How To Screen For Psychological Factors When Treating Those With Pain With Zachary Stearns, PT, DPT

Welcome back to the Healing Pain Podcast with Zachary Stearns, PT, DPT

Friends, thanks for joining me on this episode. I am speaking with Physical Therapist Zachary Stearns about how to screen for psychological factors when treating patients with chronic pain. Zachary is a physical therapist in Durham, North Carolina. He’s board-certified in Orthopedic Physical Therapy and has worked in outpatient clinics, which have a focus on musculoskeletal pain management. He’s currently working on a large research study, which is called the AIM-back program. This is a collaborative effort between Duke University and the U.S Department of Veterans Affairs. He’s also a PhD student in Health Sciences.

In this episode, we discuss the benefits of screening for psychological factors or what we call “yellow flags” in chronic pain management. What types of screening tools can you use? Self-report measures that you can use in your practice. As physical medicine professionals, should we be screening for suicidality? If we do have a positive screening, how do we approach that? How do we follow through with that? Finally, the barriers to implementing and screening psychological factors in clinical practice. I want to thank Zachary for joining me on this episode.

If you’re a clinician, this is a content-rich episode where we go deep into how to screen for psychological factors, which are important. We also touch on the topic of suicidality. We have a little bit of a healthy discussion on, “Should we be screening for suicide and what do we do after we screen for suicide?” Zachary also just finished writing a paper in the Journal of Orthopaedic & Sports Physical Therapy. I did mention that at the beginning of the episode. It’s great. It’s really useful and it would help you. Without further ado, let’s begin and let’s meet physical therapist, Zachary Stearns.

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How To Screen For Psychological Factors When Treating Those With Pain With Zachary Stearns, PT, DPT

Zachary, thanks for joining me this week on this episode.Thank you, Joe. I’m happy to be here.

I came across the paper. I want to make sure I mention the paper you lead author to co-author with some other PTs. It’s a really important topic. It’s called Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework. It’s in the September 2021 Journal of Orthopaedic & Sports Physical Therapy. It’s going to help frame our little chat here. I encourage people to go and read the paper, especially if you’re a clinician and you’re learning how to screen for yellow flags. I enjoyed the paper. It’s a short, concise paper, but it’s pretty powerful. Thanks for your work there. Tell us how the idea for this paper came about.

Thank you, Joe. I appreciate that. As far as this paper came about, it came from this network and this energy between me, Marissa Carvalho, Trevor Lentz at Duke University, and our colleague, Jason Beneciuk at the University of Florida. All of us are extremely in favor of incorporating assessment of psychological factors and physical therapy practice.

We’re on board with using a standard tool. For us, it’s the OSPRO-YF, but it’s certainly not the only tool around. The whole point was that we’ve noticed so much resistance from clinicians. This isn’t just in physical therapy, it’s really throughout healthcare. Resistance to this idea of having some type of psychological assessment for pain, as well as incorporating psychological approaches for pain management, for treating pain and for helping those who are living with pain.

There are so many factors that lead to that hesitation or reluctance to using these types of strategies, but one of the biggest ones is not knowing what it looks like, what to do and how to incorporate it in their clinical practice. We all agreed that if we could outline some type of framework or process that can be adapted to different clinical settings in different patient populations but has some concrete guidance about what we recommend and how to really improve our management for those living with pain.

That’s a great way to start. We’re almost at this watershed moment where everyone in the PT profession or almost everyone, is aware of the psychological factors that are associated with pain, as well as physical function. High awareness, but the behavior to screen for it in clinical practice is probably not there yet. Professional behavior varies widely depending on what year you graduated from school and where you work. If you’re working as a solo PT or an interprofessional team, it’s a big mixed bag, right?

It is. There are already so much research and many decades of work. It’s been known for over a century the role of the psychological approaches. The biopsychosocial model is not new, but we’re at a point where for people like me who are younger clinicians, we’ve certainly been trained about the importance of the biopsychosocial model. We’ve been trained about the importance of looking beyond the anatomy, beyond the actual physical processes and realize that we all live in a context.

Part of that context is what we think, what feel, what we care about, what we dream about, what we want in our healthcare and also our social context of where we live, who do we live with and what are our relationship is like? All of these things are so crucial. I agree that this is a watershed moment in which there is so much general awareness about the importance of these, but what do we do? How do we go about incorporating this knowledge in order to transform our practice for the sake of making it better? That’s exactly the energy behind these ideas.

