Embedding Psychosocial PerspectivesWithin Clinical Management ofLow Back Pain: Integration ofPsychosocially Informed ManagementPrinciples Into Physical TherapistPracticeChallenges and OpportunitiesNadine E. Foster, Anthony Delitto

As the biopsychosocial model of health has become increasingly understood, it hasbecome clear that there are complex, interdependent relationships between thephysical and biomedical features of low back pain and the psychological and socialfactors that present concomitantly. Epidemiological studies have not only highlightedthat psychological and social factors are associated with back pain and disability butalso have shed light on the way in which these factors serve as prognostic indicators,or obstacles to recovery, predicting which patients will have a poor prognosis.Integrating the assessment of these obstacles to recovery into physical therapistpractice and using this information to guide clinical decision making have thepotential to improve the quality of care offered by physical therapists by improvingthe targeting of treatments to individuals and enhancing the therapist-patient rela-tionship and adherence to management advice and treatment programs. In turn, suchapproaches may improve both patients clinical outcomes and the efficiency andeffectiveness of service provision, helping direct interventions to those who needthem. This article summarizes the key challenges to embedding psychosocial per-spectives within physical therapist practice for patients with low back pain and theopportunities that could be realized by doing so, and it highlights new developmentsin research, clinical practice, and education that are shaping future directions in thisfield.

N.E. Foster, DPhil, BSc(Hons),MCSP, PGCE, is Professor of Mus-culoskeletal Health in PrimaryCare, Arthritis Research UK Pri-mary Care Centre, Primary CareSciences, Keele University, KeeleST5 5BG, United Kingdom.Address all correspondence toProfessor Foster at: n.foster@keele.ac.uk.

A. Delitto, PT, PhD, FAPTA, is Pro-fessor and Chair, Department ofPhysical Therapy, School of Healthand Rehabilitation Sciences, Uni-versity of Pittsburgh, Pittsburgh,Pennsylvania.

[Foster NE, Delitto A. Embeddingpsychosocial perspectives withinclinical management of low backpain: integration of psychosociallyinformed management principlesinto physical therapist practicechallenges and opportunities.Phys Ther. 2011;91:790803.]

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Given that there is some evi-dence of benefit for interven-tions that physical therapiststraditionally provide for patientswith low back pain, one may ques-tion the added benefit of incorporat-ing psychosocial interventions intothe range of therapeutic options ofthis professional group. For exam-ple, exercise is one of the key inter-ventions within the scope of physi-cal therapist practice that has beenshown to be effective in the second-ary prevention of low back pain andin the management of chronic lowback pain.1,2 Benefits also have beenshown, for example, using direc-tional preference approaches,3 man-ual therapy,4 and acupuncture.57

In addition, the interventions thatphysical therapists offer have beenshown to be cost-effective at currentlevels of willingness to pay.8,9

However, as the biopsychosocialmodel of health has become increas-ingly understood,10 it has becomeclear that there are complex, inter-dependent relationships betweenthe physical and biomedical fea-tures of low back pain and the psy-chological and social factors thatpresent concomitantly. Epidemio-logical studies have not only high-lighted that psychological and socialfactors are associated with back painand disability but also have shed lighton the way in which these factorsserve as prognostic indicators, orobstacles to recovery, predictingwhich patients will have a poorprognosis.1113 It has been arguedthat the transition from recent-onsetpain to chronic pain might be morestrongly associated with psychoso-cial factors than with physicalfactors.10,14

Integrating the assessment of theseobstacles to recovery into physicaltherapist practice and using thisinformation to guide clinical deci-sion making have the potential toimprove the quality of care offeredby physical therapists by improving

the targeting of treatments to indi-viduals and enhancing the therapist-patient relationship and adherenceto management advice and treatmentprograms. In turn, such approachesmay improve both patients clini-cal outcomes and the efficiencyand effectiveness of service provi-sion, helping direct more-intensiveinterventions to those who needthem. However, there is uncertaintyabout how best to integrate psycho-social factors in order to improvepatients outcomes. This articlesummarizes the key challenges toembedding psychosocial perspec-tives within physical therapist prac-tice for patients with low back painand the opportunities that could berealized by doing so and highlightsnew developments in research, clin-ical practice, and education that areshaping future directions in thisfield.

ChallengesThere are many and varied chal-lenges to embedding psychosocialperspectives within physical thera-pist clinical practice. Here, we shedlight on select key challenges forentry-level (professional) physicaltherapy training and current physicaltherapist practice, which are summa-rized in Figure 1.

Entry-Level PhysicalTherapy TrainingThe focus and priorities of entry-level training. Physical therapiststudents choose their career basedon their own perception of physi-cal therapy, often informed bywork experience or placementswithin sports settings or throughtheir own experience of physicaltherapy from personal injuries. Theinitial focus of entry-level trainingtends to firmly consolidate biomedi-cal models of health and illnessand, thus, a fledgling professionalculture starts to develop, to be fur-ther influenced by the opinions ofrespected teachers and clinicians.

