Abstract
In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, termed “psychologically informed practice,” is offered as a “middle way” between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the “flags” framework, with psychologically informed practice requiring routine and specific consideration of “yellow flags” and “blue flags” (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification—but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential “black flags”). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that are associated with outcome of treatment.
In most health care systems, physical therapists are well placed to identify and address psychosocial risk factors for the development of chronic low back pain. However, a biomedical perspective persists in the education and practice of many physical therapists,1 even though cognitive and behavioral approaches to rehabilitation for low back pain are well established.2 Many physical therapists feel ill equipped to deal with psychosocial factors, possibly because most training is biomedical in orientation, with limited exposure to biopsychosocial management models.3 In our opinion, addressing the continuum of physical and psychosocial factors in patients with low back pain should be part of normal clinical management for physical therapists.
Psychologically Informed Practice as a New Approach to Physical Therapy
The articles in this special issue illustrate various facets of psychologically informed practice, ranging from risk determination to the use of interventions to implement reactivation. In the Figure, we have positioned “Psychologically Informed Practice” between narrowly focused standard physical therapist practice based on biomedical principles and the clinical approaches developed originally for the treatment of mental illness. In the Figure, we also have attempted to integrate the appropriate “flag” decisions that must be made by clinicians in various contexts,4–7 with appropriate color coding representing the focus of the different flags. The referents for the different flags are illustrated in summary form in Table 1 of the Nicholas et al5 article in this special issue. Thus, we recognize that an important part of standard practice is to consider the presence of “red flags” as indicators of serious pathology. Psychologically informed practice is characterized by routine and specific consideration of “yellow flags” and “blue flags” (depending on clinical setting) for determining risk of poor outcome and for identifying the potential for treatment modification. We view the approach as fitting best within a cognitive-behavioral framework, noting that within the field of clinical health psychology, there has been increasing interest in the cognitive-behavioral approach to a range of conditions.8 We distinguish psychologically informed practice, however, from mental health practice, from which the cognitive-behavioral approach was developed, with its primary focus on psychopathology and significant psychiatric symptoms. Finally, “black flags”4 characterize the overall environment or context in which the clinician addressing the other flags must operate, including professional culture, health care policy, and insurance reimbursement. They also include a range of other contextual factors such as cultural, subcultural, ethnic, familial, and economic factors, which clearly have the potential both to limit and to provide incentives for psychologically informed physical therapy practice, but usually are not addressed in interventions at the individual level.
Proposed theoretical framework for the management of low back pain by physical therapists.
The shift in focus necessary to include routine consideration of psychological influences is, in our view, the logical extension of an evidence-based secondary prevention approach within standard physical therapist practice. The goal, therefore, is to not only treat the individual for current symptoms, as has been the traditional role of the physical therapist, but also prevent the development of unnecessary pain-associated activity limitations. This goal may involve changes not only to clinical management at the level of the individual patient encounter, with increased consideration of psychosocial factors, but also to the manner and context of service design and delivery, incorporating appropriate incentives for the management of psychosocial factors.
Special Issue Conclusions
The articles in this issue have covered a broad canvas, and we now offer a synopsis of the key issues that have emerged by highlighting key recommendations and identifying potential future directions for practice and research.
1. Psychologically informed practice as a new clinical framework. Psychological processes are an expected and normal part of the musculoskeletal pain experience.9 Psychologically informed practice has the opportunity to improve clinical and occupational outcomes through appropriate consideration of relevant psychosocial factors. In our summary Figure, we have located this within the flags framework, developed in the context of secondary prevention, in order to highlight practice within its wider clinical, occupational, and social contexts.
2. Influence of psychological factors on the perception of pain and development of disability. Beliefs and emotional and behavioral responses have been long recognized as important concomitants of low back pain and disability. The literature to date has focused primarily on the role of patient beliefs, among which beliefs about the nature of pain, fear, pain catastrophizing, and self-efficacy appear to be particularly important.10 In psychologically informed practice, these beliefs are a primary focus of physical therapists in the management of low back pain. It is recognized that these beliefs are associated with emotional factors (eg, anxiety, depression, anger) and, in turn, influence behavioral responses. We have taken a view that a primary focus on such emotional factors is properly a matter for mental health professionals, but we recommend that in psychologically informed practice, they be addressed as potential obstacles to recovery within a cognitive-behavioral framework, for which currently there is the strongest evidence base in terms of efficacy.11 There has been less attention, although growing interest, in the influence of practitioner beliefs and the extent to which they influence treatment delivery and clinical outcome, in particular changes in behavior (as the ultimate goal).
In developing interventions, we believe that distinguishing modifiable from nonmodifiable psychosocial factors is a critical part of the process, as each may have differing roles in patient management. For example, a nonmodifiable psychological factor may be a powerful predictor of outcome, yet be inappropriate as a treatment target.
Finally, we must emphasize that we are not advocating complete disregard of biomedical approaches. We are mindful of the importance of red flags as indicators of the need for urgent specialist opinion, and we recognize further the important influence of biomedical factors as an integral part of musculoskeletal management. However, current evidence suggests that these factors should be included within a broader framework of assessment and management.
3. Implications for training. Relevant training is a key building block for the development of professional practice, and current training paradigms constitute a significant potential barrier to the established of psychologically informed practice.3 In our view, a fundamental appraisal of the approach to professional physical therapist education and within continuing education is required. This appraisal requires wider consideration of existing professional culture, as well as current reimbursement structures. There is a need specifically to revisit the Normative Model of Physical Therapist Professional Education12 to ensure that psychological factors and pain perception are handled appropriately in professional curricula and that physical therapists develop this key understanding and expertise to aid in clinical management of these patients.
