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Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study

Article

Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study

Abstract

Question: What are physiotherapists' perspectives on managing the cognitive, psychological and social dimensions of chronic low back pain after intensive biopsychosocial training? Design: Qualitative study design using semi-structured interviews to explore physiotherapists' perceptions of their identification and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive Functional Therapy (CFT) training. Participants: Thirteen qualified physiotherapists from four countries who had received specific CFT training. The training involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive descriptive analysis was performed using a qualitative software package. Results: Four main themes emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in professional practice; altered scope of practice; and increased confidence and satisfaction. Participants described increased understanding of the nature of pain, the role of patient beliefs, and a new appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in communication, and adoption of a functional approach. Since undertaking CFT training, participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors. Conclusion: Physiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training, so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K (2016) Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study.Journal of Physiotherapy62: 215-221].
1
2
Research
3
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
4
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
5
Cognitive
Functional
Therapy
training:
a
qualitative
study
6
Aoife
Synnott
Q1
a
,
Mary
O’Keeffe
a
,
Samantha
Bunzli
b
,
Wim
Dankaerts
c
,
Peter
O’Sullivan
d
,
7
Katie
Robinson
a
,
Kieran
O’Sullivan
a
8
a
Department
of
Clinical
Therapies,
University
of
Limerick,
Limerick,
Ireland;
b
Department
of
Surgery,
University
of
Melbourne,
Melbourne,
Australia;
c
Department
of
Rehabilitation
9
Sciences,
University
of
Leuven,
Leuven,
Belgium;
d
School
of
Physiotherapy
and
Exercise
Science,
Curtin
University,
Perth,
Australia
10
11
Introduction
12
Chronic
low
back
pain
is
a
costly
and
debilitating
musculoskel-
13
etal
disorder
that
imposes
a
significant
burden
on
both
the
person
14
and
society.
1,2
The
societal
and
other
costs
of
chronic
low
back
pain
15
are
such
that
establishing
an
efficacious
management
approach
to
16
chronic
low
back
pain
is
a
healthcare
priority.
3,4
17
Chronic
low
back
pain
is
no
longer
considered
a
purely
structural,
18
anatomical
or
biomechanical
disorder
of
the
lumbar
spine.
Instead,
19
there
is
strong
evidence
that
chronic
low
back
pain
is
associated
20
with
a
complex
interaction
of
factors
across
the
biopsychosocial
21
spectrum.
These
not
only
involve
structural
or
biomechanical
22
factors,
but
also
cognitive
(eg,
unhelpful
beliefs,
catastrophising,
23
maladaptive
coping
strategies,
low
self-efficacy),
psychological
(eg,
24
fear,
anxiety,
depression)
and
social
(eg,
work
and
family
issues)
25factors.
5
Whilst
the
presence
of
cognitive,
psychological
and
social
26factors
are
regarded
as
predictors
of
poor
prognosis,
when
targeted
27effectively,
these
factors
are
considered
important
mediators
for
28improved
patient
outcomes.
6–8
This
is
on
the
basis
of
trials
showing
29that
successful
outcomes,
even
after
a
purely
physical
intervention,
30are
often
mediated
by
changes
in
cognitive
and
psychological
factors
31(eg,
fear,
catastrophising,
self-efficacy,
beliefs),
not
changes
in
32physical
factors
(eg,
posture,
muscle
thickness),
which
are
often
the
33main
targets
for
treatment.
9,10
34Consequently,
chronic
low
back
pain
treatment
guidelines
11,12
35generally
acknowledge
a
shift
toward
a
biopsychosocial
manage-
36ment
approach.
In
this
approach,
the
cognitive,
psychological
and
37social
dimensions
of
chronic
low
back
pain
are
considered
in
38addition
to
the
physical
and
pathoanatomical
dimensions
of
39pain.
13,14
Journal
of
Physiotherapy
xxx
(2016)
xxx–xxx
K
E
Y
W
O
R
D
S
Physical
therapy
Qualitative
Biopsychosocial
Low
back
pain
Treatment
Training
A
B
S
T
R
A
C
T
Question:
What
are
physiotherapists’
perspectives
on
managing
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
intensive
biopsychosocial
training?
Design:
Qualitative
study
design
using
semi-structured
interviews
to
explore
physiotherapists’
perceptions
of
their
identification
and
treatment
of
the
biopsychosocial
dimensions
of
chronic
low
back
pain
after
intensive
Cognitive
Functional
Therapy
(CFT)
training.
Participants:
Thirteen
qualified
physiotherapists
from
four
countries
who
had
received
specific
CFT
training.
The
training
involved
supervised
implementation
of
CFT
in
clinical
practice
with
patients.
Interviews
were
audio-recorded
and
transcribed
verbatim.
An
interpretive
descriptive
analysis
was
performed
using
a
qualitative
software
package.
Results:
Four
main
themes
emerged
from
the
data:
self-reported
changes
in
understanding
and
attitudes;
self-
reported
changes
in
professional
practice;
altered
scope
of
practice;
and
increased
confidence
and
satisfaction.
Participants
described
increased
understanding
of
the
nature
of
pain,
the
role
of
patient
beliefs,
and
a
new
appreciation
of
the
therapeutic
alliance.
Changes
in
practice
included
use
of
new
assessments,
changes
in
communication,
and
adoption
of
a
functional
approach.
Since
undertaking
CFT
training,
participants
described
a
greater
awareness
of
their
role
and
scope
of
practice
as
clinicians
in
identifying
and
addressing
these
factors.
Conclusion:
Physiotherapists
expressed
confidence
in
their
capacity
and
skill
set
to
manage
the
biopsychosocial
dimensions
of
chronic
low
back
pain
after
CFT
training,
and
identified
a
clear
role
for
including
these
skills
within
the
physiotherapy
profession.