Early learning often focuses on mus-culoskeletal problems that studentand junior physical therapists willassess and treat, reinforcing notionsof clear anatomical and pathologi-cal links with pain and disability.The physical assessment and treat-ment emphasis within early trainingstarts physical therapists off on abiomedical perspective of musculo-skeletal pain, which then is dif-ficult to challenge as learning andexperience progresses. Definitionsof physical therapy rely heavily ondisease and injury models of pain,body structure, the application ofphysical agents and modalities, andthe focus on strength (force-generating capacity), movement,balance, and functional abilities.Even at training institutions thatintroduce a biopsychosocial modelof health to students and follownational and international guidanceon rheumatology and pain curri-cula,15,16 the majority of time andattention often is spent on the bio-medical assessment and treatment ofmusculoskeletal problems.

There is much competition for spacewithin entry-level training programs,and priorities are influenced by vari-

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ous professional organizations andregulatory bodies. A recent survey ofCanadian universities17 showed thatundergraduate pain education wasgenerally inadequate and that veteri-nary scientists received more paineducation than health care profes-sionals. A comprehensive survey ofthe curricula of 8 health care profes-sions across the United Kingdomhighlighted that current pain edu-cation is inadequate preparationfor professional practice.16 Teach-ing on pain was often found to bedelivered piecemeal as part of othertopics, and despite the manage-ment of pain often requiring multi-disciplinary approaches, studentstend to learn about pain manage-ment in narrow professional groups.Physical therapist students receivedthe highest input, with an average of37 contact hours dedicated to pain,but there was a bewildering varia-tion (ranging from 5 to 158 hours),and in only one physical therapytraining institution was the Interna-tional Association for the Study ofPain curriculum fully implemented.The amount of time devoted to spe-cific topic areas within programs var-ied widely, and instruction was most

frequently delivered through lec-tures and written patient case exam-ples, with little attention to devel-opment of skills or the learningtechniques that might best supportsuch skill development.16

The American Physical TherapyAssociations (APTAs) NormativeModel of Physical Therapist Pro-fessional Education18 provides aconsensus-based vision for profes-sional education in the United Statesand serves as the primary resourcefor the Commission on Accreditationin Physical Therapy Education whenindividual programs are reviewed. Areview of this document for curricu-lar content in the foundation andclinical science sections reveals lit-tle, if any, emphasis on pain educa-tion. In foundational sciences, painis mentioned only as primary con-tent when considering physiologicresponses to physical agents. Thereis no mention of pain in other rele-vant primary content areas, includ-ing neurophysiology, plasticity, neu-rological function, and psychology.Areas where psychology is consid-ered as primary content in the nor-mative model include emotional

responses to exercise, sport, illness,and disability, but not pain. In clini-cal sciences, pain is not explicitlyaddressed; instead, it is inferredfrom diseases, injuries, or condi-tions that require physical therapyintervention.

The lack of cohesion across entry-level clinical education. In paral-lel, when entry-level students spendtime in clinical placements or prac-tice environments, as they must doto consolidate their learning anddevelop their skills, a cohesiveapproach that spans the traininginstitutions and associated clinicalplacements is largely missing. Theknowledge and skills that are beingdeveloped within entry-level traininginstitutions on integration of psycho-social perspectives may well fail tobe consolidated by their clinical edu-cators, many of whom continue tooperate in the biomedical model, los-ing the opportunity for powerful anddeeper learning on this topic. Theseoften highly respected clinical rolemodels may heavily influence stu-dents perceptions of the relativeimportance of biomedical versuspsychosocial factors within patient

Entry-Level Physical Therapy Training Current Physical Therapist Practice

The focus and priorities of entry-level trainingemphasize anatomical, biomechanical, andbiomedical models.

Physical therapy culture and current physicaltherapist practice propagate anatomical,biomechanical, and biomedical models.

The lack of cohesion across entry-level clinicaleducation environments means thatopportunities to reinforce application of keypsychological informed managementprinciples are lost.

The focus of continuing education for physicaltherapists reinforces the biomedical emphasisfrom entry-level training.

Patients expectations of low back pain andphysical therapy can raise challenges, such astheir expectations about diagnostic certaintyand hands-on treatment approaches.

There is uncertainty about the key psychosocialfactors and how to assess and manage them inways that fit into busy clinical practice.

Reimbursement systems and service priorities donot value management of psychosocial factors.

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

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assessment and management. Thus,even when students develop knowl-edge and competencies in the assess-ment and management of psychoso-cial obstacles to recovery from theirtraining institutions, failure to con-solidate this knowledge and thesecompetencies within clinical envi-ronments essentially halts theirdevelopment.

Most clinical education is carriedout in clinical environments whereadherence to evidence-based stan-dards, in many cases, is less thanoptimal. The students then areexposed, sooner or later, to situa-tions where they are being askedor expected to practice in waysthat are incongruent with the waysin which they were taught. This isperhaps the major entry-level chal-lenge to embedding psychosocialperspectives into physical therapy,that of integration into everyday clin-ical practice.