Practicing physical therapists will need additional specific training if a psychological informed practice approach is to be successfully implemented. This approach involves both a philosophical and a practical change in education. Physical therapists will have to understand their professional practice within newer evidence-based models of pain perception, pain behavior, and the development of disability. Psychologically informed practice will require a new type of training to ensure a standardized and validated approach. A concerted effort will be needed to facilitate the development of such changes in training and clinical practice.
Implicit in much of our analysis has been recommendation of a broadening in the role of the physical therapist as not only a treating clinician, but also a clinician attempting to establish guided self-management. This recommendation also has implications for the focus of education and the nature of the educational process. In the context of secondary prevention in particular, the primary goal is to help develop and establish relevant, helpful, and sustained behavior change in our patients. As such, the education of our physical therapists needs to include a clear focus on the determinants of behavior change and how to embed these determinants of behavior change within treatment. There may be important lessons from implementation science13 that might be usefully applied to our clinical interventions.
4. Linking risk identification, clinical decision making, and delivery of interventions. The relationship between (1) a public health perspective toward risk identification treatment targeting and (2) the design of interventions at an individual level is bridged by clinical decision making, a process that is as yet insufficiently understood. Cutoffs on questionnaires can help identify those individuals at risk for poor (or indeed good) outcome from treatment, but such scores are ill equipped to do more than identify types of patients for which different outcomes (as a group) can be predicted. Identification of increased risk may involve more than just identification of an elevated score—which, in terms of individual treatment outcome, is insufficiently accurate and whose relationship with potential treatment modifiers and integration into clinical decision making are still far from established. In addressing these major challenges, we may have to recognize the limitations in the use of simple cutoff scores and consider novel approaches to decision making that take fuller account of data that are continuously distributed, while balancing pragmatic considerations of interpretability and ease of use.
This special issue highlights the importance of measurement of psychosocial factors in clinical settings14 and identifies some clinical decision tools that are of potential utility but that are not as yet sufficiently validated to be able to recommend for clinical practice. In our view, further work in this area of applied research in determining the clinical utility of commonly used measures is a top priority. Ideally, optimal screening methods should be validated, and treatment programs matched to specific factors that have the potential to enhance clinical outcomes should be evaluated. As a recent example, randomized trial designs could consider the approach used for the Keele STarT Back trial in the United Kingdom.15 We note a recent critique of the flags framework for the identification and use of screening procedures.16 These authors caricature the flags approach as “reductionist” and revisit the age-old dispute between nomothetic and idiographic approaches, with the parallel distinction between quantitative and qualitative approaches. In our opinion, critiques such as these are interesting and merit debate, but they do little to advance clinical management and seem to have little appreciation of the “real world,” where—in the context of massive financial pressures—we have an obligation to find ways of linking public health perspectives with clinical interventions, and to address individual differences within a wider perspective.
5. The need to recognize the socioeconomic context. In our recommendation of psychologically informed practice, we are mindful of the need to recognize socioeconomic realities. In parallel, we recognize the importance of health services research focused on potential cost savings and reduction in utilization for use of psychologically informed approaches to manage low back pain. Musculoskeletal pain affects not only the individual patient but also the individual's family and society (in terms of health care provision and employment). Indeed, the wider social context of musculoskeletal pain and disability (eg, black flags) is as yet insufficiently understood, but, given its importance, it merits high priority for further study. We also must acknowledge the economics of health care provision, and in recommending psychologically informed practice within a flags framework, it is important to develop socioeconomic evaluations that fully capture new service initiatives. It is equally important to ensure that future health care policy is consistent with these evaluations and that there is appropriate incentive for providing psychologically informed practice when it is indicated.
In offering a new way of thinking about low back pain and its management, we have recommended a new approach to physical therapy that we have called “psychologically informed practice.” We realize, of course, that any such endeavor is open to the charge of ignorance, stupidity, megalomania, or all in combination. We also know that recognition of psychosocial aspects of care has been around for a long time and that physical therapists already deal with such issues as part of clinical practice. We have become aware, however, that the way in which such factors are addressed and managed within the consultation is frequently unsystematic, likely resulting in suboptimal patient outcomes. This awareness has been reinforced by our experience in developing training programs. Although the potential importance of psychosocial factors usually is acknowledged by our trainees in the programs, they have consistently expressed the view that their prior professional training did not equip them sufficiently to incorporate such factors effectively within their clinical practice. We have attempted, therefore, to provide guidance on how such an approach might be developed, while recognizing the clear challenges involved, the additional research that is needed, and the potential changes that may have to be made to physical therapist education practices.
We hope that in offering this special issue, we will stimulate and encourage the development of a broader approach to physical therapist practice, with a focus on the identification and management of psychological and psychosocial obstacles to recovery of optimal function. We have developed in this special issue a primary focus on low back pain, as this area has been extensively studied. It is our opinion—and promising preliminary evidence exists to support this opinion—that a similar psychologically informed practice approach is appropriate for other musculoskeletal pain conditions. Lessons learned from years of low back pain research may indeed have broader application for the general management of musculoskeletal pain, although further research is needed before stronger clinical recommendations can be made.
Footnotes
Both authors provided concept/idea/project design and writing. Professor Main provided project management. Dr George provided consultation (including review of manuscript after submission).
- Received February 23, 2011.
- Accepted February 24, 2011.
