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Psychologically informed approaches to chronic low back pain: Exploring musculoskeletal physiotherapists' attitudes and beliefs

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SHORT REPORT
Psychologically informed approaches to chronic low back pain:
Exploring musculoskeletal physiotherapists' attitudes and
beliefs
Doré Young
1,2
|Michael Callaghan
2,3,4
|Carianne Hunt
5
|Michelle Briggs
2,6
|Jane Griffiths
6
1
University of Manchester, Manchester, UK, England, United Kingdom
2
Manchester University Hospitals NHS Foundation Trust, Manchester, UK, England, United Kingdom
3
Department of Health Professions, Manchester Metropolitan University, Manchester, UK, England, United Kingdom
4
Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK, England, United Kingdom
5
CLAHRC GM Alliance Manchester Business School, University of Manchester, Manchester, UK, England, United Kingdom
6
University of Manchester, Manchester, UK, England, United Kingdom
Correspondence
Doré Young, The Vallance Health Centre, Brunswick Street, Manchester, UK.
Email: dore.young@mft.nhs.uk
KEYWORDS
attitude, back pain, belief, physiotherapist, psychological
1|INTRODUCTION
In the UK, low back pain (LBP) is the leading cause of disability and
accounts for 14% of all primary care consultations (Sowden et al.,
2011). The National Institute for Health and Clinical Excellence
(2016) guidance for the assessment and management of LBP recom-
mends combined physical and psychological therapies (CPPP) as part
of a treatment package. Psychologically informed practice is defined
as all treatments in which physiotherapy is delivered within a psycho-
logical framework (Wilson, Chaloner, Osborn, & GauntlettGilbert,
2017) and may encompass a plethora of psychologically orientated
approaches, such as cognitive behavioural therapy, compassion
focused therapy or mindfulnessbased therapies. It is based on identi-
fying psychological and behavioural processes that affect pain percep-
tion; the response to the pain experience; and elements which may be
modified (Keefe, Main, & George, 2018; Main & George, 2011).
Encompassing a biopsychosocial management approach to LBP may
be used in combination with other treatment techniques often used
by musculoskeletal physiotherapists, such as exercise or manual ther-
apy (Foster et al., 2018; Foster & Delitto, 2011; National Institute for
Health and Clinical Excellence, 2016; Sowden et al., 2011). There is
growing interest in the use of psychological approaches within the
physiotherapy management of LBP in musculoskeletal settings (Artus,
van der Windt, Jordan, & Hay, 2010; Foster et al., 2018; Foster &
Delitto, 2011; Kamper et al., 2015; National Institute for Health and
Clinical Excellence, 2016).
There is a robust evidence base supporting the use of psycho-
logical interventions, primarily cognitive behavioural approaches, in
LBP and their superiority to minimal or no treatment (Artus et al.,
2010; Keefe et al., 2018; Keller, Hayden, Bombardier, & van Tulder,
2007; National Institute for Health and Clinical Excellence, 2016;
Oliveira et al., 2012; Wilson et al., 2017). Although attempts have
been made to classify and refine interventions, it is unclear exactly
which psychological techniques, or combinations, in which clinical
setting are most effective (Artus et al., 2010; Keefe et al., 2018; Kel-
ler et al., 2007; National Institute for Health and Clinical Excellence,
2016; Oliveira et al., 2012; Wilson et al., 2017). A wealth of research
recommends using an assessment tool, such as the Subgroups for
targeted treatment (STarT) Back, to stratify patients into subgroups;
this supports the delivery of specific, targeted treatments and the
identification of patients likely to benefit from CPPP (Hansen,
Daykin, & Lamb, 2010; Hartvigsen et al., 2018; Hill et al., 2011;
National Institute for Health and Clinical Excellence, 2016; Sowden
et al., 2011; Whitehurst et al., 2015; Wilson et al., 2017).
Alexanders and Douglas (2016) and Richmond et al. (2018)
highlighted that there have been challenges in the uptake, implemen-
tation and delivery of psychological approaches within musculoskele-
tal physiotherapy practice. There is a lack of clarity as to the reasons
behind this, although training, competence, workplace culture and
the beliefs of the physiotherapist have been suggested (Alexanders
& Douglas, 2016; Houben, Gijsen, Peterson, De Jong, & Vlaeyen,
2005; Richmond et al., 2018; Sowden et al., 2011). Physiotherapists
Received: 3 December 2018 Revised: 17 December 2018 Accepted: 18 December 2018
DOI: 10.1002/msc.1384
Musculoskeletal Care. 2019;15. © 2019 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/msc 1
with elevated fearavoidance beliefs themselves may be more likely to
advise patients to limit work and physical activities, and may be less
likely to adhere to best practice guidelines (Darlow et al., 2012). This
highlights the potential association between clinicians' attitudes and
beliefs, and their management of patients with LBP.