Current Physical TherapistPracticePhysical therapy culture andcurrent practice. Traditionallythere has been inadequate attentionto psychosocial factors in the physi-cal therapy literature. For example,the most recent online edition of thewidely regarded Guide to PhysicalTherapist Practice19 only superfi-cially includes psychosocial factors,stating that they may have an influ-ence on the complexity of the case,number of visits, and the decision-making process in choosing inter-ventions. Specific to the purposes ofthis perspective, the Guide to Phys-ical Therapist Practice makes norecommendation on which specificpsychosocial factors to measure forpatients with low back pain, despiteconsistent evidence indicatingwhich candidate psychosocial fac-tors might be most appropriate forroutine assessment for that particu-lar practice pattern. Other factorsinfluencing decision making include

the clinicians own beliefs about theeffectiveness of treatments, his orher prior clinical experience, andthe pre-eminence of his or her rela-tionship with the patient.20,21

Physical therapy culture and currentphysical therapist practice for lowback pain have been explored inresearch studies using qualitativeinterviews20,22 and survey question-naires.2328 These studies have high-lighted wide practice variation, anemphasis on the assessment of phys-ical impairments and pain, a lack ofknowledge about the content of clin-ical guidelines and the way in whichphysical therapists pain beliefs influ-ence their behavior within therapeu-tic encounters with patients. Inter-views and observations22 highlighttherapists beliefs regarding thedevelopment of craft knowledgeneeded to manage low back pain andtheir beliefs regarding the clinicalcharacteristics of patients they con-sider as good to treat and the chal-lenge of patients who are seen asdifficult to treat. Daykin and Rich-ardson22 proposed that the physicaltherapists biomedically orientedpain beliefs influenced their clinicalreasoning processes, including theexplanations given to patients. Smartand Doodys29 interviews with expe-rienced physical therapists showedtheir clinical reasoning to reflect anintegration of diverse models andtheories of pain, which the authorstermed mechanisms-based reason-ing of pain.

Survey research has shown that asubstantial proportion of physicaltherapists are unfamiliar with thecontent of clinical guidelines for lowback pain.23 In a large UK surveyusing patient vignettes, Bishop andFoster26 found that although mostphysical therapists recognized whenpatients with low back pain are athigh risk of developing chronicity,many paradoxically recommendedlimitations in patients activity levels

and advised them not to work.Advice to not work was associatedwith more-severe perceived spinalpathology, again suggesting persis-tence of the biomedical model forlow back pain within the culture ofphysical therapy. A survey 3 yearslater of both UK family physicians(general practitioners) and physicaltherapists showed that advice aboutwork was significantly related to theclinicians treatment orientations, asmeasured using the Pain Attitudesand Beliefs Scale (PABS).27 Physi-cians and physical therapists withhigh biomedical and low behavioralorientations were much more likelyto advise continued work absence(44.9%) than those with high behav-ioral scores and low biomedicalscores (11.9%). Several studies haveshown that the attitudes, beliefs, andtreatment orientations of health careprofessionals are associated with theadvice they give to patients as well asthe choice of interventions,3034 beg-ging the question of whether, and towhat extent, these attitudes, beliefs,and behaviors of professionalsinthis case, physical therapistsaremodifiable.

The focus of continuing educa-tion for physical therapists. Fol-lowing graduation, physical thera-pists pursue continuing educationin order to maintain competency,raise awareness of new develop-ments, and meet the requirements ofnational or state relicensure. Perusalof available post-qualifying educa-tion for physical therapists high-lights a plethora of mostly didacticcontinuing education opportunitiessuch as conferences, short courses,and workshops that reinforce thebiomedical emphasis from entry-level training. In the United Kingdom,for example, courses on specificphysical assessment and treatmentapproaches for low back pain arecommonly advertised and attended,yet a physical therapist wanting todevelop confidence and skills in the

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psychosocial assessment and man-agement of patients with musculo-skeletal problems will struggle tofind such educational opportunities.In the United Kingdom, there arevery few interactive educationalopportunities that focus on support-ing changes in practice toward bio-psychosocial models. In the UnitedStates, different states have differentcontinuing education requirements,but based on our anecdotal experi-ences, few of these offerings arerelated to psychosocial models andhow to integrate psychosocial prin-ciples into routine management ofpatients with low back pain.

Patients expectations of lowback pain and physical therapy.Other potential challenges to embed-ding psychosocial perspectives withinphysical therapist practice includepatients preferences and expecta-tions. Patients and, indeed, the gen-eral population have specific beliefsand expectations about low backpain and physical therapy treat-ments.35 The public expects healthcare professionals to be able to tellthem exactly what is wrong withtheir back, and 10 years ago mostexpected to have a radiograph.36

More recent data show that patientsexpect a physical examination andthe right diagnosis.37 Patients withchronic low back pain continue toexpect symptomatic improvementsand can have very clear ideas ofwhat treatment will entail.35 Someof these patients may be seen asdifficult or problem patients byphysical therapists, given their morecomplex health care needs andperceived resistance to self-careapproaches.35 Anecdotally, physicaltherapists want to deliver credibletreatments to their patients; thus,meeting patients expectations maybe a key driver in the selection ofboth assessment and managementapproaches. For example, if a newpatient refers to what he or she per-ceives to have been a previously suc-

cessful intervention, a physical ther-apist may decide to offer similartreatment for this back pain episode,irrespective of best practice recom-mendations, in order to try to meetthe patients treatment expecta-tions. Several studies have reportedhigher patient satisfaction with hands-on treatment approaches,3840 andthis finding may influence physicaltherapists decision making abouttreatments.