People will do things or they’ll continue to do things if they feel it’s beneficial. When you ask to have a seasoned professional change their practiced skills, change their behavior can be tough. There have been lots of studies on that, especially in the realm of prescribing medication. It’s hard for physicians to change their prescribing habits. Reflecting on our behaviors as PTs and other professionals, it can be difficult for us to change our behaviors. What’s the benefit for a PT or another professional in the clinic to start screening for psychological factors?

I’m so aware of how hard it is to change. Not just foreseeing other clinicians, but also myself. When we think about it, we want to improve our practice, therefore, change our habits because, as clinicians, we want things to be easy and sometimes the easiest thing is to do the same thing over and over again. It’s easy for us. We want to have the best outcomes for people. The biggest benefit is this idea of thinking about those people we’ve worked with. Even though we want them to feel better, they want to feel better, things are not improving. What is it that led that outcome to happen and what can we do to improve that outcome?

HPP 249 | Psychological Factors Of Pain
Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework –


The argument is that to be aware that there are these other factors that are important. It’s not just about pain, but also about functioning at what we do. Many people tell me about how, if they could do these things even with some pain, that would be a success for them. It’s not about pain going all the way away for many people. It’s about making their severe pain less severe, but when we realize that the outcomes for a lot of treatments that have been pretty traditional, some medications, some invasive treatments, are not seeing the outcomes. Thinking about how many people I’ve worked with, who said they felt worse after their surgery. If this surgery is meant to be this definitive treatment, why is it that someone with severe knee osteoarthritis then felt worse after their surgery?

What do we do about that? That’s the argument to make, is what if we can make some changes so that this doesn’t happen so that people feel better. Realizing that if there are some factors that can be addressed and modifiable, then what if we work to modify those? The whole reason for focusing on some of these more psychological factors, what we think about movement, what we think about pain, how we cope with pain, how we manage it and anxiety and depressive symptoms.

These are things that are modifiable. It’s just a logical step to say that if these things are modifiable, then we think about what we can do. If we’re at a spot where we are not, don’t have the expertise to do this, then how do we make sure that this person in front of us living with pain does work with someone who can help them modify it?

As we talk about this, I’m reflecting back on some of the training I’ve done with practitioners around this topic. There’s the hesitancy to go into this. There is a bit of an imposter syndrome, especially for PTs because they’re shifting from that biomedical to biopsychosocial spiritual or however you want to look at that. How do you find patients respond when you first start to talk about psychological factors associated with their challenges and where are you starting to have that conversation?

I would argue this is way more important than what clinicians think because if we start to talk about these topics in a way that’s not so great, patients can feel stigmatized. The topic can be very stigmatizing for lots of reasons. It comes down to patients want to be trusted and believed when they say I’m feeling pain. Pain is invisible. This is the hard thing. Some injuries are visible, but the actual experience of pain is not so visible.

When we start to ask some of these questions that are a little bit more psychological in nature or even use the word psychology, this can trigger a tough and tense moment between the clinician and the patient because it might sound as if the clinician is doubting the reality of pain. He is doubting that the pain is physical or that it’s even real. That is one of the biggest struggles for me because, to me, I believe we must absolutely trust what the patient is telling us. If they’re experiencing pain, then they’re experiencing pain.

What we want to do is we want to make sure we’re not missing anything that could be getting in the way of their recovery or them pursuing a more meaningful and more fulfilling life for them. That’s what some of these factors can do if we feel like I’m not going to do anything that could make my pain worse. Exercise, activity or going out with my family. I’m afraid that’s going to make my pain worse, so I’m going to stop and do nothing.

That’s what we’re talking about, it’s something that could get in the way of living their best life. We need to talk about it in a way that we say that we don’t want to miss anything. With more information about what you’re thinking, what you’re feeling, that can make sure that we amplify our care in the best way possible and making sure that we’re doing the best thing for you personally.

When we talk about it in that context where it’s not like we’re investigating or we’re testing or almost just trying to see what’s going on mentally but saying, we want to provide the best-personalized care for you, this is where patients tend to be much happier with it. They want to know that they’re being heard and listened and trusted. As long as we frame it that way and not like, “Your image looks fine, therefore, it’s psychological.” What are the psychological factors? That’s where clinicians get into big trouble. That’s not the intention of this type of process. It’s meant to be is a process that makes sure we see all of the relevant modifiable factors so that we can do the best treatment plan for you personally.