Despite
this,
further
clinical
trials
are
needed
to
justify
the
time
and
cost
of
training,
so
that
intensive
CFT
training
may
be
made
more
readily
accessible
to
clinicians,
which
to
date
has
not
been
the
case.
[Synnott
A,
O’Keeffe
M,
Bunzli
S,
Dankaerts
W,
O’Sullivan
P,
Robinson
K,
O’Sullivan
K
(2016)
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
Cognitive
Functional
Therapy
training:
a
qualitative
study.
Journal
of
Physiotherapy
XX:
XX-XX]
ß
2016
Australian
Physiotherapy
Association.
Published
by
Elsevier
B.V.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
G
Model
JPHYS
270
1–7
Please
cite
this
article
in
press
as:
Synnott
A,
et
al.
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
Cognitive
Functional
Therapy
training:
a
qualitative
study.
J
Physiother.
(2016),
http://dx.doi.org/10.1016/j.jphys.2016.08.002
J
o
u
r
n
a
l
o
f
PHYSIOTHERAPY
jou
r
nal
h
o
mep
age:
w
ww.els
evier
.co
m/lo
c
ate/jp
hys
http://dx.doi.org/10.1016/j.jphys.2016.08.002
1836-9553/ß
2016
Australian
Physiotherapy
Association.
Published
by
Elsevier
B.V.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
40
The
available
research
indicates
that
physiotherapists
theoreti-
41
cally
endorse
the
proposed
biopsychosocial
approach
to
treatment,
42
yet
very
few
are
adopting
this
approach
in
clinical
practice,
despite
43
training
in
cognitive
behavioural
principles.
12,15
A
recent
system-
44
atic
review
16
found
that
physiotherapists
lacked
confidence
in
45
their
ability
to
identify,
communicate
about
and
manage
cognitive,
46
psychological
and
social
dimensions
of
chronic
low
back
pain
47
in
practice.
Physiotherapists
reported
feeling
that
neither
their
48
initial
training
nor
currently
available
professional
development
49
equipped
them
to
successfully
deal
with
these
factors
in
practice.
50
The
physiotherapists
emphasised
a
need
for
training
on
integrating
51
these
factors
into
patient
management.
52
A
growing
body
of
research
is
exploring
the
impact
of
training
53
directed
at
altering
physiotherapists’
ability
to
manage
cognitive,
54
psychological
and
social
factors
in
chronic
low
back
pain.
17–19
It
55
remains
unclear
whether
such
training
equips
physiotherapists
56
with
the
requisite
skill
set
to
appropriately
target
these
factors
in
57
practice.
18
58
Few
treatment
approaches
in
the
domain
of
physiotherapy
59
explicitly
integrate
cognitive,
psychological
and
social
factors
in
60
the
management
of
chronic
low
back
pain.
Cognitive
Functional
61
Therapy
(CFT)
is
a
novel,
multidimensional,
patient-centred
62
intervention
that
directly
explores
and
manages
cognitive,
63
psychological
and
social
factors
deemed
to
be
barriers
to
recovery
64
in
chronic
low
back
pain.
5,20
The
CFT
approach
centres
on
the
65
retraining
of
maladaptive
movement
patterns,
reconceptualising
66
patient
pain
beliefs,
and
addressing
any
relevant
cognitive,
67
psychological,
social
or
lifestyle
factors.
20
Training
in
CFT
aims
68
to
equip
physiotherapists
with
the
required
skills
through
training
69
workshops
that
place
an
emphasis
on
practical
experimentation
70
and
demonstration
with
live
patients.
5
71
Quantitative
research
has
established
that
patient
outcomes
72
improve
with
CFT
delivered
by
trained
physiotherapists.
5,21
73
However,
physiotherapists’
experiences
after
completing
such
74
training
have
not
yet
been
qualitatively
explored.
It
is
important
to
75
establish
such
perspectives
because,
while
CFT
may
be
beneficial
to
76
patients,
if
therapists
are
unwilling
or
unconfident
to
administer
it,
77
it
may
not
be
an
approach
that
is
incorporated
regularly,
78
effectively,
or
with
ease
in
the
clinical
setting.
79
Therefore,
the
study
question
for
this
qualitative
study
was:
80
What
are
physiotherapists’
perspectives
on
treating
the
81
biopsychosocial
dimensions
of
chronic
low
back
pain
after
82
receiving
intensive
biopsychosocial
training?
83
Methodology
84
Study
Design
85
A
qualitative,
interpretive
description
design
was
chosen.
22
86
Interpretive
description
is
a
non-categorical
methodological
87
approach
that
was
developed
purposely
to
provide
healthcare
88
practitioners
with
a
conducive
framework
for
exploring
clinically
89
occurring
phenomena
in
healthcare.
23
Interpretive
description
90
allows
exploration
of
complex
experiential
clinical
phenomena
23
91
and
provides
direction
in
the
creation
of
an
interpretative
account
92
using
techniques
of
reflective,
critical
examination.
22,24
An
inter-
93
pretive
description
design
was
deemed
compatible
with
the
94
objectives
of
this
study
because
the
theoretical
standpoint
of
this
95
design
centres
on
the
ability
of
interpretive
description
to
provide
96
generalisable
insights
into
the
current
clinical
practices
of
97
healthcare
practitioners,
which
may
aid
in
guiding
future
clinical
98
approaches.
24
Due
to
the
individual
experiences
of
physiotherapists
99
in
their
management
of
chronic
low
back
pain,
semi-structured
100
interviews
were
employed.
The
authors
are
clinical
and
research
101
physiotherapists
with
an
interest
in
biopsychosocial
models
of
pain.
102
Authors
KOS,
POS
and
WD
acted
in
the
capacity
of
CFT
trainers
and
103
mentors
of
the
physiotherapist
participants
in
this
study.