There were several aims to the present study. The first aim was
to establish whether musculoskeletal physiotherapists have a more
biomedical or biopsychosocial orientation in their approach to LBP
management. The second objective was to explore the attitudes
and beliefs of those musculoskeletal physiotherapists, their under-
standing of psychologically informed approaches, and their confi-
dence to use them in clinical practice. The third objective was to
determine the LBP management techniques used by these physio-
therapists. Finally, we aimed to establish the potential barriers of
integrating psychological approaches into a musculoskeletal physio-
therapy setting.
2|METHODS
2.1 |Ethical approval
Completion of the National Health Service (NHS) Health Research
Authority decisionmaking questionnaire indicated that ethical
approval was not required. This was confirmed with local peer review
of the study protocol by the National Institute of Healthcare Research
(NIHR) Collaboration for Leadership in Applied Health Research Team
and Care for Greater Manchester (CLAHRC GM) and the University of
Manchester.
2.2 |Study design
The anonymous electronic survey was emailed to all 34 physiothera-
pists employed in musculoskeletal practice at a large NHS Trust in
the UK. Participants were asked to consider patients 16 years or over,
who had LBP for a duration of 12 weeks or over, with or without
sciatica and were without red flags or signs of serious pathology.
Any physiotherapists who had not treated a patient with LBP in the
last 6 months, and incomplete surveys were excluded.
The survey consisted of three parts: firstly, general information
about each physiotherapist; secondly, a Likert scale to assess the
physiotherapist's thoughts and opinions surrounding psychologically
informed approaches and other treatment techniques; and, thirdly,
the 19item modified Pain Attitudes and Belief Scale, (PABS) to cate-
gorize physiotherapists as having a biomedical or biopsychosocial
treatment orientation (Houben et al., 2005). The PABS has a sixpoint
scale, from which a respondent indicates the extent to which they
agree or disagree with each of the 19 items (Totally disagree=1
or Totally agree= 6). The subscale scores are calculated by a summa-
tion of the responses to the subscale items: the higher the score on a
subscale, the stronger the treatment orientation (Darlow et al., 2012;
Houben et al., 2005).
2.3 |Data analysis
IBM SPSS Statistics Version 23 was used for analyses. As data were
not normally distributed, descriptive statistics were reported as
median and interquartile ranges (IQRs). A Wilcoxon matchedpairs
signedranks test was used to test for differences between paired var-
iables. Spearman's rho correlation was used to measure the associa-
tion between variables.
3|RESULTS
There was a 100% response rate within 3 weeks. One responder was
excluded for not having treated a patient with LBP within the last
6 months, and one questionnaire was incomplete. Therefore, 32 sur-
veys were used in the analysis.
The sample comprised similar numbers of men and women (15
men, 17 women) but there was a variation in age (range 2164 years)
and number of years of working (range 135 years). Physiotherapists
were mainly based in musculoskeletal NHS practice only. Some of
the musculoskeletal physiotherapists also worked in homebased
physiotherapy, orthopaedics, rheumatology outpatients and in emer-
gency departments.
3.1 |Biomedical or biopsychosocial orientation
Cumulative scores from the PABS were higher for biopsychosocial
(median = 36.0, IQR = 4.75) than for biomedical (median = 25.0,
IQR =9.75) orientation. Twentynine respondents scored higher on
biopsychosocial orientation (Wilcoxon Matched Pairs Signed Ranks
(WMPSR) Z= 4.52, p< 0.001). There was a significant negative
relationship between selfperceptions of practice as biopsychosocial
or biomedical (Spearman's rho = 0.49, p= 0.004).
3.2 |Importance of psychologically informed
approaches, understanding and confidence
The importance placed on the use of psychologically informed
approaches, understanding and confidence to deliver it was measured
using fivepoint Likert scales. All respondents recognized that psycho-
logical approaches were important, 18 regarding them as extremely,
and 11 as very important (Table 1). A more biopsychosocial orienta-
tion correlated with attributing a higher level of importance to using
psychologically informed approaches (rho = 0.36, p= 0.046). Overall,
respondents felt they understood psychologically informed physio-
therapy, with only a small number (4/32) of physiotherapists rating
their understanding as poor (Table 2). Over twothirds (23/32)
reported that they were somewhat, slightly or not at all confident to
use psychological techniques within physiotherapy (Table 3).