I want to take a moment to clarify and correct me if I’m wrong. In your framework, the way we should approach this is we should be screening. When people hear the word screening, they understand what a screen is, but we should be screening during the initial evaluation or during the assessment, because oftentimes what newer therapist or a therapist who is just coming into the psychologically-informed care approach is they’ll do a traditional evaluation.

They’ll only screen eight or nine weeks later when they find, “This person’s not having such a great outcome here. They’re not really progressing, so let me screen now.” That’s even more jarring for someone because they say, “Now, you’re asking me about factors related to fear, anxiety, depression and emotions, etc.” They’re shocked. It doesn’t go so well, then the patient feels stigmatized. Screening happens on day one with every patient.

I’m so glad that you mentioned that. I’m not sure if controversial is too strong of a word, but the way that you outlined that process that some clinicians do, is very troublesome to not screen on day one. We’re not getting the outcome we want, so then what else could it be? What we see is it’s more like red flags. We screen everyone to make sure that we’re not missing something from the beginning, in the same way that it’s pretty standard for many clinicians.

Think about how many times we go to visit and we answer what seems like a thousand questions before we even see someone because part of that is that screen of making sure that we’re not missing any of these big deal signs or symptoms from day one. We see it more like that, considering that for many of these factors, clinicians don’t seem to be very good at guessing it. Even though we like to think that we’re really good at guessing, say how much someone avoids activity or even their depression, the evidence isn’t there that clinicians are very effective at guessing that.

HPP 249 | Psychological Factors Of Pain
The whole reason for really focusing on some of these more psychological factors, what we think about movement, what we think about pain, how we cope with pain, how we manage it, is because these are things that are modifiable.


That’s the reason for screening in the same way that we’re probably not so good at guessing some of the certain red flag symptoms. That’s why we ask to screen to make sure we pick something that’s sensitive. If it’s no, then we move on, but we get into trouble if we don’t screen from the beginning with some of these factors and look at it later. There are going to be many people who don’t see that improvement in their outcome, so to then screen later, it’s not so good because of the stigma thereof saying, “You’re saying it’s in my head the whole time and that’s why I’m not getting better?” That’s not going to be the best way to go about it.

As professionals, we’re aware of the factors and we think we’re good at identifying them. It’s like asking a professional, “Do you think you have a good therapeutic alliance with your patients?” Everyone says yes. Do you think you can identify depression in your patients or anxiety or fear of avoidance every once in a while? I see that every day, but the truth is there’s no psychometric tool to screen for it. We’ve piqued everyone’s interest and they’re going to start to screen with every patient, especially every chronic pain patient, if not every patient. What’s your favorite tool?

In my practice, it has been the OSPRO-YF and there are a few different reasons for it. The OSPRO-YF stands for the Optimal Screening for Prediction of Referral and Outcome Yellow Flag tool. There are other tools out there and there are so many questionnaires. What I like about it is that there are three essential things.

One is that the research that has been done on it, has been in a general musculoskeletal pain population. It’s not specific to one body area, which for me in my clinical practice, has been very important because my practice has not been in one specific body region. The second thing, it’s been in the general adult population. Again, that fits with my clinical practice. The third is that it’s multidimensional. This multidimensional aspect, in other words, there are many different factors, as opposed to many questionnaires out there, there is just one factor.

I’ve seen clinicians who will use a measure on fear of movement, the Tampa Scale of Kinesiophobia. That’s their analog for screening psychology. It’s important, but we want to be in a spot where if we’re going to screen, we want to have the biggest bang for the buck and the fewest questions possible. That’s the whole point of the OSPRO.

It’s meant to estimate scores for eleven different psychological factors, including positive ones. This is crucial because I’m of the opinion that we’re focusing so much on the negative things and not enough on the positive things. This questionnaire does incorporate positive factors. Self-efficacy, pain acceptance and self-efficacy for rehabilitation. This is crucial because we’re looking at many factors, negative and positive.

People are going to want to know, what does it look? How many questions is it? How long does it take? Time management and ease to integrate this into an assessment or an evaluation process are important.

There are three different versions. There’s a 7, 10 and 17 item. Many of the studies have suggested that the ten-item is this happy medium that we’d expect. It’s nice if it’s on one page. The scoring of it’s different from other measures. Because it’s meant to estimate all these questionnaires, it’s not like you add up the number. You need an answer for every question so that it can estimate how people score on these questionnaires. You do need all ten answers.