Uncertainty about the key psy-chosocial factors and how toassess or manage them. Therehas been much uncertainty by phys-ical therapists about which psycho-social obstacles to recovery inpatients with low back pain are themost important to identify, assess,or focus on within clinical manage-ment. Even physical therapists whohave been eager to integrate psy-chosocial perspectives into practicefor some time have been somewhatundermined by the ambiguity sur-rounding how best to do this inways that can be easily embeddedin routine practice. Many psycho-social factors are reported to beimportant obstacles to recovery, suchas patients fear avoidance,4144 cata-strophizing,4547 perceptions aboutrisk of persistence,48 depression,45,48

self-efficacy,49 expectations,10,44,49,50

beliefs about the future,51 and illnessperceptions regarding their backproblem.52 Clearly, the assessmentand management of all of these fac-tors cannot be integrated into every-day practice.

Even for those factors that appear tohave a relatively consistent evidencebase, there is only limited evidenceabout specific measurement proper-ties. For example, the diagnosticaccuracy of brief screening ques-tions has only been established for afew factors.53 Rather, the screeningtools that have been available arelengthy and not suited for routineuse in busy clinical practice, and

some have complicated scoring sys-tems.53 The current variation in prac-tice in the psychosocial factors thatare assessed or addressed28 could belargely a consequence of this dearthof easy-to-use assessment and screen-ing tools. Long54 has already identi-fied that practice style differencesflourish in environments of profes-sional uncertainty.

A further challenge is the dearth ofknowledge and confidence aboutwhat to do with patients for whomkey psychosocial obstacles to recov-ery are identified. Kent and col-leagues28 pointed out that the uncer-tainty about effective interventionsfor patients who have psychosocialobstacles to recovery may well meanthat clinicians do not see the value inroutine assessment of these factors.Some of these psychosocial obsta-cles to recovery (eg, pain-relateddistress, perceptions of poor per-sonal control, catastrophizing, fearof movement) are likely to be modi-fiable using physical therapy treat-ment approaches. Other factors,such as unemployment, low levelsof perceived job control, and socialisolation, may be much more chal-lenging to address within the con-text of physical therapy servicesalone. Many physical therapists workin settings where there are no, orlimited, patient pathways to, forexample, mental health specialists.This situation may serve to furtherinhibit physical therapists fromopening the black box of patientscognitive appraisals and emotionalconsequences of their pain. Theyfear they are ill-equipped to managethese problems and may well havelittle or no support from other spe-cialists in pain management teams.55

There are many pain managementcourses of varying quality and spe-cific relevance to low back painavailable; thus, the current picture inphysical therapy is one of highly vari-able levels of competence and con-fidence in the assessment and man-

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agement of patients with low backpain in whom key psychosocialobstacles to recovery are important.

Reimbursement systems and ser-vice priorities. In some healthcare systems, physical therapist prac-tice is heavily influenced by the reim-bursement systems in place. This sit-uation is problematic given thatthese reimbursement systems lookto standards of practice rather thanbest or optimal practice. For exam-ple, a study of practice in the Neth-erlands showed that the mean num-ber of treatment sessions (X10)was similar to the number eligiblefor reimbursement by their publichealth insurance funds.25 The fee-for-service model that dominates reim-bursement in the United States rarelyincludes reimbursement codes forpsychosocial interventions in physi-cal therapy. In other health care sys-tems, such as the National HealthService in the United Kingdom, thereare increasing pressures on waitingtimes and access to physical therapyservices. Service managers are con-stantly looking at ways to delivermore efficient and more accessibleservices, using routinely collecteddata on waiting times and patient

numbers to justify service changeswithout supporting systematicallycollected clinical or cost outcomedata. New service initiatives in theUnited Kingdom include, for exam-ple, physical therapy telephoneassessment and treatment,56 self-referral57 and increased reliance onphysical therapist assistants andtechnical staff in patient manage-ment. In these contexts, it may beparticularly challenging to offer thetime some patients with low backpain and key psychosocial obstaclesto recovery may need to elicit andaddress these issues successfully.Anecdotally, physical therapists inthe United Kingdom have expressedconcerns about identifying psycho-social issues with patients, given thelimited amount of time and numberof treatment sessions they are able tooffer patients in a resource-strappedhealth care system. In the UnitedStates, similar trends are evident, asmanaged care initiatives limit thenumber of sessions and the amountof time per session that therapistsspend with patients. The end resultof these pressures is that currentclinical environments act as a disin-centive to directly address psycho-social factors and may encourage

further application of biomedicalapproaches, as they are most familiarto most practicing clinicians.