3.3 |Treatment techniques used
The treatment techniques used by the respondents are shown in
Table 4. The predominant treatments were manual therapy, advice
and education, and exercise. The psychologically informed techniques
2YOUNG ET AL.
used were stated as pain education, relaxation, mindfulness, neurosci-
ence education, cognitive functional therapy and cognitive behav-
ioural therapy.
3.4 |Barriers
Physiotherapists reported that reduced knowledge, skills and
confidence were barriers to integrating psychological approaches.
This was due a lack of funding for training, and availability of a local
specialist pain services. Environmental barriers included treatment
time constraints, with short followup appointments. Practitioners
highlighted that the outpatient environment was too busy and lacked
privacy for more complex consultations with patients.
4|DISCUSSION
The perceptions presented by the present sample of physiotherapists
may not relate to what actually occurs in clinical practice. Our results
showed that the musculoskeletal physiotherapists in our sample had a
more biopsychosocial orientation in their approach to LBP management.
All respondents recognized that psychological approaches are important
in the management of this condition. They felt that they understood
the concept, but often lacked the confidence to deliver it. This may be
due, to variations in training, which were not explored in this question-
naire, but were highlighted as a barrier to delivery.
Some biopsychosocially orientated physiotherapists who selfreported
a good understanding of this approach stated that they did not use psycho-
logical techniques, but then, by contrast, went on to describe what could be
considered as psychological techniques under the othertreatments sec-
tion. This may have been due, in part, to physiotherapists overestimating
their understanding. Alternatively, it may have been the result of the
lack of an absolutedefinition of psychologically informed approaches
in physiotherapy or limited implementation guidelines supporting physio-
therapists to assimilate these approaches into musculoskeletal practice.
The physiotherapists in this sample used a variety of treatment
techniques with LBP patients, including acupuncture, which is no lon-
ger recommended in current best practice guidance (National Institute
for Health and Clinical Excellence, 2016). The majority of physiother-
apists used exercise as a treatment, but significantly fewer used CPPP.
Our findings showed that reported use of CPPP was much higher than
that of psychologically informed techniques alone, which may present
further evidence of a lack of consensus and understanding. Psycholog-
ically informed physiotherapy may be an umbrella term for many
psychological techniques, which are therefore open to personal inter-
pretation by individual physiotherapists. This was supported by the
wide variety of educational, otherand psychological techniques
described by physiotherapists. These included pain education, cogni-
tive functional therapy, motivational interviewing, neuroscience edu-
cation, cognitive behavioural therapy and mindfulness.
The physiotherapists in this sample reported barriers to delivery
which included a lack of confidence, insufficient training, a lack
of funding and the unsuitability of the clinical environment. They
highlighted that busy musculoskeletal outpatient departments lack
the privacy to have the more personal conversations which physiother-
apists felt would be required. In order for physiotherapists to support
patients to selfmanage their LBP, they themselves require the appro-
priate support, resources, skills and a suitable environment. Our find-
ings were in keeping with the limited amount of available research in
this field, particularly in relation to the challenges surrounding deliver-
ing psychologically informed approaches within a musculoskeletal
setting, and highlighted the need for further learning opportunities for
physiotherapists (Darlow et al., 2012; Foster & Delitto, 2011; Main &
TABLE 2 How would you rate your understanding of psychologically
informed physiotherapy?
Excellent 1
Very good 4
Good 16
Fair 7
Poor 4
TABLE 3 How would you rate your confidence to deliver psycho-
logically informed physiotherapy?
Extremely confident 0
Quite confident 9
Somewhat confident 10
Slightly confident 8
Not confident at all 5
TABLE 4 Treatment techniques used in the management of lower
back pain
Treatment
Number of physiotherapists
using treatment
Manual therapy 19
Acupuncture 9
Exercise 23
TENS 1
Psychological techniques 6
Electrotherapy 0
Injection therapy 4
Advice and education 27
Combined physical and
psychological programmes
13
TENS: transcutaneous electrical nerve stimulation.
TABLE 1 How would you rate the importance of psychologically
informed approaches to physiotherapy within the management of low
back pain?
