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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, & Gauntlett‐Gilbert,
2017) and may encompass a plethora of psychologically orientated
approaches, such as cognitive behavioural therapy, compassion‐
focused therapy or mindfulness‐based 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;1–5. © 2019 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/msc 1
with elevated fear‐avoidance 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 decision‐making 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 19‐item 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 six‐point
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 matched‐pairs
signed‐ranks 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 21–64 years)
and number of years of working (range 1–35 years). Physiotherapists
were mainly based in musculoskeletal NHS practice only. Some of
the musculoskeletal physiotherapists also worked in home‐based
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. Twenty‐nine 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 self‐perceptions 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 five‐point 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 two‐thirds (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 follow‐up 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 self‐reported
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 “other”treatments 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 “absolute”definition 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, “other”and “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 self‐manage 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 evidence‐to‐
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;1–5.
https://doi.org/10.1002/msc.1384
YOUNG ET AL.5