As physiotherapists (PTs) quickly learn after entering the profession, the troubles and concerns of patients with pain often go beyond physical pain. Distress, manifested by fear of movement, anxiety, frustration, or anger, are common in people experiencing persistent pain. Many forms of chronic pain do not respond to pharmacotherapy or invasive procedures. And modern pain professionals recognize disability can persist even after the resolution of pathology or injury.
There is great interest and potential in treatments aimed at improving function and quality of life by changing the way patients cope and recover. These interventions fit within the biopsychosocial model of pain care, which takes into account interactions between biological, psychological, and social factors in determining why a person might suffer from pain or disease.
The biopsychosocial approach seeks to fill key gaps in the traditional biomedical approach of western medicine, which sees pain and pathology as consequences of organic/physiological imbalances. The biomedical perspective is somewhat restrictive and may even delay recovery: research suggested that PTs with a biomedical approach are more likely to view daily activity as harmful and limit activities for patients with pain compared to those employing a more biopsychosocial approach (1).
Psychological Flexibility: Support for Patients and Practitioners
In Acceptance and Commitment Therapy (ACT) the general goal is to increase psychological flexibility defined as “the ability to contact the present moment fully as a conscious human being, and to persist or change behaviour in the service of chosen values” (2). Psychological flexibility is established through six core ACT processes (acceptance, defusion, values, committed action, self-as-context and present moment awareness). The methods of ACT contrast with those of more traditional Cognitive Behavioral Therapy (CBT), which seeks to neutralize negative cognitions so they don’t influence and impede recovery from physical or emotional pain.
Both ACT and CBT have shown effectiveness in diverse clinical scenarios and for different conditions; likewise, some people are more receptive and respond better to one approach. The ability to implement key precepts of ACT, CBT, and other psychologically-informed treatment approaches can be a game-changing skill for PTs treating chronic pain.
But besides benefiting patients, understanding and practicing the principles of PF can be extremely helpful for PTs themselves (and other health professionals), especially those working in highly demanding clinical environments. Research shows that PF can help them deal better with complex, difficult daily situations, and respond better to patients’ fears, anxiety, and depression. PF may also instill confidence to open up and accept the discomfort of having to explain to a client that further medical tests and interventions are unlikely to reduce chronic pain (3, 4).
Can Psychologically Informed Training Change PTs’ Attitudes Towards the Management of Patients with Persistent Pain?
Several recent studies suggested that brief training sessions consistent with PF significantly decrease work-related stress and burnout symptoms among health care professionals, and may shift perspectives about treatment options for chronic pain.
A 2016 study published in the British Journal of Pain evaluated whether brief psychologically informed training could help PTs better recognize the role of psychosocial factors in chronic pain and identify the key processes of the PF model in their treatment interactions at the individual and group level (5).
Twenty six PTs working in an outpatient musculoskeletal department in the UK participated in a 7-hour training session delivered by two PTs and a psychologist from a specialist pain unit at St. Thomas’ Hospital in London. The intervention covered the following:
- Recognition of barriers to engagement in activity with pain (e.g. anxiety, fear of increased pain). This was done experientially, with participants exploring movements in anxiety-inducing mock-up scenarios.
- Flexible and targeted use of pain education to facilitate PF and goal engagement.
- Most of the training time was devoted to teaching skills to apply the methods that target the core PF processes of values, acceptance, contact with the present moment, cognitive defusion and committed action. Participants were introduced to mindful movement and were invited to explore the sensations, thoughts, emotions, urges, and memories that came out as they did so. Following ACT precepts, they were guided to allow or ‘make room for’ these experiences, including unpleasant ones, with curiosity and without attempting to change them.
On the same day (before and after the intervention) participants completed the following self-reported questionnaires:
- Health Care Provider–Pain and Impairment Relationship Scale (HC-PAIRS): Measures health practitioners’ beliefs about the relationship between low back pain and function. Specifically, the belief that pain and disability are directly associated and that disability and activity avoidance are inevitable consequences of pain. Example items are “All of chronic back pain patients’ problems would be solved if their pain would go away” and “Chronic back pain patients cannot go about normal life activities when they are in pain.”
- The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT): Measures health practitioners’ endorsement of treatment orientation (biomedical or biopsychosocial) towards care of patients with low back pain. Example items include “back pain indicates the presence of organic injury” and “functional limitations associated with back pain are the result of psychosocial factors” (6).
- Acceptance and Action Questionnaire-II (AAQ-II): Measures general psychological acceptance or experiential avoidance; higher scores indicate greater experiential avoidance or psychological inflexibility and lower scores indicate greater acceptance and PF. The 7-item AAQ-II includes items such as “I worry about not being able to control my worries and feelings” and “I’m afraid of my feelings”, which are scored on a scale from 1 (never true) to 7 (always true).
