therapy telephone
assessment and treatment,56 selfreferral57 and increased reliance on
physical therapist assistants and
technical staff in patient management. In these contexts, it may be
particularly challenging to offer the
time some patients with low back
pain and key psychosocial obstacles
to recovery may need to elicit and
address these issues successfully.
Anecdotally, physical therapists in
the United Kingdom have expressed
concerns about identifying psychosocial issues with patients, given the
limited amount of time and number
of treatment sessions they are able to
offer patients in a resource-strapped
health care system. In the United
States, similar trends are evident, as
managed care initiatives limit the
number of sessions and the amount
of time per session that therapists
spend with patients. The end result
of these pressures is that current
clinical environments act as a disincentive to directly address psychosocial factors and may encourage

further application of biomedical


approaches, as they are most familiar
to most practicing clinicians.

Opportunities
Despite these challenges, many
opportunities are available to physical therapists to facilitate embedding
psychosocial perspectives within
clinical management of low back
pain. Again, we present these key
opportunities under the 2 broad
headings of Entry-Level Physical
Therapy Training and Current
Physical Therapist Practice, and
they are summarized in Figure 2.
Entry-Level Physical Therapy
Training
Changing the focus and priorities
of entry-level training in pain.
Given the woefully inadequate
pain education identified in entrylevel training programs58 and the
burden of pain in the general population, there are many opportunities
for improvement. Recent studies
have shown that single modules on
low back pain59 and physical therapy
degree courses60 can bring about
more positive student attitudes
toward function despite pain. Equipping students with knowledge of

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psychosocial models of chronic musculoskeletal pain development and
more specific knowledge about the
key psychosocial obstacles to recovery in low back pain and providing
better clarity about how to structure
their assessment and reassessment
are areas for improvement. Emphasis
on the limitations of the biomedical
model also should be a standard part
of entry-level education. For example, students should be well versed
in the limitations of imaging findings
for the management of low back
pain. Greater specificity about which
patient behaviors are best to target
within rehabilitation will help focus
interventions on supporting patients to achieve meaningful living
even in the context of persistent
pain. Teaching methods on psychosocial issues and their impact on the
effectiveness of physical therapy
could better utilize adult learning
theories, encouraging problem solving, deeper learning, and skill development rather than knowledge
recall alone. It is likely that in order
to provide competent and confident
physical therapists who can integrate psychosocial perspectives into
low back pain management, teaching approaches that facilitate interpersonal, communication, behavior
change, and problem-solving skills
are needed. Skills in establishing a
therapeutic relationship that encourages disclosure are likely to be very
important.61 These approaches may
challenge the traditional therapeutic
styles often seen within physical
therapy consultations.
Utilizing specific frameworks upon
which to hang learning about the
biopsychosocial aspects of the pain
experience and guide decision making about interventions also may be
helpful, facilitating tangible shifts
away from a sole focus on the biomechanical and physical features of
the back problem. A promising case
report published recently used the
World Health Organizations Inter796

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national Classification of Functioning, Disability and Health (WHOICF) as a framework for physical
therapists to understand each
patients experience of his or her
back problem and assist in treatment
selection.62
The use of education benchmarks
may offer an additional opportunity
to improve entry-level training. For
example, the British Pain Society58
recommends that educational standards from professional regulators
and Quality Assurance Agency
(QAA) subject benchmark statements should include pain-related
knowledge and competencies to
ensure they are integrated into the
curricula. Currently, for example,
physical therapy in the United Kingdom has recommended standards by
professional bodies but has established no QAA benchmarks for painrelated knowledge.
A further opportunity to improve
entry-level training in pain is interprofessional education. Interprofessional education models that include
2 or more health care professionals
can improve physical therapists
understanding of their own and others roles and develop teamwork and
collaborative problem solving. Interprofessional education that includes
pain specialists and physical therapists, for example, may better equip
future physical therapists to appreciate the practical aspects of psychosocial evaluation and treatment in
everyday clinical situations. Many
health care professions are advocating interprofessional educational
models to better prepare their students for the workplace by embedding collaborative practice environments as part of the learning
experience.63
With regard to adding content to
entry-level physical therapy curricula, a successful strategy was used
by the orthopedic community

