There is considerable evidence demonstrating the multi-dimensional nature of non-specific low back pain (NSCLBP)[1], and recent guidelines and mission statements recommend a broad bio-psychosocial (BPS) approach to NSCLBP [2,3]. However, despite growing awareness of the value of embedding psychosocial factors into clinical practice recent studies suggest that physiotherapists lack confidence and competence to extend their scope of practice to include these dimensions [4-7]. This has been attributed to traditional undergraduate biomedical training and lack of available post-graduate training opportunities [4,8].
We recently published two qualitative studies; the first study [9] explored the perceptions of physiotherapists in primary care in managing NSCLBP from a BPS perspective. The results of this study resonated with recent evidence in that the physiotherapists demonstrated a strong recognition of the multi-dimensional nature of NSCLBP but highlighted challenges in delivering a broad model of care. These challenges included managing patients’ unhelpful causation beliefs and strong expectations for biomedically oriented treatments, a self-reported lack of confidence and competence to address patients’ psychological factors (cognitive and emotional), and a lack of time to manage patients well who were deemed to be at high risk of developing persistent pain. They also stressed the importance of empowering patients to self-manage their NSCLBP, but acknowledged that engaging patients in this process was not always straightforward. This study suggests that awareness of best evidence guidelines is no guarantee that such perspectives are necessarily translated into actual practice, and highlights the need for training better aligned to a contemporary understanding of NSCLBP and recommended guidelines.
These key insights derived from study 1 helped to inform the content and delivery of a 10-month training programme in Cognitive Functional Therapy (CFT), a psychologically informed physiotherapy intervention for NSCLBP [10]. This programme included a mix of theoretical and experiential learning approaches, including direct clinical observation and feedback in the physiotherapist’s own clinical environment, as well as face to-face video review sessions of their recorded assessments from the pre-training observation period. This programme aimed to change clinical behaviour and develop the competencies and confidence required by physiotherapists to embed broad BPS perspectives into their practice.
The second qualitative study [11] explored the physiotherapists’ perceptions of managing NSCLBP following this training programme. The results of this study highlighted the learning challenge of extending scope of practice. The physiotherapists felt that the approach required structured learning to accurately identify pain drivers and develop competencies to deliver effective interventions tailored to each patient’s unique BPS profile. However, the formal training enhanced the physiotherapists’ self-reported confidence in identifying and addressing psychosocial factors and raised their awareness of developing patient understanding of these factors. The physiotherapists also reported changes in the way they communicated with patients, stressing the importance of experiential learning and video review in raising their awareness of effective communication practice. Although their enthusiasm for this approach was clear, as they reported better outcomes, a lack of time and difficulty to engage patients with strong biomedical beliefs were seen as possible barriers to implementing this approach. Both qualitative studies identified that patient beliefs and treatment expectations represented barriers to effective care suggesting that more consideration should be given to addressing such beliefs at population levels and creating a cultural shift in understanding [12].
The most effective training model to equip physiotherapists to implement best practice guidelines remains elusive. However, our second study suggests that successfully integrating psychologically informed physiotherapy interventions into routine practice will require training that is experiential, extensive and multi-staged over time. Such training has obvious implications in terms of levels of physiotherapist commitment and resources required, but would appear important to better translate awareness of recommended guidelines into changes in clinical behaviour.
Work underway
A novel aspect of these two studies is that the physiotherapists’ perceptions in studies 1 and 2 were, in part, contextualized around their experiences of assessing and treating two NSCLBP patients that were video-recorded and observed by myself. These recorded “live” encounters allowed the research team to observe therapist-patient interaction and capture the physiotherapists’ ‘actual’ clinical behaviour, rather than relying on proxy measures. There is currently a lack of interactional evidence supporting physiotherapists’ willingness or ability to successfully achieve recommended ideals of practice, and these recorded data gave us an opportunity to analyse communication practice using a qualitative data-driven inductive method called conversation analysis. These data not only provided empirical data on physiotherapists’ communication approach it also allowed us to use this data as part of the training approach that attempted to change communication practice. These papers are currently under review.
About Ian Cowell
Ian is a physiotherapist who works in private practice in the UK. He is in the final year of a part-time PhD at Imperial College London, evaluating the training requirements for physiotherapists to implement psychologically informed physiotherapy approaches for low back pain. He is a CFT clinical educator and part of a research group that promotes evidence-based assessment and management of chronic pain www.pain-ed.com. I would like to acknowledge the funding from the Private Physiotherapy Educational Foundation and the Musculoskeletal Association of Chartered Physiotherapists.
References
[1] Hill, J.C. and J.M. Fritz, Psychosocial influences on low back pain, disability, and response to treatment. Physical Therapy, 2011. 91(5): p. 712-21.
[2] NICE, National Institute for Health and Care Excellence: Clinical Guidelines. Low Back Pain and Sciatica in Over 16s: Assessment and Management, 2016.
[3] Foster, N.E., et al., Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet, 2018. 391(10137): p. 2368-2383.
[4] Synnott, A., et al., Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J Physiother, 2015. 61(2): p. 68-76.
[5] Sanders, T., et al., Biopsychosocial care and the physiotherapy encounter: physiotherapists’ accounts of back pain consultations. BMC Musculoskelet Disord, 2013. 14: p. 65.
[6] Zangoni, G. and O.P. Thomson, ‘I need to do another course’ – Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain. Musculoskelet Sci Pract, 2017. 27: p. 71-77.
[7] Brunner, E., et al., Physical Therapists’ Ability to Identify Psychological Factors and Their Self-Reported Competence to Manage Chronic Low Back Pain. Phys Ther, 2018. 98(6): p. 471-479.
[8] Foster, N.E. and A. Delitto, Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice–challenges and opportunities. Phys Ther, 2011. 91(5): p. 790-803.
[9] Cowell, I., et al., Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskelet Sci Pract, 2018. 38: p. 113-119.
[10] O’Sullivan, P.B., et al., Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther, 2018. 98(5): p. 408-423.
[11] Cowell, I., et al., The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study. Musculoskeletal Care, 2018.
[12] O’Keeffe, M., et al., Mass media campaigns are needed to counter misconceptions about back pain and promote higher value care. Br J Sports Med, 2018.