Extremely important 18
Very important 11
Moderately important 3
Slightly important 0
Not important at all 0
YOUNG ET AL.3
George, 2011; Richmond et al., 2018). By identifying specific learning
needs, appropriate training opportunities can be supported. This may
involve a workplace cultural change or improved knowledge and skills,
resulting in a shift in the attitudes, beliefs and management approach
of physiotherapists. Training needs may be different for those who
have a biomedical orientation than for those with a biopsychosocial ori-
entation. Therefore, training could be specifically tailored to individual
learning needs and treatment orientation.
If psychological techniques are to become well established within
musculoskeletal physiotherapy, further research into the evidenceto
practice gap, and to define and refine psychological interventions,
would be of benefit. This would encompass a clear definition of psy-
chologically informed approaches for physiotherapists, their feasibility
and detailed guidance on how to incorporate them into a musculoskel-
etal setting. To refine the types of psychological techniques, intensity
and combinations that are more effective in each clinical setting would
support the implementation of current best practice.
5|CONCLUSION
The physiotherapists surveyed had a more biopsychosocial orientation
in their approach to LBP management. They recognized the impor-
tance of psychologically informed approaches, but the majority of
physiotherapists lacked the confidence to deliver it. The most com-
mon treatments used were manual therapy, advice, education and
exercise. Some physiotherapists were using treatments no longer rec-
ommended in best practice guidelines.
Barriers to delivering psychological interventions included a lack
of confidence and training, and an unsuitable clinical environment.
Challenging these barriers may result in a workplace where appropri-
ate use of psychologically informed approaches is commonplace.
Delivering personalized learning packages, tailored to physiothera-
pists' individual needs and treatment orientation, may improve confi-
dence, standardize understanding and facilitate the delivery of an
effective biopsychosocial model of care.
ACKNOWLEDGEMENTS
M. Campbell Statistical support J. Suckley Clinical and dissemination
support.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest that could be
perceived as prejudicing the impartiality of the research reported.
ORCID
Doré Young https://orcid.org/0000-0001-7167-385X
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How to cite this article: Young D, Callaghan M, Hunt C, .
Briggs M, Griffiths J. Psychologically informed approaches to
chronic low back pain: Exploring musculoskeletal physiothera-
pists' attitudes and beliefs. Musculoskeletal Care. 2019;15.
https://doi.org/10.1002/msc.1384
YOUNG ET AL.5
... Dazu ist es notwendig, sich anzusehen, was eigentlich unter solchen Skills verstanden werden kann. Viele TherapeutInnen sind sich scheinbar gar nicht bewusst, welche Handlungsweisen in dieses Feld hineinfallen (Coronado et al., 2020;Young et al., 2019). Aktuell werden aus Sicht befragter PhysiotherapeutInnen Techniken wie Edukation, Entspannungs-und Achtsamkeitstraining, neurophysiologische bzw. ...
... Aktuell werden aus Sicht befragter PhysiotherapeutInnen Techniken wie Edukation, Entspannungs-und Achtsamkeitstraining, neurophysiologische bzw. Schmerz-Edukation, die Cognitive Functional Therapy und die kognitive Verhaltenstherapie als psychologisch informierte Bestandteile in der Physiotherapie betrachtet (Young et al., 2019). Allgemein versuchten Coronado et al (2020) basierend auf der jeweils primären psychologischen Strategie eine Einteilung in vier folgende Kategorien darzustellen. ...
... 'The psychological and emotional aspects of LBP often play a primordial role in the development of LBP; it might be interesting to explore it more deeply'. These results confirm previous research revealing that physiotherapists may lack confidence to deliver a psychologically informed approach to their patients [59] and that this approach should be better integrated into the physiotherapy training curriculum, at least in French-speaking Belgium and France. Other participants highlighted the importance of exercise and wondered whether information regarding the type of exercises could be more elaborated in the module. ...
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Introduction: Low back pain (LBP) is ranked as the first musculoskeletal disorder considering years lived with disability worldwide. Despite numerous guidelines promoting a bio-psycho-social (BPS) approach in the management of patients with LBP, many health care professionals (HCPs) still manage LBP patients mainly from a biomedical point of view. Objective: The purpose of this pilot study was to evaluate the feasibility of implementing an interactive e-learning module on the management of LBP in HCPs. Methods: n total 22 HCPs evaluated the feasibility of the e-learning module with a questionnaire and open questions. Participants filled in the Back Pain Attitude Questionnaire (Back-PAQ) before and after completing the module to evaluate their attitudes and beliefs about LBP. Results: The module was structured and easy to complete (91%) and met the expectations of the participants (86%). A majority agreed that the module improved their knowledge (69%). Some participants (77%) identified specific topics that might be discussed in more detail in the module. HCPs knowledge, beliefs and attitudes about LBP significantly improved following module completion (t = -7.63, P < .001) with a very large effect size (ds = -1.63). Conclusion: I The module seems promising to change knowledge, attitudes and beliefs of the participants. There is an urgent need to develop and investigate the effect of educational interventions to favor best practice in LBP management and this type of e-learning support could promote the transition from a biomedical to a bio-psycho-social management of LBP in HCPs.