What’s nice is we work to integrate it with our electronic medical records so we can ask of it within the visit or if they were to complete it ahead of time, whether electronically or on paper. We’re able to just populate the scores and use them as it’s intended. Even before we see someone, we see how someone scores on these. That’s a big benefit of it and with it being ten questions, it can be done very quickly.

Is there a measure of statistical significance with that? Is it more qualitative, just seeing how someone’s progressing throughout their plan of care?

Again, unlike some of the legacy questionnaires that have the sum score, it’s not designed to be able to see this change. This is where another reason why it’s a little bit more analogous to red flag screen where we don’t think about minimal detectable change or minimal clinically important difference for red flags. Similarly for this questionnaire, we use it as a screen initially. We can follow up down the road as monitoring the response to treatment. Monitoring some of these factors that can inform our decision-making, but not in the same type of quantitative aspect. There is a quantitative summary score that’s used in research.

Some clinicians can use it as well, but the way that most clinicians use it is that it estimates whether or not someone has this yellow flag based on whether or not they’re in the top quartile or they’re 75 percentile or above for the negative factors. Are they in the bottom quartile, 25 percentile or below, in the positive? It has the output of yes or no. Do they present with a screen positive for this psychological factor for this yellow flag? Therefore, it’s more of the screen. Do they screen positive or negative for that? It’s to inform our decision-making afterwards.

It’s what I use in practice. I find it to be really easy. I personally like that there’s not a number that I’m looking for as far as a significant change. Some professionals have a hard time with that. They want to be able to measure things specifically. I like the idea of it being a little bit more loose and flexible. Just being that screen where this could be a trigger for a referral, for example, to a mental health professional or to another professional. With that in mind, you have a pretty good step-by-step framework in this paper. There are four phases to it, which are important for people to become aware of. Can you talk us through those four phases? It starts with a standard physical therapy screen.

We start with a standard screen. This is where ideally, there’s a screen either before the evaluation itself or during the evaluation. From then, that initial screen can look different based on what setting you’re in. From there, we engage in shared decision-making with the patient. This is so important to me because we need to make sure that the patient is on board with our plan and that thinks it’s a good idea.

That does include giving a rationale for asking these questions that we’ve talked about before, is the importance of framing it in a way that we want to make sure we get a glimpse of everything that we need to know to make this the best treatment possible. From there, the shared decision-making aspect can lead to four general pathways. One pathway is standard physical therapy.

HPP 249 | Psychological Factors Of Pain
Some injuries are visible, but the actual experience of pain is not so visible.


It’s hard to define that, but what we mean is that we know that exercise and physical activity is very helpful for those with musculoskeletal pain. We know that there are specific exercises out there, as well as a general exercise that’s very helpful. We know that a multimodal approach that incorporates exercise and manual therapy is worth considering. Above all, we know that self-management is so crucial for those, particularly those with musculoskeletal pain.

For many people, we don’t need to incorporate some different psychological interventions in our practice. If someone were to present with no positive screens in the OSPRO Yellow Flag tool, we would say, “We don’t need to move forward with progressive muscle relaxation or activity rest cycling and these other psychological skills.” For some people, if they were to screen positive, we can consider one of a few different pathways. These other three pathways are either a more psychologically-informed physical therapy practice in which we use some different psychological skills or interventions.

Another pathway is doing that psychologically-informed physical therapy, but also considering a referral, particularly for someone who presents with signs or symptoms of mental illness. In which case we say, “I, as a physical therapist, am not the expert to treat a clinical depression or an anxiety disorder.” We want to expand the team around the patient to make sure that we have professionals who specialize in treating their own respective conditions, their own respective specialties. That last category being an immediate referral for someone who’s in either a suicidal crisis or something that’s very severe and needs immediate intervention.

The final step is an ongoing step of treatment monitoring in which cases, as 2 or 4 weeks go by, we’re reconsidering how things are going. Not just in terms of the range of motion, strength, or endurance, but also in terms of the psychosocial profile of how someone is thinking, feeling or acting in their context living with pain. That can go back to inform our shared decision making moving forward.

I want to frame this out for people because they’re not looking at the paper, but the four steps are Standard Physical Therapy, step one. PIPT, step two. PIPT with referral, step three and then, immediate referral, step four. I don’t mean to say step like a step wise, but it’s a conceptual model to help you make some decisions in practice.