OpportunitiesDespite these challenges, manyopportunities are available to physi-cal therapists to facilitate embeddingpsychosocial perspectives withinclinical management of low backpain. Again, we present these keyopportunities under the 2 broadheadings of Entry-Level PhysicalTherapy Training and CurrentPhysical Therapist Practice, andthey are summarized in Figure 2.

Entry-Level Physical TherapyTrainingChanging the focus and prioritiesof entry-level training in pain.Given the woefully inadequatepain education identified in entry-level training programs58 and theburden of pain in the general popu-lation, there are many opportunitiesfor improvement. Recent studieshave shown that single modules onlow back pain59 and physical therapydegree courses60 can bring aboutmore positive student attitudestoward function despite pain. Equip-ping students with knowledge of

Entry-Level Physical Therapy Training Current Physical Therapist Practice

Change the focus and priorities of entry-level training toemphasize integrated biopsychosocial models andconsider the value of benchmarking standards in paineducation and interprofessional education.

Gather more evidence from clinical trials about theoutcomes of patients managed through biopsychosocialmanagement approaches and from implementationstudies about how to facilitate tangible shifts in physicaltherapist practice.

Facilitate cohesion across entry-level clinical educationusing, for example, interprofessional clinical education,different educational methods, and innovative academicand clinical partnerships.

Enhance the role of physical therapists in educatingpatients and the public, using all available media.

Identify and target key psychosocial factors moresystematically and use them in decision making abouttreatment and advice about work.

Change the reimbursement system and service prioritiesto include patient-reported outcome measures andoptimal standards of care to positively influenceimprovements in practice.

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

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psychosocial models of chronic mus-culoskeletal pain development andmore specific knowledge about thekey psychosocial obstacles to recov-ery in low back pain and providingbetter clarity about how to structuretheir assessment and reassessmentare areas for improvement. Emphasison the limitations of the biomedicalmodel also should be a standard partof entry-level education. For exam-ple, students should be well versedin the limitations of imaging findingsfor the management of low backpain. Greater specificity about whichpatient behaviors are best to targetwithin rehabilitation will help focusinterventions on supporting pati-ents to achieve meaningful livingeven in the context of persistentpain. Teaching methods on psycho-social issues and their impact on theeffectiveness of physical therapycould better utilize adult learningtheories, encouraging problem solv-ing, deeper learning, and skill devel-opment rather than knowledgerecall alone. It is likely that in orderto provide competent and confidentphysical therapists who can inte-grate psychosocial perspectives intolow back pain management, teach-ing approaches that facilitate inter-personal, communication, behaviorchange, and problem-solving skillsare needed. Skills in establishing atherapeutic relationship that encour-ages disclosure are likely to be veryimportant.61 These approaches maychallenge the traditional therapeuticstyles often seen within physicaltherapy consultations.

Utilizing specific frameworks uponwhich to hang learning about thebiopsychosocial aspects of the painexperience and guide decision mak-ing about interventions also may behelpful, facilitating tangible shiftsaway from a sole focus on the bio-mechanical and physical features ofthe back problem. A promising casereport published recently used theWorld Health Organizations Inter-

national Classification of Function-ing, Disability and Health (WHO-ICF) as a framework for physicaltherapists to understand eachpatients experience of his or herback problem and assist in treatmentselection.62

The use of education benchmarksmay offer an additional opportunityto improve entry-level training. Forexample, the British Pain Society58

recommends that educational stan-dards from professional regulatorsand Quality Assurance Agency(QAA) subject benchmark state-ments should include pain-relatedknowledge and competencies toensure they are integrated into thecurricula. Currently, for example,physical therapy in the United King-dom has recommended standards byprofessional bodies but has estab-lished no QAA benchmarks for pain-related knowledge.

A further opportunity to improveentry-level training in pain is inter-professional education. Interprofes-sional education models that include2 or more health care professionalscan improve physical therapistsunderstanding of their own and oth-ers roles and develop teamwork andcollaborative problem solving. Inter-professional education that includespain specialists and physical thera-pists, for example, may better equipfuture physical therapists to appreci-ate the practical aspects of psycho-social evaluation and treatment ineveryday clinical situations. Manyhealth care professions are advo-cating interprofessional educationalmodels to better prepare their stu-dents for the workplace by embed-ding collaborative practice environ-ments as part of the learningexperience.63

With regard to adding content toentry-level physical therapy curri-cula, a successful strategy was usedby the orthopedic community

when it was determined that man-ual therapy content was either notas explicit as it should be or simplylacking. To address this concern, atask force was formed by APTAand its components along with theAmerican Association of Orthopae-dic Manual Therapists. First, theessential elements of a manual ther-apy curriculum were determinedby a consensus of expert academi-cians and clinicians and publishedas proceedings.64 The proceedingsincluded curriculum resources thatcould serve as a resource to anyphysical therapy program, such ascurricular content (eg, theory, prin-ciples, technique, clinical educationconsiderations), sample instructionalmaterials (eg, syllabi content, labora-tory handouts), and instructor quali-fication criteria. As part of the ongo-ing review, material from the manualwas used as a guide to influence stan-dards and criteria in the Commissionon Accreditation in Physical TherapyEducation to better ensure concor-dance between the relevant evalua-tive criteria related to manual ther-apy and the findings of the taskforce. A similar approach could beconsidered for pain components ofthe physical therapy curriculum,whereby a consensus panel can beassigned to construct a similar man-ual to be used to facilitate more com-prehensive coverage of pain.