... Despite evidence emphasizing the assessment of psychosocial factors in pain population, osteopaths may be inclined to have a greater orientation towards the biomedical rather than the biopsychosocial (BPS) model of care [14][15][16][17] and have a relatively low utilisation of clinical practice guidelines in osteopathic practice [18][19][20]. The reasons for non-adherence to clinical practice guideline recommendations include inadequate knowledge and lack of time, skills and confidence to incorporate a psychologically informed approach in people with chronic low back pain [21,22]. Further, clinical practice guidelines often recommend active interventions (e.g. ...
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Full-text available
Background Clinical practice guidelines commonly recommend adopting a biopsychosocial (BPS) framework by practitioners managing musculoskeletal pain. However, it remains unclear how osteopaths implement a BPS framework in the management of musculoskeletal pain. Hence, the objective of this review was to systematically appraise the literature on the current practices, barriers and facilitators experienced by osteopaths in implementing a BPS framework of care when managing people with musculoskeletal pain. Methods The following electronic databases from January 2005 to August 2020 were searched: PubMed, CINAHL, Science Direct, Google Scholar, ProQuest Central and SCOPUS. Two independent reviewers reviewed the articles retrieved from the databases to assess for eligibility. Any studies (quantitative, qualitative and mixed methods) that investigated the use or application of the BPS approach in osteopathic practice were included in the review. The critical appraisal skills program (CASP) checklist was used to appraise the qualitative studies and the Mixed Methods Appraisal Tool (MMAT) was used to appraise quantitative or mixed methods studies. Advanced convergent meta-integration was used to synthesise data from quantitative, qualitative and mixed methods studies. Results A total of 6 studies (two quantitative, three qualitative and one mixed methods) were included in the final review. While two key concepts (current practice and embracing a BPS approach) were generated using advanced meta-integration synthesis, two concepts (barriers and enablers) were informed from qualitative only data. Discussion Our review finding showed that current osteopathic practice occurs within in the biomedical model of care. Although, osteopaths are aware of the theoretical underpinnings of the BPS model and identified the need to embrace it, various barriers exist that may prevent osteopaths from implementing the BPS model in clinical practice. Ongoing education and/or workshops may be necessary to enable osteopaths to implement a BPS approach.
... Despite evidence emphasizing the assessment of PS factors in pain population, osteopaths may be inclined to have a greater orientation towards the biomedical rather than the biopsychosocial (BPS) model of care (14)(15)(16)(17) and have a relatively low utilisation of CPGs in osteopathic practice (18)(19)(20). The reasons for non-adherence to CPG recommendations may include inadequate knowledge, perceived time, skills and con dence to incorporate a psychologically informed approach in people with chronic LBP (21,22). Further, CPG's often recommend active interventions (e.g. ...
Preprint
Full-text available
Background: Clinical practice guidelines commonly recommend adopting a biopsychosocial (BPS) framework by practitioners managing musculoskeletal (MSK) pain. However, it remains unclear how osteopaths implement a BPS framework in the management of MSK pain. Hence, the objective of this review was to systematically appraise the literature on the current practices, barriers and facilitators experienced by osteopaths in implementing a BPS framework of care when managing people with MSK pain. Methods: The following electronic databases from January 2005 to August 2020 were searched: PubMed, CINAHL, Science Direct, Google Scholar, ProQuest Central and SCOPUS. Two independent reviewers reviewed the articles retrieved from the databases to assess for eligibility. Any studies (quantitative, qualitative and mixed methods) that investigated the use or application of the BPS approach in osteopathic practice were included in the review. The critical appraisal skills program (CASP) checklist was used to appraise the qualitative studies and the Mixed Methods Appraisal Tool (MMAT) was used to appraise quantitative or mixed methods studies. Advanced convergent meta-integration was used to synthesise data from quantitative, qualitative and mixed methods studies. Results: a total of 6 articles (two quantitative, three qualitative and one mixed methods) were included in the final review. While two key concepts (current practice and embracing a BPS approach) were generated using advanced meta-integration synthesis, two concepts (barriers and enablers) were informed from qualitative only data. Discussion: Our review finding showed that current osteopathic practice occurs within in the biomedical model of care. Although, osteopaths are aware of the theoretical underpinnings of the BPS model and identified the need to embrace the BPS model, various barriers exist that stop osteopaths BPS model use in osteopathic clinical practice. Ongoing education and/or workshops may be necessary to enable osteopaths to implement a BPS approach.