There are two important distinctions here which are worth talking about. PIPT, which stands for Psychological Informed Physical Therapy or we can just shorten it to psychologically-informed care. The first one there is that the PT does not refer out. They realize that there are psychological factors and they have to bring in some type of cognitive behavioral techniques with their traditional PT treatment. There’s a ton of cognitive behavioral techniques that practitioners can use that are evidence-based.

The second one is psychologically informed care with referral. What you did is brilliant because people hear that if someone screens high for depression that I should stop treating them and they should be referred out to a mental health professional. What you’re saying here, which I appreciate is, no, we continue to care for them. What we do as PTs has a very positive impact on their depression, but we also need someone else here to help this whole process along because this person is high on the depression scale.

I’m so glad that you mentioned that because that is an instinct that many physical therapists will have. I’m sure many clinicians and other specialties, too. Depression is seen as something as, “I need to refer out.” Many people feel like they’re this ping pong ball going back and forth from provider to provider and they’re not receiving care. Think about how many people might be living with pain and depression, and with chronic pain. Most people live with depression at some point with chronic pain.

Think about this experience of you having pain. You go to a physical therapist, you have depression. You need to get that taken care of before we can do anything. You need to go out mental health provider. The mental health provider says, “You have pain. You need to go see physical therapy.” In reality, we are treating a whole lot of people with what is a normal response.

If you live with debilitating pain, if you’re asking someone not to feel down about that, that’s a lot to ask. In reality, depression is not a contraindication for physical therapy, for musculoskeletal rehabilitation. What we need to make sure that we are staying in our lane and are also making sure that we have the best possible team of providers working with this patient.

What about times where we don’t refer? There are some factors that are not depression. They are considered psychological factors, which are not mental illnesses. If someone is avoiding physical activity, that’s not a mental illness. That’s not something that we would need to refer to. That’s when we think about strategies that we can use in physical therapy practice that are meant to help with that situation.

Mental health physical therapy is a strong interest of mine. When we look at the United States of America, there are about 60 million Americans who struggle with some type of mental illness. Most of them are somewhere in the healthcare system. There’s a bidirectional relationship between poor mental health and poor physical health. They’re in our clinic. If we started referring every single person out that had a yellow flag, one, we’d probably overwhelm the already overwhelmed mental health system, and two, it’s not good for our professional stance.

One of the reasons I was so excited to talk to you is I think what your paper does if people take the time to read into it is they realize, “I, as a PT, have a big role in helping someone with whatever mental health struggle they’re having.” That’s important, so I appreciate that. The immediate referral column, which is the red column.

The flashing red light, the red flag, talk to me about that because there’s something in your paper. You used some case examples, which is great. There’s a case example there, immediate referral. The physical therapist should call 911 and wait until emergency services arrive to transport them to the emergency room. Can you talk to us about that?

This happened to a colleague of mine. Marissa Carvalho, who is one of the co-authors of the paper. She and I agreed that this is not going to happen very often, but it’s a matter of time for everyone at some point. If they’re in a situation where they practice with those living with pain and many other situations as well. It’s not just about pain. You might be that provider who is working with someone at a crisis moment, especially if you’re in a setting where “I went to my doctor. They said there’s nothing they can do, so they’re sending me to physical therapy.”

This is potentially a breakdown moment for someone to come in to see a physical therapist. If someone’s act has active suicidal ideation, if they have plans for suicide, I do think it’s important to be comfortable asking this question. If they’re flagging the five OSPRO if we have some other depression screening process and flagging that as well, this is where it’s our responsibility to make sure that we know how to handle a crisis moment.

HPP 249 | Psychological Factors Of Pain
It’s really meant to be a process that makes sure we see all of the relevant modifiable factors so that we can do the best treatment plan for you personally.


You said it’s important to ask the question. What is the question? There’s one key question that we should be asking someone if we think suicidality is a problem, but what is that question, in your opinion?

I usually will have two. One is, have you had thoughts about harming yourself or harming someone else? Do you have an active plan for harming yourself?

Do you have thoughts and do you have a plan? They are two simple questions. They don’t take more than 30 seconds, probably.