Facilitate cohesion across entry-level clinical education. As wellas agreeing on benchmarks uponwhich to judge training institutions,there is much opportunity to facili-tate more cohesive pain educationflowing from the educational institu-tion into the clinical practice settingswhere students gain their experi-ence. Tools to achieve this aiminclude interprofessional educationin the clinical environment, differentmethods of education, and joint clin-ical/academic posts and academic/clinical partnerships. Interprofes-sional efforts may be particularly

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well suited for clinical environmentsand can serve a number of purposes.First, they provide opportunities forphysical therapist students and otherhealth care professionals to learnfrom one another in an applied envi-ronment. Second, they facilitate theapplication of the material deliveredlargely in a theoretical framework tothe patient. Furthermore, they createan environment that facilitates rolemodeling of interprofessional behav-ior, which is much needed by futureprofessionals involved in the treat-ment of patients with pain.

Different education methods may behelpful; for example, a train-the-trainer model65 may help to spreadtraining and confidence among clini-cians in the psychosocial manage-ment of back pain. Team reviews ofpatient cases as well as innovativeways of involving patients them-selves in the education of physi-cal therapist students may helpachieve early focus on the prob-lems described from patients per-spectives rather than the traditionalclinician-led assessment and identifi-cation of key problems.

Other opportunities include jointposts for experienced physical ther-apists between research and clinicalsettings to help embed a culture ofevidence-based practice, supportingcolleagues to review relevant high-quality research evidence and agreeon changes to practice and to helpfacilitate plan-do-study-act cycles ofimprovements in practice. Theseclinical champions can be seen asenthusiastic and professional rolemodels who can mentor and sup-port colleagues in making suggestedchanges. There are real opportuni-ties for academic institutions andprogressive clinical environments towork together in active partnershipswhere integrated biopsychosocialtraining is modeled to the student aspart of standard of care. There arefew such integrated partnership

models currently in use. The shortcourse training culture embeddedalready within physical therapistpractice could be further enhancedby agreeing on specific and measur-able goals that are reviewed on aregular basis to support meaningfulshifts in practice within a learningorganization culture.

Current Physical TherapistPracticeMore evidence from clinical trialsand implementation studies.Undoubtedly, further high-qualityresearch evidence and patient out-come data are needed showing thatintegrating psychosocial perspec-tives into physical therapist practiceleads to better outcomes. The cur-rent evidence base is promising66,67

but not yet compelling.68,69 Themost recent United Kingdom guide-lines for the management of lowback pain6 recommend intensivecognitive-behavioral intervention (ofapproximately 100 hours) forpatients who fail to improve afterreceiving first-line recommendedtreatments of exercise, manual ther-apy, or acupuncture. Most physicaltherapists, however, are unable toprovide this level of intensive inter-vention for their patients, and thereis some question as to who wouldbe the preferred provider for thiscognitive-behavioral intervention.New trials testing whether patientssubgrouped on the basis of risk sta-tus, integrating information aboutpsychosocial prognostic indicators,and matching them with less-intensive, targeted treatments arelikely to contribute useful informa-tion for physical therapists.70 Thistype of quality evidence, over time,will begin to be incorporated intobest practice guidelines for low backpain.

The reality is that even when thereis good evidence to support changesin practice, we are still unclearabout optimal implementation strat-

egies.71 Passive dissemination of infor-mation is generally ineffective,71

and even contextualized, free infor-mation posted directly to physicaltherapists has small effects.72 It isclear that there is no single magicbullet, but that multiple and spe-cific implementation strategies, andperhaps financial incentives and mar-keting approaches, are likely to beneeded to support tangible changesin practice.71 A key opportunity inthis is that we are now better ableto provide recommendations aboutpsychosocial issues that are clear,specific, and unambiguouskeyattributes needed for recommenda-tions in practice (the Appraisal ofGuidelines Research and Evalua-tion73) and that we have lacked untilrecently.