... "The psychological and emotional aspects of LBP often play a primordial role in the development of LBP; it might be interesting to explore it more deeply". These results confirm previous research revealing that physiotherapists lack confidence to deliver a psychologically informed approach to their patients [55] and that this approach should be better integrated into the physiotherapy training curriculum, at least in French-speaking Belgium. Other participants highlighted the importance of exercise and wondered whether information regarding the type of exercises could be more elaborated in the module. ...
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BACKGROUND Low back pain (LBP) is ranked as the first musculoskeletal disorder considering years lived with disability worldwide. Despite numerous guidelines promoting a bio-psycho-social (BPS) approach in the management of patients with LBP, many health care professionals (HCPs) still manage LBP patients mainly from a biomedical point of view. This is reflected by overuse of medical imaging and medication, advice to restrict work and activities, and insufficient attention towards psychosocial risk factors during actual consultation, which is all guideline discordant. Implementation strategies designed until now to change HCPs behavior had only limited effects or were not effective at all. OBJECTIVE The purpose of this pilot study was to evaluate the feasibility and effectiveness of implementing an interactive e-learning module on the management of LBP in HCPs. HCPs’ perceptions of their change in knowledge and beliefs about LBP as well as the content, structure, length and access of the module were assessed. METHODS In total 22 HCPs have been recruited. Participants completed and evaluated the e-learning module with an online questionnaire including 20 items based on similar feasibility studies. Likert Scales (n=15) and qualitative open questions (n=5) were both used. Before and after completing the module, participants filled in the Back-PAQ questionnaire to evaluate the potential effect of the module on their attitudes and beliefs about LBP. The Back-PAQ data were analyzed with the paired Student t-test. RESULTS The feasibility of the module was confirmed, it was structured and easy to complete (91%) and met the expectations of the participants (86%). A majority agreed that the module improved their knowledge (69%). According to the HCPs the time to complete the module (36 ± 9.6 minutes) was adequate (91%). Some participants (77%) identified specific topics that might be discussed in more detail in the module. Moreover, HCPs’ knowledge, beliefs and attitudes about LBP significantly improved following module completion (P < .001). CONCLUSIONS The interactive e-learning module seems feasible and effective. Participants were positive regarding the content, they found it sufficient and clear. The module was appealing, structured and easy to complete. Moreover, the module has been effective to change knowledge and beliefs of the participants. Suggestions have been made to improve it in the future.
Article
Background: Persistent pain is the biggest global cause of years lived with disability. Physiotherapists working in pain care aim to take a holistic perspective helping persons to gain a multidimensional understanding of their condition and achieve meaningful goals despite their symptoms. In recent years there has been a paradigm shift in physiotherapeutic pain care toward a psychologically informed physiotherapy approach. Physiotherapists have incorporated principles of strategies such as: cognitive behavioral therapy (CBT); acceptance and commitment therapy (ACT); psychological flexibility; or mindfulness-based therapies in helping persons move forwards despite their pain. Objectives: The purpose of this study was to explore the lived experience of physiotherapists using psychological strategies in pain care. Methods: Seven participants were purposefully recruited for this study and data was collected through semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Master themes were developed to help express the qualitative meanings of the lived experiences. Findings: Seven master themes were identified: 1) Trust; 2) Active listening; 3) Developing understanding; 4) Exploring the journey; 5) Making it meaningful; 6) Being held; and 7) Holding space and sitting with emotions. All themes are interwoven and profoundly connected in the essence of a safe "space." Conclusion: Participants described a journey toward holding space and sitting with emotions. All themes were interwoven and profoundly connected in the essence of a safe "space," where persons can voice their emotions in a non-judgmental environment. The themes may represent a pathway for the physiotherapist to facilitate a person on their journey of healing.