104
The
Consolidated
Criteria
for
Reporting
Qualitative
Research
105
(COREQ)
checklist
guided
the
reporting
of
this
study.
25
To
ensure
106that
the
questions
had
a
valid
and
meaningful
theoretical
107scaffolding,
the
questioning
route
or
topic
guide
for
this
study
108was
generated
based
on
a
literature
review
of
research
articles
in
109the
area.
24
The
route
was
then
refined
by
discussion
within
the
110research
team
to
ensure
the
questions,
content
and
structure
were
111suitably
open-ended,
neutral
and
sensitive.
26
112Participants
113CFT
trainers
(inclusive
of
authors
KOS,
POS
and
WD)
(www.
114pain-ed.com)
nominated
physiotherapists
whom
they
deemed
115competent
in
the
delivery
of
CFT,
after
training,
and
e-mail
116addresses
for
individual
contacts
were
provided.
A
recruitment
117email
containing
an
information
leaflet
and
consent
form
was
118emailed
to
potential
participants.
Fourteen
physiotherapists
were
119invited
to
participate.
120Participants
represented
a
purposive
sample
of
English-
121speaking
physiotherapists
who
had
completed
CFT
training.
All
122participants
had
received
CFT
training
from
CFT
trainers
(www.
123pain-ed.com)
(inclusive
of
authors
KOS,
POS
and
WD).
Training
124included
both
workshop
attendance,
in
which
they
observed
CFT
125trainers
assessing
and
treating
live
patients,
and
supervision
of
126clinical
practice.
All
participants
had
participated
in
at
least
two
127CFT
workshops
(average
of
nine
workshops
completed
to
date,
128average
duration
of
12
hours),
and
were
supervised
by
CFT
trainers
129for
at
least
four
sessions
of
clinical
practice
with
patients.
The
key
130criterion
for
inclusion
was
that
a
CFT
trainer
had
observed
the
131participant
assessing
and
treating
multiple
patients
and
deemed
132that
the
participant
was
competent
in
the
administration
of
CFT.
133Data
collection
134Semi-structured
telephone
and
Skype
interviews
were
com-
135pleted
by
a
researcher
(AS)
who
was
unknown
to
the
participants
136and
was
guided
by
a
flexible
question
route.
The
questioning
route
137covered:
changes
in
practice
as
a
result
of
CFT
training;
the
138participant’s
confidence
and
competence
in
identifying,
discussing
139and
addressing
cognitive,
psychological
and
social
factors
with
140patients;
and
the
participant’s
confidence
in
establishing
a
strong
141patient-therapist
alliance.
Interviews
lasted
from
45
minutes
to
1421
hour
in
length.
Interviews
were
recorded
using
computer
audio
143software
a
and
audio
taped
with
a
voice
recorder.
144During
the
interviews
the
researcher
took
notes,
as
needed,
and
145statements
of
relevance
and
contextual
field
notes
were
written
146verbatim.
This
aided
in
the
identification
of
the
point
of
data
147saturation,
as
it
was
evident
when
no
new
material
or
concepts
148arose.
27
Data
saturation
was
achieved
after
the
completion
of
14911
interviews,
with
13
conducted
in
total.
150At
the
conclusion
of
each
interview,
the
researcher
debriefed
151the
participant
on
the
main
content
of
the
interview,
and
time
was
152permitted
for
any
additional
commentary
to
facilitate
the
153emergence
of
new
unanticipated
information.
26
154Data
analysis
155Interviews
were
transcribed
verbatim.
Specialist
qualitative
156research
software
b
was
used
to
aid
in
sorting
the
data.
28
Three
157transcripts
were
randomly
selected
and
initial
inductive
codes
158were
formed
individually
by
three
authors
(AS,
KOS
and
MOK).
The
159three
initial
code
lists
were
then
amalgamated
and
a
comprehen-
160sive
code
list
was
finalised,
in
view
of
the
codes
most
representa-
161tive
of
the
dataset
informed
by
background
reading
related
to
the
162research
question.
The
finalised
code
list
was
then
applied
to
all
163transcripts
by
AS.
164Coded
data
was
categorised
using
the
qualitative
research
165software
and
through
a
process
of
repetitive
interpretation,
166synthesising
and
theorising
themes
were
identified.
22
Tran-
167scripts
were
then
re-read
several
times
and
the
selected
themes
168were
finalised
based
on
consensus
discussion
between
AS,
KOS
and
169MOK.
The
software
aided
in
determining
the
intensity
and
Synnott
et
al:
Cognitive
Functional
Therapy
training
in
back
pain
2
G
Model
JPHYS
270
1–7
Please
cite
this
article
in
press
as:
Synnott
A,
et
al.
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
Cognitive
Functional
Therapy
training:
a
qualitative
study.
J
Physiother.
(2016),
http://dx.doi.org/10.1016/j.jphys.2016.08.002
170
coverage
of
codes
that
contributed
to
the
formation
of
these
171
themes.
28
Four
categories
were
identified
to
account
for
all
172
identified
themes.
Throughout
data
collection
and
analysis,
widely
173
accepted
strategies
for
ensuring
quality
in
qualitative
analysis
174
were
maintained,
including
auditability,
fit
and
transferability.
29
175
Finalised
transcripts
with
a
summary
of
selected
themes
were
then
176
emailed
to
participants
for
validation
with
no
amendments
177
received
from
participants.
30
178
Results
179
Compliance
with
the
study
protocol
180
Fourteen
initial
recruitment
emails
were
sent.
One
physiother-
181
apist
did
not
reply
to
the
invitation.
Therefore,
13
participants
were
182
enrolled
in
the
study
and
completed
an
interview.
183
Participants
184
The
participants
included
nine
men
and
four
women,
from
four
185
countries.
Participants
had
an
average
of
13
years
of
experience
186
since
qualification.