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when it was determined that manual therapy content was either not
as explicit as it should be or simply
lacking. To address this concern, a
task force was formed by APTA
and its components along with the
American Association of Orthopaedic Manual Therapists. First, the
essential elements of a manual therapy curriculum were determined
by a consensus of expert academicians and clinicians and published
as proceedings.64 The proceedings
included curriculum resources that
could serve as a resource to any
physical therapy program, such as
curricular content (eg, theory, principles, technique, clinical education
considerations), sample instructional
materials (eg, syllabi content, laboratory handouts), and instructor qualification criteria. As part of the ongoing review, material from the manual
was used as a guide to influence standards and criteria in the Commission
on Accreditation in Physical Therapy
Education to better ensure concordance between the relevant evaluative criteria related to manual therapy and the findings of the task
force. A similar approach could be
considered for pain components of
the physical therapy curriculum,
whereby a consensus panel can be
assigned to construct a similar manual to be used to facilitate more comprehensive coverage of pain.
Facilitate cohesion across entrylevel clinical education. As well
as agreeing on benchmarks upon
which to judge training institutions,
there is much opportunity to facilitate more cohesive pain education
flowing from the educational institution into the clinical practice settings
where students gain their experience. Tools to achieve this aim
include interprofessional education
in the clinical environment, different
methods of education, and joint clinical/academic posts and academic/
clinical partnerships. Interprofessional efforts may be particularly
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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


well suited for clinical environments
and can serve a number of purposes.
First, they provide opportunities for
physical therapist students and other
health care professionals to learn
from one another in an applied environment. Second, they facilitate the
application of the material delivered
largely in a theoretical framework to
the patient. Furthermore, they create
an environment that facilitates role
modeling of interprofessional behavior, which is much needed by future
professionals involved in the treatment of patients with pain.
Different education methods may be
helpful; for example, a train-thetrainer model65 may help to spread
training and confidence among clinicians in the psychosocial management of back pain. Team reviews of
patient cases as well as innovative
ways of involving patients themselves in the education of physical therapist students may help
achieve early focus on the problems described from patients perspectives rather than the traditional
clinician-led assessment and identification of key problems.
Other opportunities include joint
posts for experienced physical therapists between research and clinical
settings to help embed a culture of
evidence-based practice, supporting
colleagues to review relevant highquality research evidence and agree
on changes to practice and to help
facilitate plan-do-study-act cycles of
improvements in practice. These
clinical champions can be seen as
enthusiastic and professional role
models who can mentor and support colleagues in making suggested
changes. There are real opportunities for academic institutions and
progressive clinical environments to
work together in active partnerships
where integrated biopsychosocial
training is modeled to the student as
part of standard of care. There are
few such integrated partnership
May 2011

models currently in use. The short


course training culture embedded
already within physical therapist
practice could be further enhanced
by agreeing on specific and measurable goals that are reviewed on a
regular basis to support meaningful
shifts in practice within a learning
organization culture.
Current Physical Therapist
Practice
More evidence from clinical trials
and implementation studies.
Undoubtedly, further high-quality
research evidence and patient outcome data are needed showing that
integrating psychosocial perspectives into physical therapist practice
leads to better outcomes. The current evidence base is promising66,67
but not yet compelling.68,69 The
most recent United Kingdom guidelines for the management of low
back pain6 recommend intensive
cognitive-behavioral intervention (of
approximately 100 hours) for
patients who fail to improve after
receiving first-line recommended
treatments of exercise, manual therapy, or acupuncture. Most physical
therapists, however, are unable to
provide this level of intensive intervention for their patients, and there
is some question as to who would
be the preferred provider for this
cognitive-behavioral
intervention.
New trials testing whether patients
subgrouped on the basis of risk status, integrating information about
psychosocial prognostic indicators,
and matching them with lessintensive, targeted treatments are
likely to contribute useful information for physical therapists.70 This
type of quality evidence, over time,
will begin to be incorporated into
best practice guidelines for low back
pain.
The reality is that even when there
is good evidence to support changes
in practice, we are still unclear
about optimal implementation strat-

egies.71 Passive dissemination of information is generally ineffective,71


and even contextualized, free information posted directly to physical
therapists has small effects.72 It is
clear that there is no single magic
bullet, but that multiple and specific implementation strategies, and
perhaps financial incentives and marketing approaches, are likely to be
needed to support tangible changes
in practice.71 A key opportunity in
this is that we are now better able
to provide recommendations about
psychosocial issues that are clear,
specific, and unambiguous key
attributes needed for recommendations in practice (the Appraisal of
Guidelines Research and Evaluation73) and that we have lacked until
recently.
Several groups around the world
have been investigating whether key
beliefs, attitudes, and behaviors of
clinicians can be modified,74 77 and,
to date, there are mixed results.
Training programs tested invariably
include facilitating a shift from thinking of low back pain as a disease of
the body and the spine to that of a
health condition caused by the interrelationships of factors within the
individual and between the individual and his or her environment,
including family relationships and
work. Stevenson and colleagues
showed that a brief training program
can effect some changes in attitudes
toward evidence-based practice,78
but did not result in actual changes
in physical therapist practice.79
Overmeer and colleagues74 showed
that the pain beliefs and attitudes
of physical therapists changed following an 8-day training course;
they became more biopsychosocially and less biomedically oriented and their knowledge of and
skills related to psychosocial risk
factors increased. Yet, despite these
positive changes, their patients perceived their practice behavior before
and after the course as similar and