They don’t take more than 30 seconds. Anytime I’ve asked that, I’ve always been glad I asked that because someone’s like, “No.” If someone says yes though, then what do we do? That’s where we need to work with our organization. What’s our crisis plan and have a standard operating procedure for that, because that’s going to depend on where you are. Are you already in a hospital? Are you in private practice? Are you in someone’s home? This is going to be so different based on your setting.

Fortunately for us, at our pain clinic, we worked with psychologists and that was our process. We’re going to bring in a psychologist and determine, is this a 911 call where someone is an immediate threat? If they leave this building, they will harm themselves. We need to be prepared for that. There’s 24/7 suicide hotline in America. This is going to be available in many countries.

Knowing what that is and making sure people are aware of that as well is another option for those who don’t have suicidal ideation, but may have signs of depression and they’re already working with the provider. It’s something to be aware of. Working with your own organization and being aware of the questions to ask and what to do if someone were to say, “Yes, I do have plans.”

Different organizations, different practice settings can create their own plan if in fact, you come across that challenge. Again, I appreciate you putting that in the paper because it’s forward-thinking and one that requires a professional to feel safe to have that conversation and to be brave. This is a brave conversation to have with someone if you’re not used to having the conversations, but they’re important within the chronic pain population because suicidality rates are higher.

There’s also some controversy though, about how to handle a patient when they’re in that position. Some people say call 911 away. There are also other mental health professionals that say not to do that. There are challenges that have happened with that. I’ve come across these both within my own patients, as well as speaking with other mental health providers.

Some of the challenges are that the person winds up in the emergency room and their care is not handled properly. They feel stigmatized. They’re placed into a long-term psychiatric ward and place on heavy doses of medication. They’re in the mental health community itself. If you talk to psychologists, there’s not a clear way to handle it. It’s important to mention that. Practitioners don’t feel like calling 911 is the only option. You mentioned a hotline. You mentioned if you’re in a setting that you can call someone into the clinic. There are lots of different options, right?

Absolutely. I’m really glad that you mentioned it because these are some of those clinical decisions where it’s hard to know what the right decision is at that moment. Anyone who’s a clinician has either been in that moment, or they’ve been with another clinician who was in that moment of, “I don’t have a good feeling here. We need to do something.” We need to be considerate of what are the consequences on someone’s life potentially. It depends on what state you’re in. There are different rules depending on your state about what happens in that situation.

Before I was a physical therapist, I worked at a psychiatric hospital for kids. I saw the consequences of some of these situations in which someone’s unfortunately in a tough spot and then their life is turned upside down for a period of time. We need to take it very seriously, not just call 911 when anyone says that they’re really sad. That’s not what we want to do. We need to work within our organization and have this conversation. We need to talk about what to do and what makes the most sense, given that we’re all in different parts of the country. We’re in different organizations. We work with our colleagues who are in mental health, behavioral health and what do they recommend given that we’re in a similar context.

I’ve talked to a couple of colleagues of mine who are psychologists and have actually shared papers with me that even well-qualified mental health professionals at times have a hard time screening properly and knowing exactly what to do. Let’s not forget there’s some liability there. If you’re screening for something and you potentially make the wrong decision, in PT, the liability factor is extremely small. Probably more so for the mental health professional because that is their scope of practice. As we’re talking about other professionals, what do other professionals think of this framework that you’ve created and laid out and the idea of PT screening for psychological factors?

I’d love to say that everyone loves this idea and everyone wants to do it and everyone I’ve talked to has just changed their life. In reality, it’s not the case. There’s so much inertia around in any specialty, but part of our inertia in physical therapy is training. For many people, this is not part of their training. Any of it. Screening psychological factors, doing psychological treatments, even collaborating with mental health providers is not part of it.

For clinicians, we, in the same way, that here I am talking about how we need to meet patients where they are, we need to meet clinicians where they are and see, is this something that interests them? Engage in a little planning about, “Is this something that you’d like to incorporate?” If so, what are the barriers and navigate that. For some people, it’s using what tool it is. The big challenge is almost the philosophy. This is where this biopsychosocial versus biomedical debate is.

I’ve seen a lot of people actually talking about moving beyond this biopsychosocial model, but for many people, they’re still not beyond the biomedical model of saying that it’s about what’s going on physically in someone’s body. Even for those who care about psychological factors, who care about trying to incorporate psychologically informed physical therapy, there’s one thing I hear so much. I call it the can of worms’ problem, which is that if we ask about this, many clinicians feel like they’re opening a can of worms.