Table
1
details
the
demographic
characteristics
187
of
the
study
participants.
188
Key
themes
189
Four
main
themes
were
identified
in
the
data:
self-reported
190
changes
in
understanding
and
attitudes,
self-reported
changes
in
191
professional
practice,
scope
of
practice
and
increased
confidence
192
and
perceived
patient
and
therapist
satisfaction.
Box
1
presents
the
193
categories
constituting
each
theme.
194Theme
1:
Self-reported
change
in
understanding
and
attitudes
195New
understanding
of
the
multidimensional
nature
of
pain
196Many
participants
stated
that
CFT
training
improved
their
197understanding
of
the
multidimensional
nature
of
pain,
as
prior
to
198training,
a
biomedical
approach
to
treatment
dominated
their
199practice.
200But
the
cognitive
part
has
been
the
greatest
change...
understand-
201ing
the
influence
of
sleeping
poorly,
being
stressed...
I
mean
back
202then
[before
training]
I
probably
realised
it
somewhere
in
the
back
203of
my
head
but
I
didn’t
act
on
it.
(P6)
204In
recognition
of
the
multifactorial
nature
of
pain,
participants
205reported
a
change
in
practice
where
they
now
consistently
206explored
cognitive,
psychological
and
social
dimensions
of
a
207patient’s
pain
and
were
cognisant
of
the
importance
of
promoting
208the
patient’s
understanding
of
pain.
209Previously
I
didn’t
have
an
awareness
of
the
psychosocial
factors...
210Now
I
systematically
explore
stress,
fear,
catastrophising,
worrying
211about
life,
belief
in
the
future,
readiness
to
change.
(P4)
212Heightened
awareness
of
the
influence
of
patient
beliefs
and
213expectations
214In
several
interviews,
participants
acknowledged
the
influence
215of
patient
beliefs
that
often
made
the
identification
and
216management
of
cognitive,
psychological
and
social
factors
217challenging,
including
rigid
biomedical
belief
systems
among
218patients.
Table
1
Participant
characteristics.
Gender
Time
since
qualification
(yr)
Workplace
setting
Time
in
current
work
setting
(yr)
Experience
with
chronic
low
back
pain
caseload
(yr)
Country
of
practice
CFT
training
workshops
completed
(n)
Sessions
implementing
CFT
under
supervision
(n)
Male
5
Private
5
5
Belgium
7
5
Male
10
Private
5
10
Australia
15
12
Female
12
Public
7
7
Denmark
7
4
Male
12
Public
7
10
Denmark
7
4
Male
12
Private
10
10
Australia
15
20
Male
14
Public
3
12
Ireland
3
10
Male
14
Public
12
9
Ireland
2
10
Female
14
Public
1
12
Ireland
15
12
Female
14
Private
10
13
Ireland
12
4
Female
15
Public
5
4
Denmark
6
6
Male
16
Public
10
15
Denmark
6
6
Male
18
Private
13
18
Australia
15
10
Male
19
Private
5
15
Australia
15
10
CFT
=
Cognitive
Functional
Therapy
Specific
participant
codes,
eg,
(P1,
P2)
have
been
omitted
from
the
table
of
demographics
to
ensure
confidentiality
and
anonymity
due
to
the
small
pool
of
specialised
physiotherapists
available
for
recruitment.
It
should
not
be
assumed
that
order
of
appearance
in
the
table
relates
to
participant
numbering.
Box
1.
Themes
and
categories
constituting
each
theme
Self-reported
changes
in
understanding
and
attitudes
Self-reported
changes
in
professional
practice
Scope
of
practice
Increased
confidence
and
satisfaction
New
understanding
of
the
multidimensional
nature
of
pain
Heightened
awareness
of
the
influence
of
patient
beliefs
and
expectations
Increased
awareness
of
the
importance
of
the
therapeutic
alliance
Adoption
of
new
screening
tools
Altered
communication
style
Adoption
of
a
functional
behavioural
approach
Expanded
role
of
the
physiotherapist
Role
boundaries
Increased
confidence
Perceived
patient
and
therapist
satisfaction
Research
3
G
Model
JPHYS
270
1–7
Please
cite
this
article
in
press
as:
Synnott
A,
et
al.
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
Cognitive
Functional
Therapy
training:
a
qualitative
study.
J
Physiother.
(2016),
http://dx.doi.org/10.1016/j.jphys.2016.08.002
219
There
is
a
belief
that
manipulating
their
back
is
the
only
thing
that
220
can
help,
and
then
it’s
quite
difficult
to
introduce
this
biopsycho-
221
social
model
because
they
kind
of
deny
the
presence
of
these
222
psychosocial
factors.
(P13)
223
Patient
expectations,
reflecting
patient
beliefs,
were
frequently
224
cited
as
fuelling
these
difficulties.
225
Some
people
want
a
quicker
fix...
for
them
their
back
is
just
another
226
problem
in
their
life
and
they
want
you
as
a
therapist
to
deal
with
227
that,
not
them
as
a
patient
to
deal
with
that.
(P5)
228
This
heightened
awareness
of
the
role
that
beliefs
of
the
patient
229
play
when
implementing
CFT
provided
participants
with
confi-
230
dence
to
address
those
beliefs.
In
turn,
many
of
the
participants
231
were
not
fazed
by
the
limitation
the
negative
beliefs
posed,
but
232
instead
were
happy
to
address
them.
233
Sometimes
they
don’t
want
to
hear
what
you
have
to
say.
They’ll
234
just
say
‘yeah,
my
disc
is
the
problem,
I
just
know
I
have
a
235
prolapse’...
that’s
a
barrier
that’s
hard
to
move
.
.
.
but
one
I’m
236
happy
to
start
to
change.