- Maslach Burnout Inventory: A 22-item tool to measure occupational burnout, from which 3 items were assessed: “I feel emotionally drained from my work”, “I feel I’m positively influencing other people’s lives through my work” and “I feel I treat some patients as if they were impersonal ‘objects’”.
Finally, a series of questions assessing the perceived importance of treatment goals directed to pain reduction and function, as well as an open question: “What makes it hard to achieve treatment goals with chronic pain patients?”, were formulated to further examine PT’s potential treatment choices and barriers to working effectively with chronic pain patients.
Unmasking the Psychological Components of Chronic Pain
The study showed that a significant switch in PT’s attitudes and beliefs towards chronic pain treatment, consistent with novel or greater appreciation of biopsychosocial factors, occurred after the brief training:
- Both HC-PAIRS and PABS-PT post-treatment scores changed with moderate- and large-scale effects in the intended direction, indicated by significant increases and decreases in biopsychosocial and biomedical scores, respectively.
- PT’s perceptions of different treatment goals and treatment priorities also changed following psychologically informed training: importance ratings dropped significantly for range of movement, posture, diagnosis, core muscle strength, reassurance, education about chronic pain and aids and adaptations.
- Consistent with the ACT model, the importance of pain reduction as a treatment goal was decreased, but not significantly. On the other hand, participants identified pain acceptance and return to work as highly important treatment goals both before and after the training.
- In response to “What makes it hard to achieve treatment goals with chronic pain patients?”, the most common answer was ‘lack of acceptance of pain’, followed by ‘patients’ expectations from physiotherapy treatment’. Other barriers cited were psychosocial issues (including stress and family situations), patients’ poor understanding of chronic pain and the role of investigations, patients’ unrealistic goals, organizational pressures, and clinicians’ lack of training and experience.
In summary, after psychologically informed training, “the physiotherapists were less likely to assume disability is an inevitable consequence of pain and that pain reduction is not always the primary aim of treatment” (5).
Some study limitations noted it is not clear whether post-training changes in attitudes toward chronic pain would be maintained over time and reflected by changes in clinical practice. It is also possible that actual implementation of the PF skills learned would lead to improved burnout and AAQ-II scores -which were not modified by the session- after a follow-up period back in the clinical environment.
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(It’s About) Time to Embrace Psychologically Informed Physical Therapy?
The biopsychosocial orientation, focused on a return to function rather than pain reduction, is now widely accepted as the best approach to the management of non-specific low back pain (7). Brief, well-designed training sessions are demonstrating to be very effective in changing perceptions and attitudes of PTs towards chronic pain and helping them understand the physical and mental struggles of clients and patients. Psychologically informed physical therapy training also means a qualitative leap from conventional physical therapy practice, by providing key skills to reduce disability, facilitate return to function, and enhance the quality of life for people with chronic pain.
Don’t miss out! The Integrative Pain Science Institute now offers Acceptance and Commitment Therapy in Motion – a course on integrative strategies to reshape the human pain experience.
1- Houben, R. M., Ostelo, R. W., Vlaeyen, J. W., Wolters, P. M., Peters, M., & den Berg, S. G. S. V. (2005). Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. European Journal of Pain, 9(2), 173-183.
2- Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour research and therapy, 44(1), 1-25.
3- McConachie, D. A. J., McKenzie, K., Morris, P. G., & Walley, R. M. (2014). Acceptance and mindfulness-based stress management for support staff caring for individuals with intellectual disabilities. Research in Developmental Disabilities, 35(6), 1216-1227.
4- Waters, C. S., Frude, N., Flaxman, P. E., & Boyd, J. (2018). Acceptance and commitment therapy (ACT) for clinically distressed health care workers: Waitlist‐controlled evaluation of an ACT workshop in a routine practice setting. British Journal of Clinical Psychology, 57(1), 82-98.
5- Jacobs, C. M., Guildford, B. J., Travers, W., Davies, M., & McCracken, L. M. (2016). Brief psychologically informed physiotherapy training is associated with changes in physiotherapists’ attitudes and beliefs towards working with people with chronic pain. British journal of pain, 10(1), 38–45. doi:10.1177/2049463715600460
6- Houben, R. M. A., Gijsen, A., Peterson, J., De Jong, P. J., & Vlaeyen, J. W. S. (2005). Do health care providers’ attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures. Pain, 114(3), 491-498.
7- Roditi, D., & Robinson, M. E. (). The role of psychological interventions in the management of patients with chronic pain. Psychology research and behavior management, 4, 41–49. doi:10.2147/PRBM.S15375