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Figure 3.
A suggested model for integration: the psychosocial factors pyramid.

were equally satisfied with their


treatment. Vonk et al80 showed that
training might influence therapists
treatment approaches, as their PABS
biomedical scores decreased following a training program. However, in
a recent study of general practitioners treatment orientations, treatment recommendations, and treatment behaviors and outcomes of
patients with low back pain, no associations were found.76
So far, this growing body of research
appears to show that we can modify physical therapists beliefs and
attitudes about low back pain, but
that achieving and sustaining meaningful changes in practice behavior
are much more difficult. This perhaps remains the ultimate challenge
for the future: how to ensure that
quality evidence about psychosocial
perspectives in low back pain is actually incorporated into clinical practice by physical therapists for the
benefit of patient care. The solutions
are not simple and are likely to need
to include meaningful mentoring
programs and clinical supervision by
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clinical experts, interprofessional


group discussion of patient cases,
outcome data collection and feedback, and perhaps even peer- and
service-level comparison, plus organizational and reimbursement incentives to adopt new ways of working.
Enhanced role of physical therapists in educating patients and
the public. The success of some of
the public awareness campaigns for
low back pain81,82 highlights the
potential role for physical therapists
in educating the public about both
the primary and secondary prevention of low back pain. For example,
Working Backs Scotland83 is now
being relaunched and updated as
Web-based educational and interactive material for the Scottish public
(www.nhsinform.co.uk/health-zones/
scottish-backs.aspx), an initiative led
by a physical therapist. There are
clearly many opportunities for physical therapists to get involved in
influencing patients, and more
broadly, the publics perceptions
about back pain and its management.

Number 5

Identify and target key psychosocial factors more systematically.


Key psychosocial obstacles to recovery are becoming clearer; thus, we
are in a better position to advocate
which factors should be the focus
for assessment and treatment. Key
psychological factors include depression, anxiety, fear avoidance, social
isolation, catastrophization, perceptions about the future, and low personal control.11,12,53 Occupational
factors that have evidence from
more than one systematic review
include heavy physical demands,
ability to modify work, social support, short job tenure, job satisfaction, and fears of reinjury.84 As we
achieve greater clarity on which
obstacles to recovery to focus on,
this should lead to systematic ways
to incorporate these factors into education programs (entry-level and
continuing education), identify these
factors in clinical practice, and use
them in decision making about treatment, building on the few tools that
are already available.85,86 There is
much opportunity to develop and
validate new clinical prediction rules
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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


within physical therapy and to
ensure they include the assessment
of psychosocial prognostic factors.87
A suggested pyramid for the integration of psychosocial factors into clinical practice is given in Figure 3. At
the base of the pyramid are the common key psychosocial obstacles to
recovery that are relatively easy to
incorporate into physical therapist
practice, such as enhancing personal
control and self-efficacy in patients
with pain. Identifying and addressing
these factors is unlikely to require
intensive additional education and
skill development for physical therapists. Moving up the pyramid are
the psychosocial factors and intervention techniques that are likely to
require more specialist training to
identify and address, but that can
and should be part of at least some
physical therapists practice and skill
set. At the top of the pyramid are
the patients with psychosocial obstacles to recovery who are most likely
to need onward referral to mental
health professionals. This model
may be helpful in directing how to
accomplish better integration of psychosocial factors into practice.
Intervention studies are increasingly
trying to develop and test targeted
interventions that modify key psychosocial obstacles to recovery.39,88,89
It is likely to be most useful to focus
on beliefs about specific aspects of
pain or treatment, whether as specific targets for cognitive-behavioral
intervention or as potential obstacles
to optimal engagement in treatment.90 Attempting to address such
beliefs within a reactivation framework has become an integral part of
new approaches to help prevent
pain-associated incapacity in both
health care settings70 and occupational settings.91 For some patients, it
might be beneficial for physical therapists to directly communicate with
employers and managers in order to
facilitate sustained return to work,
May 2011