(P2)
237
Increased
awareness
of
the
importance
of
the
therapeutic
238
alliance
239
All
participants
in
this
study
regarded
a
strong
therapeutic
240
alliance
as
an
intrinsic
ingredient
for
addressing
cognitive,
241
psychological
and
social
factors.
242
Well
the
relationship
I
think...
I
do
believe
that
it
creates
a
more
243
open
environment
for
the
patient
to
feel
heard...
If
they
don’t
feel
244
there’s
an
alliance
there,
you
can
ask
all
the
questions
in
the
world
245
but
they
won’t
tell
you
anything.
(P1)
246
Participants
described
how
an
individualised
approach
to
247
treatment
aided
in
the
development
and
maintenance
of
rapport,
248
and
how
this
facilitated
a
deeper
insight
into
the
individual
249
cognitive
and
psychological
drivers
of
pain
for
each
patient.
250
I
think
that
individual
interaction
is
highly
important...
rather
than
251
take
them
as
being
just
another
person
with
a
low
back
pain
252
problem...
show
that
you
are
understanding
of
their
viewpoint
and
253
individual
pain
.
.
.
suss
out
what
really
makes
them
tick.
Then
I
254
believe
you
make
it
work.
(P10)
255
Theme
2:
Self-reported
changes
in
professional
practice
256
Adoption
of
new
screening
tools
257
Several
participants
reported
regularly
using
validated
psycho-
258
social
screening
tools
after
completing
the
CFT
training.
Tools
used
259
included
the
Orebro
Musculoskeletal
Pain
Questionnaire
and
the
260
STarTback
Tool
31
for
the
identification
of
individuals’
barriers
to
261
recovery.
262
So
we
get
a
score
from
0
to
10
on
how
depressed
are
you,
how
much
263
fear
avoidance
do
you
have...
It
makes
you
think
if
you
score
264
between
7
and
10
on
some
of
these
questions,
it’s
of
course
relevant.
265
(P6)
266
For
many
participants,
the
results
of
these
screening
tools
267
informed
their
route
of
questioning
during
patient
interviews.
268
I
might
use
the
question
to
explore
a
particular
problem...
so
you
269
can
go
‘Well
look
you
answered
this
in
such
a
way,
tell
me
a
little
bit
270
more
about
it.’
(P1)
271
Altered
communication
style
272
After
completing
the
CFT
training,
participants
reported
a
shift
273
in
their
communication
style
from
a
rigid
structured
approach
to
274
an
open
and
unrestrictive
style.
Participants
identified
how
an
275
open
communication
style
promoted
an
easiness
and
fluidity
in
the
276exploration
of
the
cognitive,
psychological
and
social
dimensions
277with
patients.
278Now
I
think
I’m
much
more
open-ended,
so
I
kind
of
ask
open-
279ended
questions
like
‘What’s
your
story?’
you
know,
or
‘What
280brings
you
here?’
(P1)
281Adoption
of
a
functional
behavioural
approach
282The
majority
of
participants
described
observing
functional
283behaviours
to
gain
insight
into
relevant
cognitive
and
psychologi-
284cal
factors
(such
as
distress,
anxiety,
and
fear
avoidance)
since
285completing
CFT
training.
The
observation
of
functional
behaviours
286may
vary
between
individuals,
but
will
be
likely
to
include
287targeting
activities
such
as
rolling
in
bed,
sitting,
standing
up
from
288sitting,
walking,
bending
and
lifting.
Participants
described
this
289information
as
guiding
the
physiotherapy
assessment
process.
290Sometimes
you
get
people
in
that
don’t
wear
laces
on
shoes
because
291they
won’t
bend
down
to
their
laces...
and
it
gives
you
an
idea
of
292‘Right,
well,
I
better
ask
this
person
to
do
some
bending
and
see
293what
they
look
like.’...
You
have
a
look
at
how
they
move
on
a
day-
294to-day
basis
as
opposed
to
just
from
a
clinical
basis.
(P1)
295Since
completing
CFT
training,
participants
reported
assessing
296and
changing
functional
behaviours
such
as
assessing
and
297changing
bending
or
sitting,
if
reported
as
painful
by
the
patient
298to
increase
the
patient’s
awareness
of
the
relevance
of
cognitive
299and
psychological
factors
in
their
pain
experience.
300If
you
[as
a
patient]
think
your
disc
is
vulnerable
and
you
get
301extreme
pain
from
forward
bending,
and
within
minutes
you
can
302actually
move
into
a
forward
bending
position
pain
free,
most
303people
would
be
ready
to
change
that
belief.
(P6)
304Theme
3:
Scope
of
practice
305Expanded
role
of
the
physiotherapist
306Following
the
CFT
training,
participants
described
a
clear
307understanding
of
how
traditional
hands-on
approaches
could
be
308used
in
combination
with
newly
developed
skills
to
address
309cognitive,
psychological
and
social
factors.
All
participants
310commented
on
their
ideal
professional
positioning
as
physiothera-
311pists
to
combine
their
hands-on
skills
with
the
newly
learned
312biopsychosocially
orientated
approach
to
successfully
address
the
313cognitive,
psychological
and
social
dimensions
of
pain.
314As
physios
we
can
put
our
hands
on
patients
and
assure
them
315nothing
is
physically
wrong...
and
with
the
training
we
can
316complement
our
hands-on
and
exercise
expertise
to
treat
things
317like
anxiety.
(P12)
318Role
boundaries
319Alongside
this
new
understanding
of
their
role,
participants
320articulated
an
understanding
of
the
limits
or
boundaries
of
their
321role.
For
example,
participants
acknowledged
that
addressing
322social
factors
(eg,
workplace
interventions)
was
an
area
that
323prompted
participants
to
consider
the
boundaries
of
their
role.
324I
personally
find
interacting
with
people’s
workplaces
really
tough,
325partly
because
I
think
there
isn’t
necessarily
a
relationship
between
326me
as
a
therapist
and
their
workplace...