That ultimately comes down to some healthy fear of what do I do when these things come up. The point is that a lot of skills should be developed if we’re going to incorporate this framework. The skill of talking about these factors, of engaging in decision making, of actually assessing, using a tool, using a measure, and skill of using psychological approaches and skill of collaborating with clinicians There is a lot in that. That is what is essentially the can of worms’ problems of, what do we do now?

I hope that there continues to be developed in terms of entry-level education and continuing education that can help build competence for clinicians in that department. There are some who are, “This is putting words on stuff that I already wanted to do anyway.” It’s cool to see that a lot of clinicians are acting in parallel and incorporating this. You mentioned this too, using the OSPRO that a lot of people are acting in parallel of doing this already. It’s powerful to be in a spot where you see this in print and be able to say, “Here’s a framework to consider.” Hopefully, it can be part of ongoing training and development for future clinicians.

The OSPRO and the Chronic Pain Acceptance Questionnaire are the two big ones I use. There are other ones, but those two are standard. It gives me a lot of great information to work with people. We talked a little bit about barriers, time management, which tool and implementation. There’s obviously some education here that’s required of the professional. Are there any other barriers that you see with screening?

HPP 249 | Psychological Factors Of Pain
If you’re in a situation where you practice with those living with severe pain, you might be that provider who is working with someone just at a crisis moment.


Absolutely. A big one that comes up is evidence. If we say, “Here’s the evidence that these factors are important,” great. We’re at that point where there’s evidence that these factors are important. The evidence of what to do about it needs to be bolstered. We need to have some convincing evidence. Part of the reason that this paper is the way that it is, is it’s certainly my hope that we can put some of these thoughts to the test. Is taking an approach like this, which is a little standardized, but it’s not very rigid.

There are conceptual ideas. Does that make a difference? Does that help? I hope that it does. I feel like it does, but if we were to implement that on a bigger scale, would that make a difference? We need evidence that would be a meaningful way of going about it. So long as there’s not this convincing evidence that you should do this, there’s going to be a clinician who’s reluctant to say, “There’s no evidence that this is better for me to do, so I’m just going to go about my own way.” There’s the inertia there. I hear that and that makes a lot of sense.

That leads to the other barrier is it needs to be consensus all the way up and down this vertical line for healthcare organizations, for the clinician and the administrators. There needs to be some consensus that this is the right way to go about it. I would hope that the concepts there are meaningful. Just talking about some of these factors to make sure that we’re doing what we can to help everyone. That collaboration between different professionals and different people within an organization is a significant barrier. We’re seeing more improvement there. More specialties are working together on different projects. I’m hoping that can continue to improve. Evidence and collaboration are really significant barriers that I’ve perceived.

Those of us who follow the show here appreciate this and think it’s a big leap forward, not just a step. It’s nice to see this in a journal in a way that’s succinct and useful. You provide a couple of different screening tools. There are two in there those practitioners can use in practice. If you’re interested, make sure you check out the paper. It’s in the September 2021 Journal of Orthopaedic & Sports Physical Therapy. It’s a clinical commentary and it’s called Screening for Yellow Flags and Orthopaedic Physical Therapy: A Clinical Framework. It’s been great having you on the podcast. Please let everyone know how they can learn more about you and follow your work.

Thanks, Joe. I appreciate it. It’s an honor considering you’ve interviewed some of the most amazing heroes of mine. It’s an honor to be a part of this interview. You can find me on Twitter. @ZachRStearns is my Twitter handle. I’m happy to answer questions or engage with anyone.

You can reach out to Zach on Twitter. For me, you can take a screenshot of this episode and you can tag me on Instagram. It’s @DrJoeTatta. At the end of every episode, I ask you to share this information with your friends, family and colleagues on social media, Facebook, LinkedIn, Twitter and anyone, anywhere where people are talking about psychological factors with regards to chronic pain. We’ll see you next week. Thanks for joining us.


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About Zachary Stearns, PT, DPT

HPP 249 | Psychological Factors Of PainZachary Stearns, PT, DPT is a physical therapist in Durham, North Carolina. He is a board-certified specialist in orthopaedic physical therapy and has worked in outpatient clinicians focusing on musculoskeletal pain management. Zachary is working within a large research study, the AIM-Back Program, which is a collaboration between Duke University and the U.S. Department of Veterans Affairs. He is also a PhD student in Health Sciences.



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