Several groups around the worldhave been investigating whether keybeliefs, attitudes, and behaviors ofclinicians can be modified,7477 and,to date, there are mixed results.Training programs tested invariablyinclude facilitating a shift from think-ing of low back pain as a disease ofthe body and the spine to that of ahealth condition caused by the inter-relationships of factors within theindividual and between the indi-vidual and his or her environment,including family relationships andwork. Stevenson and colleaguesshowed that a brief training programcan effect some changes in attitudestoward evidence-based practice,78

but did not result in actual changesin physical therapist practice.79

Overmeer and colleagues74 showedthat the pain beliefs and attitudesof physical therapists changed fol-lowing an 8-day training course;they became more biopsycho-socially and less biomedically ori-ented and their knowledge of andskills related to psychosocial riskfactors increased. Yet, despite thesepositive changes, their patients per-ceived their practice behavior beforeand after the course as similar and

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were equally satisfied with theirtreatment. Vonk et al80 showed thattraining might influence therapiststreatment approaches, as their PABSbiomedical scores decreased follow-ing a training program. However, ina recent study of general practitio-ners treatment orientations, treat-ment recommendations, and treat-ment behaviors and outcomes ofpatients with low back pain, no asso-ciations were found.76

So far, this growing body of researchappears to show that we can mod-ify physical therapists beliefs andattitudes about low back pain, butthat achieving and sustaining mean-ingful changes in practice behaviorare much more difficult. This per-haps remains the ultimate challengefor the future: how to ensure thatquality evidence about psychosocialperspectives in low back pain is actu-ally incorporated into clinical prac-tice by physical therapists for thebenefit of patient care. The solutionsare not simple and are likely to needto include meaningful mentoringprograms and clinical supervision by

clinical experts, interprofessionalgroup discussion of patient cases,outcome data collection and feed-back, and perhaps even peer- andservice-level comparison, plus orga-nizational and reimbursement incen-tives to adopt new ways of working.

Enhanced role of physical thera-pists in educating patients andthe public. The success of some ofthe public awareness campaigns forlow back pain81,82 highlights thepotential role for physical therapistsin educating the public about boththe primary and secondary preven-tion of low back pain. For example,Working Backs Scotland83 is nowbeing relaunched and updated asWeb-based educational and interac-tive material for the Scottish public(www.nhsinform.co.uk/health-zones/scottish-backs.aspx), an initiative ledby a physical therapist. There areclearly many opportunities for phys-ical therapists to get involved ininfluencing patients, and morebroadly, the publics perceptionsabout back pain and its management.

Identify and target key psychoso-cial factors more systematically.Key psychosocial obstacles to recov-ery are becoming clearer; thus, weare in a better position to advocatewhich factors should be the focusfor assessment and treatment. Keypsychological factors include depres-sion, anxiety, fear avoidance, socialisolation, catastrophization, percep-tions about the future, and low per-sonal control.11,12,53 Occupationalfactors that have evidence frommore than one systematic reviewinclude heavy physical demands,ability to modify work, social sup-port, short job tenure, job satisfac-tion, and fears of reinjury.84 As weachieve greater clarity on whichobstacles to recovery to focus on,this should lead to systematic waysto incorporate these factors into edu-cation programs (entry-level andcontinuing education), identify thesefactors in clinical practice, and usethem in decision making about treat-ment, building on the few tools thatare already available.85,86 There ismuch opportunity to develop andvalidate new clinical prediction rules

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

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within physical therapy and toensure they include the assessmentof psychosocial prognostic factors.87

A suggested pyramid for the integra-tion of psychosocial factors into clin-ical practice is given in Figure 3. Atthe base of the pyramid are the com-mon key psychosocial obstacles torecovery that are relatively easy toincorporate into physical therapistpractice, such as enhancing personalcontrol and self-efficacy in patientswith pain. Identifying and addressingthese factors is unlikely to requireintensive additional education andskill development for physical thera-pists. Moving up the pyramid arethe psychosocial factors and inter-vention techniques that are likely torequire more specialist training toidentify and address, but that canand should be part of at least somephysical therapists practice and skillset. At the top of the pyramid arethe patients with psychosocial obsta-cles to recovery who are most likelyto need onward referral to mentalhealth professionals. This modelmay be helpful in directing how toaccomplish better integration of psy-chosocial factors into practice.

Intervention studies are increasinglytrying to develop and test targetedinterventions that modify key psycho-social obstacles to recovery.39,88,89

It is likely to be most useful to focuson beliefs about specific aspects ofpain or treatment, whether as spe-cific targets for cognitive-behavioralintervention or as potential obstaclesto optimal engagement in treat-ment.90 Attempting to address suchbeliefs within a reactivation frame-work has become an integral part ofnew approaches to help preventpain-associated incapacity in bothhealth care settings70 and occupa-tional settings.91 For some patients, itmight be beneficial for physical ther-apists to directly communicate withemployers and managers in order tofacilitate sustained return to work,

but in most cases, simple efforts toidentify and discuss work issuesdirectly with patients can lead to bet-ter work outcomes.84 These effortscould include proposals from theCanadian Medical Association92 suchas discussing expectations aboutreturn to work early on; understand-ing the psychosocial context of thepatients work and his or her workdemands, risks, and return-to-workoptions; and facilitating a return-to-work plan.