Chapter
Low back pain is a leading cause of musculoskeletal disability worldwide, recorded in both low- and high-income countries. Recent levels of disability associated with low back pain have increased despite a significant increase in expenditure on low back pain management. Effective care for persistent musculoskeletal pain is informed by triage to rule out red flags, identification of pain mechanisms and application of evidence-based interventions. Currently, research on low back pain encourages exercise rehabilitation and pain education, both of which allow for self-management. The person-centered care and shared decision-making of the self-management model can support adherence to prescribed exercise regimens and may lower healthcare utilization. As clinicians we have the responsibility to educate patients, the community, funders, policymakers, and clinicians on self-management to help reduce the disease burden on society. Although the evidence for self-management as a treatment approach in low back pain is just beginning to evolve, contemporary knowledge of pain neuroscience and a move toward patient-centered care may demonstrate improved outcomes in the future.
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Background While the biopsychosocial model is advocated for pain management, biomedical approaches continue to dominate in practice. Understanding musculoskeletal clinicians’ perspectives and practices related to pain can inform training needs to optimize care. Little is known regarding the viewpoint of hand therapists who may not have exposure to modern pain models. Objective To explore hand therapists’ perspectives and practices related to musculoskeletal pain using a biopsychosocial lens. Methods This interpretive descriptive qualitative study was embedded in an explanatory sequential mixed methods design. Thirteen hand therapists in the United States were purposefully sampled based on low and high scores on the Revised Neurophysiology of Pain Questionnaire. Each therapist participated in one semi-structured virtual interview. Data were analyzed using open and a priori codes, which were synthesized into themes that aligned with each domain of the biopsychosocial model. Findings Participants described “balancing local tissues and the brain,” “empowering through education and function,” and “looking beyond the individual.” Recognition of multidimensional components of pain reinforced participants’ awareness that “pain is always real.” Discussion Hand therapists appreciated pain as a multidimensional phenomenon, with biological, psychological, and social facets. However, a potential bias toward structural pathology warrants additional training to promote high-value musculoskeletal care.
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There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.
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To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. Systematic review and random effects meta-analysis of randomised controlled trials. Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials. Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention. Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, -0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery. Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care. © Kamper et al 2015.
Article
Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause—eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.
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Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
Article
Objectives Our objectives were two-fold: (i) to describe physiotherapists’ experiences of implementing a cognitive behavioural approach (CBA) for managing low back pain (LBP) after completing an extensive online training course (iBeST), and (ii) to identify how iBeST could be enhanced to support long-term implementation before scale up for widespread use. Design We conducted semi-structured interviews with 11 physiotherapists from 6 National Health Service departments in the Midlands, Oxfordshire and Derbyshire. Questions centred on (i) using iBeST to support implementation, (ii) what barriers they encountered to implementation and (iii) what of information or resources they required to support sustained implementation. Interviews were transcribed and thematically analysed using NVivo. Themes were categorised using the Theoretical Domains Framework (TDF). Evidence-based techniques were identified using the behaviour change technique taxonomy to target relevant TDF domains. Results Three themes emerged from interviews: anxieties about using a CBA, experiences of implementing a CBA, and sustainability for future implementation of a CBA. Themes crossed multiple TDF domains and indicated concerns with knowledge, beliefs about capabilities and consequences, social and professional roles, social influences, emotion, and environmental context and resources. We identified evidence-based strategies that may support sustainable implementation of a CBA for LBP in a physiotherapy setting. Conclusions This study highlighted potential challenges for physiotherapists in the provision of evidence-based LBP care within the current UK NHS. Using the TDF provided the foundation to develop a tailored, evidence-based, implementation intervention to support long term use of a CBA by physiotherapists managing LBP within UK NHS outpatient departments.