We
can’t
give
people
a
new
327job
if
they
get
fired
because
of
their
back
pain.
(P10)
328Additionally,
all
participants
identified
situations
in
which
329addressing
certain
psychological
factors,
particularly
those
associ-
330ated
with
severe
psychological
trauma,
were
beyond
their
scope
of
331practice.
332If
someone
has
a
post-traumatic
stress
disorder
or
had
been
333abused,
some
of
those
instances
are
extremely
depressing
for
Synnott
et
al:
Cognitive
Functional
Therapy
training
in
back
pain
4
G
Model
JPHYS
270
1–7
Please
cite
this
article
in
press
as:
Synnott
A,
et
al.
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
Cognitive
Functional
Therapy
training:
a
qualitative
study.
J
Physiother.
(2016),
http://dx.doi.org/10.1016/j.jphys.2016.08.002
334
patients
and
may
be
beyond
our
professional
boundaries
to
be
335
managing...
so
I
would
refer
onto
someone
with
more
specialised
336
training.
(P12)
337
In
considering
their
scope
of
practice
in
these
situations,
338
participants
acknowledged
these
issues
and
their
relevance
for
the
339
patient’s
pain,
yet
described
their
understanding
that
they
were
340
not
appropriately
qualified
to
treat
these
issues
in
practice.
341
I
can
identify
it,
I
can
talk
with
the
patient
and
help
them
consider
342
the
relevance
of
it
to
their
pain,
but
when
it
is
really
traumatic
for
343
the
patient
then
I
am
not
capable
enough
of
addressing
this
344
problem...
It
is
because
I
am
not
trained
in
it.
(P13)
345
Theme
4:
Increased
confidence
and
satisfaction
346
Increased
confidence
347
Most
participants
described
increased
confidence
in
their
348
ability
to
identify
and
address
these
factors
in
practice.
349
I
feel
I’ve
got
enough
grounding
in
research
and
training
to
say
I
feel
350
completely
confident
in
doing
it.
(P11)
351
More
specifically,
many
participants
described
how
they
were
352
now
confident
to
challenge
the
patient’s
belief
system,
even
if
this
353
led
to
some
conflict.
354
Now
I’m
more
inclined
to
say
‘Listen,
hold
on
a
minute.
Anyway
I’ve
355
just
got
to
re-examine
your
point
of
view
on
this’
and
that
can
356
sometimes
lead
to
conflict...
but
I
think
you
sometimes
need
conflict
357
for
conceptual
change.
(P1)
358
Perceived
patient
and
therapist
satisfaction
359
Overall,
participants
acknowledged
that
the
CFT
training
had
360
contributed
to
improved
therapist
satisfaction,
patient
outcomes
361
and
overall
job
satisfaction.
362
I
think
a
lot
of
the
patients
since
I
started
using
the
CFT
type
363
approach
is
positive
in
that
they
feel
we’re
addressing
the
364
problem...
I
have
a
feeling
that
I’m
doing
something
different
365
and
helping
them
a
lot
more.
(P7)
366
Discussion
367
The
primary
objective
of
this
study
was
to
gain
an
insight
into
368
physiotherapists’
perceptions
of
the
identification
and
treatment
369
of
the
cognitive,
psychological
and
social
dimensions
of
chronic
370
low
back
pain
after
CFT
training.
Four
main
themes
emerged
from
371
the
data:
changed
understanding
and
attitudes;
changes
in
372
professional
practice;
altered
scope
of
practice;
and
increased
373
confidence
and
satisfaction.
Participants
described
increased
374
understanding
of
the
nature
of
pain,
the
role
of
the
patient’s
375
beliefs
and
a
new
appreciation
of
the
therapeutic
alliance.
Changes
376
in
practice
included
use
of
new
assessments,
changes
in
377
communication
and
adoption
of
a
functional
approach.
Partici-
378
pants
described
greater
awareness
of
their
scope
of
practice
since
379
undertaking
CFT
training.
Finally,
participants
reported
increased
380
confidence
and
job
satisfaction
as
a
result
of
addressing
cognitive,
381
psychological
and
social
factors.
382
The
therapeutic
relevance
of
cognitive
factors,
such
as
patient
383
beliefs,
to
the
success
of
an
intervention
has
been
explored
384
extensively
within
the
literature.
32–34
In
the
present
study,
385
participants
clearly
articulated
a
perception
that
cognitive
factors
386
were
modifiable
by
physiotherapy
intervention.
However,
parti-
387
cipants
acknowledged
that
addressing
cognitive
factors
could
388
sometimes
be
challenging
or
difficult.
Nevertheless,
participants
389
explicitly
described
feeling
equipped
to
challenge
patients’
belief
390
systems
after
participating
in
CFT
training.
This
is
in
contrast
to
a
391
recently
conducted
systematic
review,
16
where
cognitive
factors
392
such
as
patient
beliefs
and
expectations
were
often
perceived
by
393physiotherapists
to
be
clinically
unmodifiable
in
light
of
a
394predominantly
biomedical
skill
set.
This
may
point
to
a
relation-
395ship
between
the
attributes
attained
from
training
(newly
acquired
396therapeutic
tools,
understanding
and
confidence)
and
the
per-
397ceived
degree
of
modifiability
of
cognitive
factors.
398Additionally,
within
this
study
there
was
no
evidence
of
a
399negative
characterisation
of
patients
based
on
their
attitudes
or
400beliefs.
This
is
in
direct
contrast
to
that
described
in
a
previous
401systematic
review,
16
where
physiotherapists
were
seen
to
402stigmatise
cognitive
dimensions
of
pain
secondary
to
a
lack
of
403understanding
into
the
relevance
of
such
factors
on
a
patient’s
pain
404presentation.