Changes to the reimbursementsystem and service priorities.Given that it is clear that in somehealth care systems the reimburse-ment arrangements for services influ-ence the number and content oftreatments offered by physical ther-apists, it must follow that reimburse-ment systems could potentially beused to positively influence improve-ments in practice. In the UnitedKingdom, the Chartered Society ofPhysiotherapy (CSP) has recentlydeveloped a 5-year plan or vision forthe profession.93 Among the manyideas within the CSPs vision, severalhave the potential to positively influ-ence quality improvements in clini-cal practice. For example, beingresearch-informed in all its activity,actively engaging in standardizeddata collection, changing practicein light of changing evidence, andleading and contributing to fit-for-work schemes are all part of theCSPs vision.

These goals are similar to those artic-ulated in other national directives forhealth services about demonstratingreal value in terms of patients out-comes. Recent initiatives in Europe(eg, in Norway and in Scotland)include the start of standardized out-come data collection in physicaltherapy services, and one of the realopportunities of these initiatives willbe to use feedback and peer and ser-vice comparisons to facilitate qualityimprovements in practice. With the

introduction and use of standardizeddata collection on patient outcomesas well as process measures (eg,numbers and waiting times), futurebenchmarking initiatives will befacilitated, likely serving to enhancequality improvements in physicaltherapist practice. The CSPs visionrequires support for coordinated,standardized data collection andclearly defined minimum as well asoptimum standards of care. In addi-tion, there are clear opportunitiesto work with reimbursement sys-tems to identify codes to reflectphysical therapy-led psychosocialassessments and interventions and toidentify and test ways in which toencourage judicious use of psycho-social approaches.

Future DirectionsThere is little question about theneed for more biopsychosocialresearch related to low back pain aswell as innovative ways in which toimplement research findings in oureducational programs and everydayclinical settings. In Figure 4, webriefly highlight key future direc-tions that will facilitate the integra-tion of psychosocial perspectivesinto physical therapist practiceacross the areas of research, clinicalpractice, and education.

ConclusionAlthough it is clear that there aremany and varied challenges to inte-grating psychosocial perspectiveswithin physical therapists manage-ment of low back pain, there alsoare many opportunities to improveon the current order of affairs. Tak-ing advantage of these opportunitiesseems to be especially importantfor low back pain, which is com-monly experienced and has a strongadverse impact on society, yet oftenis not managed from a psychosocialperspective. Ultimately, it is envis-aged that progress in the biopsycho-social management of low back painwill serve to enhance physical ther-

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Future Directions Current Physical Therapist Practice

Research Despite recent advances in our understanding of psychosocial aspects of lowback care, the following research directions should provide important additionalcontributions: a clear set of variables to accurately identify patients in need of more-

intense and comprehensive management;

clearly establish which psychosocial factors are most appropriate asprognostic factors, treatment effect modifiers, and treatment mediators;

accurate and systematic psychosocial screening protocols that are feasiblefor use in clinical practice;

evidence on approaches to better target treatment interventions using moredefined dosages;

high-quality research that tests education strategies at both entry andpostgraduation levels.

Clinical practice One of the greatest challenges facing practice environments is findingappropriate mechanisms with which to provide incentives for physicaltherapists to engage in, and adhere to, best practice recommendations thatinclude appropriate psychosocial assessments and treatments.

Although pay-for-performance concepts and pilot programs have beendesigned with incentives in mind, there has not been a consensus on theirimplementation, yet they have the potential to facilitate both more-widespread use of simple screening tools to identify psychosocial obstaclesto recovery and a clearer focus on their assessment and management. Thisapproach appears to be especially effective if the explicit management ofthe psychosocial obstacles results in better patient outcomes.

Once physical therapists realize that their clinical performance is going to bebased partly on how well they conform to best standards of practice, itwould seem logical that there might be renewed interest in professionaldevelopment activities aimed at increasing knowledge and skills in theassessment and management of psychosocial factors.

Education Entry-level physical therapist programs are already credit rich, with littleroom for additional course material related to psychosocial and pain factors.Thus, the addition of more material related to psychosocial factors mayseem improbable.

However, if education programs are truly dedicated to the notion ofevidence-based care, the time dedicated to specific topics should be relatedto the degree to which these topics have an evidence base for direct impacton clinical management. Such an approach may lead to decisions to spendless time on biomechanical and biomedical areas lacking underpinningclinical evidence and more time on other, more evidence-based areas suchas the detection and elimination of psychosocial obstacles to recovery.

These sorts of arguments can be contentious, as they may require reductionof time or even elimination of some sacred cows within the professionalcurriculum. However, elimination of content areas that lack supportingevidence should be seen as a way to potentially advance the profession intoareas associated with better patient management skills.

Figure 4.Future directions.

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apists clinical practice and scope ofpractice to meet the challenges ofthe impact of musculoskeletal andlow back pain on patients and asso-ciated demand for physical therapyservices.

Professor Foster provided concept/idea/project design and project management.Both authors provided writing.

This article was submitted August 30, 2010,and was accepted January 27, 2011.

DOI: 10.2522/ptj.20100326

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