but in most cases, simple efforts to


identify and discuss work issues
directly with patients can lead to better work outcomes.84 These efforts
could include proposals from the
Canadian Medical Association92 such
as discussing expectations about
return to work early on; understanding the psychosocial context of the
patients work and his or her work
demands, risks, and return-to-work
options; and facilitating a return-towork plan.
Changes to the reimbursement
system and service priorities.
Given that it is clear that in some
health care systems the reimbursement arrangements for services influence the number and content of
treatments offered by physical therapists, it must follow that reimbursement systems could potentially be
used to positively influence improvements in practice. In the United
Kingdom, the Chartered Society of
Physiotherapy (CSP) has recently
developed a 5-year plan or vision for
the profession.93 Among the many
ideas within the CSPs vision, several
have the potential to positively influence quality improvements in clinical practice. For example, being
research-informed in all its activity,
actively engaging in standardized
data collection, changing practice
in light of changing evidence, and
leading and contributing to fit-forwork schemes are all part of the
CSPs vision.
These goals are similar to those articulated in other national directives for
health services about demonstrating
real value in terms of patients outcomes. Recent initiatives in Europe
(eg, in Norway and in Scotland)
include the start of standardized outcome data collection in physical
therapy services, and one of the real
opportunities of these initiatives will
be to use feedback and peer and service comparisons to facilitate quality
improvements in practice. With the

introduction and use of standardized


data collection on patient outcomes
as well as process measures (eg,
numbers and waiting times), future
benchmarking initiatives will be
facilitated, likely serving to enhance
quality improvements in physical
therapist practice. The CSPs vision
requires support for coordinated,
standardized data collection and
clearly defined minimum as well as
optimum standards of care. In addition, there are clear opportunities
to work with reimbursement systems to identify codes to reflect
physical therapy-led psychosocial
assessments and interventions and to
identify and test ways in which to
encourage judicious use of psychosocial approaches.

Future Directions
There is little question about the
need for more biopsychosocial
research related to low back pain as
well as innovative ways in which to
implement research findings in our
educational programs and everyday
clinical settings. In Figure 4, we
briefly highlight key future directions that will facilitate the integration of psychosocial perspectives
into physical therapist practice
across the areas of research, clinical
practice, and education.

Conclusion
Although it is clear that there are
many and varied challenges to integrating psychosocial perspectives
within physical therapists management of low back pain, there also
are many opportunities to improve
on the current order of affairs. Taking advantage of these opportunities
seems to be especially important
for low back pain, which is commonly experienced and has a strong
adverse impact on society, yet often
is not managed from a psychosocial
perspective. Ultimately, it is envisaged that progress in the biopsychosocial management of low back pain
will serve to enhance physical ther-

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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


Future Directions

Current Physical Therapist Practice

Research

Despite recent advances in our understanding of psychosocial aspects of low


back care, the following research directions should provide important additional
contributions:
a clear set of variables to accurately identify patients in need of moreintense and comprehensive management;
clearly establish which psychosocial factors are most appropriate as
prognostic factors, treatment effect modifiers, and treatment mediators;
accurate and systematic psychosocial screening protocols that are feasible
for use in clinical practice;
evidence on approaches to better target treatment interventions using more
defined dosages;
high-quality research that tests education strategies at both entry and
postgraduation levels.
One of the greatest challenges facing practice environments is finding
appropriate mechanisms with which to provide incentives for physical
therapists to engage in, and adhere to, best practice recommendations that
include appropriate psychosocial assessments and treatments.

Clinical practice

Although pay-for-performance concepts and pilot programs have been


designed with incentives in mind, there has not been a consensus on their
implementation, yet they have the potential to facilitate both morewidespread use of simple screening tools to identify psychosocial obstacles
to recovery and a clearer focus on their assessment and management. This
approach appears to be especially effective if the explicit management of
the psychosocial obstacles results in better patient outcomes.
Once physical therapists realize that their clinical performance is going to be
based partly on how well they conform to best standards of practice, it
would seem logical that there might be renewed interest in professional
development activities aimed at increasing knowledge and skills in the
assessment and management of psychosocial factors.
Entry-level physical therapist programs are already credit rich, with little
room for additional course material related to psychosocial and pain factors.
Thus, the addition of more material related to psychosocial factors may
seem improbable.

Education

However, if education programs are truly dedicated to the notion of


evidence-based care, the time dedicated to specific topics should be related
to the degree to which these topics have an evidence base for direct impact
on clinical management. Such an approach may lead to decisions to spend
less time on biomechanical and biomedical areas lacking underpinning
clinical evidence and more time on other, more evidence-based areas such
as the detection and elimination of psychosocial obstacles to recovery.
These sorts of arguments can be contentious, as they may require reduction
of time or even elimination of some sacred cows within the professional
curriculum. However, elimination of content areas that lack supporting
evidence should be seen as a way to potentially advance the profession into
areas associated with better patient management skills.

Figure 4.
Future directions.

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Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain


apists clinical practice and scope of
practice to meet the challenges of
the impact of musculoskeletal and
low back pain on patients and associated demand for physical therapy
services.
Professor Foster provided concept/idea/
project design and project management.
Both authors provided writing.
This article was submitted August 30, 2010,
and was accepted January 27, 2011.
DOI: 10.2522/ptj.20100326

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