The
attributes
attained
from
training
may
have
aided
405in
eliminating
stigmatisation
in
light
of
new
insights,
greater
406empathy
and
a
greater
understanding
of
the
role
of
the
therapeutic
407alliance.
408In
contrast
to
previous
studies,
16,35
participants
in
the
present
409study
reported
an
increased
awareness
of
the
influence
of
410cognitive,
psychological
and
social
factors
on
chronic
low
back
411pain.
16,36
Participants
described
being
motivated
to
systematically
412incorporate
exploration
of
these
factors
in
all
interactions
with
413chronic
low
back
pain
patients.
Participants
described
using
a
more
414functional
behavioural
examination
and
management
approach
415and
changes
in
their
interaction
style
in
keeping
with
the
ethos
of
416CFT.
4,21
In
previous
studies,
physiotherapists
have
described
417sporadic
use
of
unstructured
questions
based
on
instinct
or
418professional
judgement,
which
often
resulted
in
important
419cognitive,
psychological
and
social
factors
being
missed.
This
420may
indicate
that
physiotherapists
need
to
be
multi-skilled
in
their
421practice.
They
may
need
to
understand
the
biopsychosocial
model
422of
chronic
low
back
pain,
be
skilled
communicators
and
be
able
to
423perform
a
competent
yet
flexible
assessment
of
functions
and
424limitations
to
optimise
patient-centred
care.
Depending
on
the
425factors
that
are
relevant
to
the
patient,
physiotherapists
may
need
426to
be
comfortable
with
altering
their
assessment
and
approach
to
427put
emphasis
on
certain
components
of
therapy
(eg,
education,
428exercise).
This
may
require
upskilling
in
communication
skills:
429listening;
empathy;
encouragement;
patient
education,
including
430use
of
analogies
and
simple
language;
individualising
care
to
suit
a
431person’s
preferences
and
needs;
and
giving
patients
time
to
discuss
432their
story.
Patients
see
these
skills
as
very
important
to
433outcome;
37
CFT
aims
to
encompass
and
teach
such
skills.
434A
number
of
studies
have
reported
that
physiotherapists
435perceive
the
management
of
cognitive,
psychological
and
social
436factors
as
extending
beyond
their
scope
of
practice.
16,35
This
has
437resulted
in
the
widespread
avoidance
of
the
assessment
and
438management
of
these
factors
within
clinical
practice.
16
439Participants
in
this
study
clearly
articulated
a
more
multi-
440dimensional
view
of
their
scope
of
practice
and
confidence
441in
addressing
cognitive,
social
and
psychological
factors.
This
is
442in
contrast
to
the
‘fear-avoidant’
status
applied
to
the
profession
in
443the
past
when
confronted
with
cognitive,
psychological
and
social
444issues.
38
The
extension
in
perceived
scope
of
practice
in
compari-
445son
to
previous
research
is
interesting,
with
participants
in
the
446present
study
identifying
the
limit
of
their
professional
role
as
not
447extending
to
the
treatment
of
deep
psychological
trauma
and
448depression.
This
is
an
appropriate
limitation
because
the
objective
449of
CFT
training
is
to
identify
when
it
is
appropriate
to
refer
onwards
450for
specialised
consultations.
20
However,
participants
in
the
451present
study
did
not
perceive
it
as
appropriate
to
immediately
452transfer
care
and
discharge
from
physiotherapy,
as
performed
by
453physiotherapists
in
previous
studies
when
such
psychological
454traumas
were
highlighted.
39–41
Instead,
participants
in
this
study
455perceived
it
as
appropriate
to
remain
involved
in
helping
the
456patient
to
identify
the
links
between
such
traumas
and
their
pain
457disorder
as
part
of
multi-disciplinary
care.
458Whilst
participants
perceived
cognitive
and
psychological
459barriers
as
being
largely
modifiable,
work-related
barriers
were
460regarded
as
particularly
challenging,
and
modifying
them
was
461regarded
as
extending
beyond
their
professional
remit.
This
is
462similar
to
a
recent
study,
which
found
that
physiotherapists
were
Research
5
G
Model
JPHYS
270
1–7
Please
cite
this
article
in
press
as:
Synnott
A,
et
al.
Physiotherapists
report
improved
understanding
of
and
attitude
toward
the
cognitive,
psychological
and
social
dimensions
of
chronic
low
back
pain
after
Cognitive
Functional
Therapy
training:
a
qualitative
study.
J
Physiother.
(2016),
http://dx.doi.org/10.1016/j.jphys.2016.08.002
463
satisfied
to
listen
to
workplace
factors
implicit
in
a
patient’s
pain,
464
yet
perceived
no
role
in
their
management.
35
Risk
of
chronic
low
465
back
pain
has
been
shown
to
increase
with
workplace
factors
such
466
as
low
job
satisfaction,
night
shift
work,
perceived
lack
of
support
467
from
colleagues
or
superiors,
and
perceived
lack
of
a
pleasant
and
468
supporting
environment.
42,43
While
physiotherapists
seem
to
be
469
comfortable
assessing
physical
factors
in
work,
like
sitting,
470
bending
and
lifting,
these
have
been
shown
to
have
weak
471
relationships
with
chronic
low
back
pain.
44–46
Instead,
difficulties
472
with
integrating
the
management
of
workplace
factors,
as
473
mentioned
above,
into
physiotherapy
practices
have
regularly
474
been
highlighted.
47,48
Currently,
more
than
68%
of
patients
with
475
chronic
low
back
pain
do
not
discuss
workplace
factors
in
the
476
manifestation
of
their
pain
with
a
physiotherapist
because
they
do
477
not
consider
this
as
within
the
physiotherapist’s
role.
