Welcome back to the Healing Pain Podcast with Riikka Holopainen, PT, MSc
We’ve got an interesting and important episode that I know you’re going to love to sink your teeth into. If you’ve been following us for some time, we speak a lot about a biopsychosocial approach for the management of chronic pain conditions. As you know, many physical therapists are enrolling in courses such as explained pain, pain neuroscience education, Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, mindfulness-based stress reduction, pain coaching. All these courses are ways to help improve patient outcomes and for physical therapists and other health professionals to advance their skills in the realm of psychosocial care when it comes to the treatment of chronic pain. However, the challenge is that many physical therapists report, once they start taking these courses, is that sometimes they feel like they’ve been inadequately trained. They lack the confidence to take the skills and then go back to the clinic Monday morning and start to use them with their patients in clinical practice.
I know you can relate to that. There’s nothing worse than spending your money and your time on a course and not be able to take the information and apply it to your clinical practice on Monday morning. Even though a growing number of research studies have explored physical therapist perceptions of biopsychosocial training, we still don’t have a good picture of what physical therapists think of training and how they can take that training and place it into their clinical practice. Our guest Riikka Holopainen is a Physiotherapist from Finland. She is a PhD student and her main research project is to explore patients, as well as the physical therapist’s perceptions of a biopsychosocial approach to the management of musculoskeletal conditions. A good part of her PhD work includes studying physical therapist perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions.
You’ll learn how biopsychosocial training can change the understanding of pain for physical therapists, the professional benefits of learning about a biopsychosocial approach to pain, and the clinical challenges encountered by some practitioners as they implement these skills into practice. After reading this, I recommend that you go and read the paper that Riikka wrote. It’s a great paper and talks about the opportunities as well as the challenges a physical therapist learning a biopsychosocial or a psychosocial approach to pain. It’s interesting to me as someone who teaches on these topics. Many of you know that I have a course in Acceptance and Commitment Therapy as well as pain science. Some of the things that she mentions in her paper, some of her findings are findings that I’ve found when I teach students as well. There are two things that she does not mention her paper that I’d like to bring to light.
The reason why physical therapists have challenges with implementing these types of topics into practice, there are two reasons. One is access to content. Oftentimes someone will take a course, whether it’s a weekend or an online course and they go through the training. In essence, they’re cut off from the training. They may have a manual they can read, but there’s nothing like accessing a video course that you can play over and over again and go back to the content so you can review it as you implement these skills into clinical practice. Continued access to content is one key that’s missing from the training. The second and perhaps the most important, is ongoing clinical mentorship. Once someone has completed an explained pain course or a course on Acceptance and Commitment Therapy, physical therapists need a little bit of extra mentorship, coaching and guidance as they begin to implement these skills into practice.
The two keys to training physical therapists and psychosocial aspects of care is continued access to content and ongoing membership. If you are a participant of one of the Integrative Pain Science Institute courses, you know that you have access to the content for life. You can keep coming back to that content over and over again so you can watch all the video recordings. Of course, there’s ongoing mentorship each month. We have monthly mentorship calls that continue throughout the year, whether you’re currently in the course or whether you’re complete with it. Everyone is invited back to those courses once you joined. I know you’re interested to learn more about Riikka and her research. Let’s begin.
Physiotherapists’ Perceptions Of Learning And Implementing A Biopsychosocial Intervention To Treat Musculoskeletal Pain Conditions With Riikka Holopainen, PT, MSc
Riikka, welcome. It’s great to have you here.
Thank you, Joe. It’s nice to be here. Thank you for inviting me.
I’m excited to chat with you. I came across an early publication of a paper that you published and it’s important not only for the physiotherapy community around the globe but also for other practitioners and of course people who live with pain, as we’re starting to find out safe and effective ways that we can treat them. The paper you published was in 2020 in The Journal of Pain and the paper is called Physiotherapists’ Perceptions of Learning and Implementing a Biopsychosocial Intervention to Treat Musculoskeletal Pain Conditions: A Systematic Review and Meta Synthesis of Qualitative Studies. It was a qualitative analysis versus quantitative. Both are important, but I find qualitative to be interesting because we get some good information from the participants of the study. Tell us why it was important that you proceeded and did this work.
First of all, we were doing a similar study in Finland. It’s not published yet, but it’s under review. Under that process, we noticed that there are other studies going on and the problems that people are facing around the world are quite similar. It was important to summarize this research to help us build maybe better training interventions in the future because that’s what we’re doing as well for future studies. We could maybe learn ourselves and maybe others learn too.
Can you define in your terms, and maybe I guess in the terms of the study, what a biopsychosocial intervention is for musculoskeletal pain?
There are a lot of different definitions and another term that it’s used in this context is psychologically informed physiotherapy or psychological informed practice. In our study, that would mean an intervention that would consider not only the physical side of pain. That would be more than exercise. Usually, there would be a cognitive-behavioral component in the study. Something related to the psychological and social side of pain and that patient’s experience as well. Many of the interventions from the studies that we included were, for example, Cognitive Functional Therapy, STarT Back approach.
There was even some ACT in there as well. You identified Cognitive Functional Therapy, Cognitive Behavioral, ACT, and then the STarT Back. Different types of cognitive and behavioral interventions that a physiotherapist may choose to inform their care of people with pain.