Article
The importance of treating the psychological well-being of patients is increasingly recognised as an integral part of physiotherapy provision and specified in the World Health Organisation (WHO) and National Institute for Health and Care Excellence (NICE) guidelines. However, the term psychology encompasses a huge variety of aspects including; communication skills, goal setting, imagery, personality theories and effective inter disciplinary practices which need be trained. The purpose of this review is to explore the historical development of physiotherapy as a profession in the context of present standards requiring physiotherapists to manage psychological issues that impact rehabilitation. The review will focus specifically on how the role of psychology in practice has evolved and whether this is reflected in current physiotherapy training programmes. Electronic papers were identified through a rigorous search of CINAL, AMED, MEDLINE, PsychINFO and EMBASE. Due to the historical exploration of this review, no time limits were applied to the searches and articles were retrieved as far back as 1894. The history of the profession demonstrates a very ‘hands on’ approach to treatment with minimal psychology related practices. Whilst numerous studies exploring psychology training in physiotherapy have reported significant inconsistencies across UK undergraduate physiotherapy programmes. Due to shifts in the dynamics of healthcare, it is apparent that physiotherapy programmes would benefit from including psychology skills training, as a core module, to meet these ever changing demands. Future research should explore what psychological interventions physiotherapists currently utilise in daily practice, as well as practitioner feelings on the standard and relevance of the psychology content provided in their formal training. Keywords: Physiotherapy, Profession, Undergraduate training, Psychology
Article
Objectives: Psychologically informed physiotherapy is used widely with patients with chronic pain. This study aimed to investigate patients' beliefs about, and experiences of, this type of treatment, and helpful and unhelpful experiences. Design: A qualitative study using Interpretative Phenomenological Analysis of semi-structured interviews. Participants: Participants (n=8) were recruited within a national specialist pain centre following a residential pain management programme including 2.25hours of physiotherapy each day. Participants were eligible for inclusion if they had achieved clinically reliable improvements in physical functioning during treatment. Interviews were conducted 3 months post-treatment. Results: Participants reported differing experiences of physiotherapy interventions and differences in the therapeutic relationship, valuing a more individualised approach. The themes of 'working with the whole of me', 'more than just a professional', 'awareness' and 'working through challenges in the therapeutic relationship' emerged as central to behavioural change, together with promotion of perceptions of improved capability and physical capacity. Conclusion: Psychologically informed physiotherapy is an effective treatment for some patients with chronic pain. Participants experienced this approach as uniquely different from non-psychologically informed physiotherapy approaches due to its focus on working with the patient's whole experience. Therapeutic alliance and management of relationship ruptures may have more importance than previously appreciated in physiotherapy.
Article
Study design: Within-study cost-utility analysis. Objective: To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain). Summary of background data: Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up. Methods: Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence. Results: Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean health care cost savings of £124 and an incremental QALY estimate of 0.023. The likelihood that stratified care provides a cost-effective use of resources for patients at low and medium risk is no greater than 60% irrespective of a decision makers' willingness-to-pay for additional QALYs. Patients at medium and high risk of persistent disability in paid employment at 6-month follow-up reported, on average, 6 fewer days of LBP-related work absence in the stratified care cohort compared with usual care (associated societal cost savings per employed patient of £736 and £652, respectively). Conclusion: At the observed level of adherence to screening tool recommendations for matched treatments, stratified care for LBP is cost-effective for patients at high risk of persistent disabling LBP only. Level of evidence: 2.
Article
Objective: To determine the effectiveness of self-management for nonspecific low back pain (LBP). Methods: We performed a systematic review searching the Medline, Embase, CINAHL, PsycINFO, LILACS, PEDro, AMED, SPORTDiscus, and Cochrane databases from earliest record to April 2011. Randomized controlled trials evaluating self-management for nonspecific LBP and assessing pain and disability were included. The PEDro scale was used to assess the methodologic quality of included trials. Data were pooled where studies were sufficiently homogenous. Analyses were conducted separately for short- (less than 6 months after randomization) and long-term (at least 12 months after randomization) followup. Six criteria for self-management were used to assess the content of the intervention. Results: The search identified 2,325 titles, of which 13 original trials were included. Moderate-quality evidence showed that self-management is effective for improving pain and disability for people with LBP. The weighted mean difference at short-term followup for pain was -3.2 points on a 0-100 scale (95% confidence interval [95% CI] -5.1, -1.3) and for disability was -2.3 points (95% CI -3.7, -1.0). The long-term effects were -4.8 (95% CI -7.1, -2.5) for pain and -2.1 (95% CI -3.6, -0.6) for disability. Conclusion: There is moderate-quality evidence that self-management has small effects on pain and disability in people with LBP. These results challenge the endorsement of self-management in treatment guidelines.
Article
Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control). 1573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406. 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4·7 [SD 5·9] vs 3·0 [5·9], between-group difference 1·81 [95% CI 1·06-2·57]) and at 12 months (4·3 [6·4] vs 3·3 [6·2], 1·06 [0·25-1·86]), equating to effect sizes of 0·32 (0·19-0·45) and 0·19 (0·04-0·33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0·039 additional QALYs) and cost savings (£240·01 vs £274·40) compared with the control group. The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care. Arthritis Research UK.