49
Phy-
478
siotherapists
may
not
actively
seek
to
identify
strategies
to
modify
479
work-related
issues
in
chronic
low
back
pain
because
they
are
not
480
routinely
highlighted
in
consultations
by
patients
as
pertinent
481
barriers
to
recovery.
To
date,
clinic-based
interventions
have
not
482
routinely
included
addressing
work-related
issues,
which
often
483
involves
liaising
with
employers
and
other
stakeholders.
In
turn,
484
this
continues
to
be
a
limitation
of
the
clinical
profession
that
was
485
not
addressed
by
CFT
training
for
many
of
the
physiotherapists
486
involved
in
this
study.
487
Participants
perceived
that
the
increased
focus
on
the
cognitive,
488
psychological
and
social
dimensions
of
pain
in
practice
proved
489
professionally
stimulating.
This
is
similar
to
the
results
found
by
490
Sanders
et
al,
50
in
which
physiotherapists
perceived
their
existent
491
work
practices
to
be
more
rewarding
once
tools
to
treat
complex
492
pain
presentations
were
taught.
50
Additionally,
participants
493
perceived
that
this
targeted
intervention
was
mutually
beneficial
494
for
patients.
Research
has
highlighted
that
patients
with
chronic
495
low
back
pain
seek
explanations
for
the
origin
of
their
pain,
so
as
to
496
provide
a
legitimisation
of
their
pain
as
long
as
a
psychosomatic
497
origin
is
not
inferred.
51,52
The
fact
that
CFT
aims
to
explain
the
498
often
important
role
of
cognitive
and
psychological
factors
in
pain,
499
whilst
legitimising
the
validity
of
the
subsequent
pain,
may
help
500
overcome
this
concern.
51,52
Similarly,
the
emphasis
on
functional
501
movement
rehabilitation
may
be
more
acceptable
to
patients
who
502
yearn
for
physical
treatment
rather
than
a
purely
‘psychological’
503
approach;
32
this
might
be
especially
important
in
facilitating
504
patient
adherence
at
least
initially.
505
The
participants’
reported
confidence
and
competence
in
506
identifying
and
treating
the
cognitive,
psychological
and
social
507
dimensions
of
pain
is
in
stark
contrast
to
that
described
by
508
physiotherapists
in
previous
qualitative
reviews.
16,35
Participants
509
in
the
present
study
collectively
perceived
that
the
attainment
of
510
evidence-based
therapeutic
tools
through
training
proved
benefi-
511
cial,
as
they
were
better
equipped
and
more
confident
to
address
512
these
factors
in
practice.
Furthermore,
this
professional
confidence
513
may
indirectly
bode
favourably
for
patient
outcomes,
because
514
perceiving
the
physiotherapy
professional
as
confident
and
expert
515
remains
a
patient
priority.
53
What
remains
largely
novel
about
the
516
CFT
training
is
that
it
incorporates
the
use
of
live
patient
517
assessment
and
treatment
sessions.
Being
shown
how
to
imple-
518
ment
a
CFT
approach
may
have
increased
the
participants’
519
confidence
and
clinical
competence.
While
previous
studies
have
520
employed
the
use
of
vignettes,
recent
research
has
demonstrated
521
that
vignettes
do
not
serve
as
a
valid
tool
for
therapist
education.
54
522
There
are
a
number
of
methodological
considerations
that
may
523
adversely
influence
the
generalisability
of
the
research.
Firstly,
the
524
participants
in
this
sample
were
recruited
for
having
achieved
525
competency
standards
set
out
in
CFT
training
guidelines.
526
Consequently,
the
study
captured
the
experiences
of
physiothera-
527
pists
who
were
deemed
capable
in
delivering
the
approach.
Those
528
initially
selected
for
intensive
CFT
training
may
also
have
had
a
529
specific
interest
and/or
experience
in
treating
those
with
chronic
530
low
back
pain.
531
Participants’
reflexive
accounts
of
clinical
behaviour
may
have
532
been
influenced
by
social
desirability,
particularly
as
participants
533were
aware
of
those
involved
in
recruitment.
55
This
may
have
534resulted
in
inaccurate
reporting
of
participant
perceptions,
despite
535reassurances
of
confidentiality.
An
alternative
approach
may
have
536been
to
employ
clinical
vignettes;
however,
these
have
been
537shown
to
be
of
limited
validity
in
understanding
healthcare
538practitioners’
clinical
behaviours.
54
539Intensive
CFT
training
may
be
an
effective
tool
to
increase
the
540perceived
confidence
and
skillset
of
physiotherapists
involved
in
541assessing
and
managing
cognitive,
psychological
and
social
542barriers
to
recovery
in
people
with
chronic
low
back
pain.
543Physiotherapists
who
are
deciding
whether
to
undertake
such
544training
may
be
encouraged
by
knowing
that
their
peers
who
were
545deemed
competent
after
the
CFT
training
also
reported
confidence
546and
satisfaction
with
the
approach.
547In
summary,
physiotherapists
expressed
confidence
in
their
548capacity
to
identify
and
manage
the
cognitive,
psychological
and
549social
factors
in
chronic
low
back
pain
after
CFT
training,
secondary
550to
gaining
an
understanding
of
the
multidimensional
nature
of
551pain
and
an
expansion
of
their
clinical
skill
set.
Despite
this,
further
552clinical
trials
are
needed
to
justify
the
time
and
cost
of
training,
so
553that
intensive
CFT
training
may
be
made
more
readily
accessible
to
554clinicians,
which
to
date
has
not
been
the
case.
While
participants
555perceived
commonly
encountered
cognitive
factors
as
modifiable,
556addressing
workplace
factors
remains
challenging,
and
may
be
an
557area
to
target
in
future
physiotherapist
training.
559What
is
already
known
on
this
topic:
Chronic
low
back
pain
560is
associated
with
a
complex
interaction
of
factors
across
the
561biopsychosocial