Also, behavioral change interventions to get people moving more. It’s stuff like that as well. Quite variable approaches.
When we talk about cognitive behavioral therapies or techniques that physiotherapists are using, is that a means by which we engage a patient in addressing function or activity, or is that an individual component itself that we may utilize?
I’m most familiar with the Cognitive Functional Therapy approach because our research is around that. I can mostly say from that perspective, but yes, in a way, we combine. It’s not a therapy that we would do like in psychology, but we use those techniques from psychology to enhance our physiotherapy approaches. For example, we use a lot of graded exposure things and goal setting. That’s also cognitive-behavioral techniques.
Cognitive Functional Therapy has a decent amount of exposure therapy, which is wonderful, especially with that back pain population. In essence, it still may take the therapists a bit of time to sit down and talk to a patient, coach them, guide them, counsel them, whatever word you’d like to use.
That was one thing that came up in our study and also in the previous studies. In the beginning, when people learn approaches like this, they feel that they don’t have enough time when they’re learning to listen to the patients more and ask open questions. At first, it feels like it takes more time, but also in this study, so quite often when people got used to it, they actually notice that they can make it. You don’t need to do everything at once.
Give us an overview of this study. Tell us what you studied and tell us what some of the findings were.
In the beginning, we made a systematic search in the databases. We ended up finding twelve studies that considered physiotherapists’ perceptions of learning and implementing these biopsychosocial interventions. There were altogether 116 physiotherapists involving these studies and there were different kinds of approaches analyzing the data. Most were doing thematic analysis for the data, but there were other approaches. We summarized the data, of course. We took the results in parts of these articles, the interpretations from the researchers, the quotations, and made a thematic synthesis about the data. That’s where we ended up with our results. We found 14 themes and 16 sub-themes from the data. Do you want me to describe them?
There were four major ones. If you can go into those four, that would be useful for the readers.
First of all, most of the physios seem to have benefited from the training. The first two themes describe that the physios change their understanding of practice as a result of the training. They saw some professional benefits from that. There were also barriers and quite a lot of barriers to the learning and implementation in the clinic that the physios faced. The fourth theme was learning requirements. Why the physio is so important in the learning process? What they needed to support their learning.
The four areas are change, understanding and practice, professional benefits for the clinician, clinical challenges or barriers that have come up in the training, and then learning requirements, how a therapist learns it. Let’s dive into these ones by one and talk about some points to them. A change, understanding, and practice, what does that mean in terms of physiotherapists moving from a biomedical model to a biopsychosocial model?
First of all, the physiotherapist reported that they started seeing pain as more multidimensional, including also the psychological and social side aspect. Some of the training interventions had taught physiotherapists to use questionnaires to identify these factors. The physios started using the questionnaires. There were some breathing relaxation exercises that the physio started to use. Also, they understood that the care needed would be patient-centered. Before, some had been fixers and doers in their work and they started getting more responsibility for their patients. The big theme was also that many physios reported that their therapeutic alliance and their communication got better. Quite a lot of them also started using the approach wider, which means that if the intervention in the study they participated in was about low back pain. They started using their skills also with patients who had knee pain, neck pain, or stuff like that.
These are all very important points. I think, especially the fixer mentality that many physiotherapists have when they first come out of school, oftentimes they notice that change when they first started taking some type of cognitive-behavioral training. Typically, the mindfulness and behavior change approaches have less of an emphasis on fixing or alleviating pain. Some traditional Cognitive Behavioral Therapy approaches still have the belief that we can change, modify, fix, eliminate, alleviate pain right off the bat. It’s different approaches. The second one is the professional benefits. Professionals are always interested in how they can move their career forward, how they can benefit themselves, how their practice may benefit. Can you go into some of those specifics?
Quite many reported that they felt that they were better able to help their patients. That is important because everybody notices a situation, where we have patients who have persistent pain and you feel like that, “I have nothing to give to this person. They’ve been seeing many professionals and nobody has been able to fix them.” You end up feeling a little bit helpless. This is something that the physios in many of the studies reported that they didn’t feel. They have more tools to help these people.
They have more cognitive technologies that they can draw on in addition to their skill set as a physical therapist.
It’s also that we don’t feel the pressure of fixing somebody anymore, so much so, we can more be there to support them, to take care and ask questions and helping people to figure things out themselves. That’s part of that as well.
You become a guide instead of the responsibility of having to actually fix someone.
Especially those physios who participated in training in the STarT Back approach. They reported that their practice had become more effective. That means that they were able to discharge some of the patients earlier. Based on the questionnaires, they notice it would get better anyway without their help. Some physios even reported that their job satisfaction increased. They found their job more fulfilling and rewarding after the training. It would be a win-win situation. We are able to help our patients better and we are feeling better ourselves.
The training I’ve done with a therapist on ACT, Acceptance, and Commitment Therapy, I find that it helps with professional burnout, which is important. Let’s talk about some of the challenges with the barriers that have come up in training.
The first challenge that has also come up in the previous studies is the psychosocial factors again because a lot of physios have had the training in more biological things. When they thought about the psychosocial factors and they should be dealing with patients who bring those issues in a discussion. They are not prepared for that. It looks like that the training hasn’t been able to give confidence to everybody in doing that. A lot of physios were afraid of opening the Pandora’s box, can of worms, or whatever you call it. They didn’t feel comfortable yet.
When you say opening Pandora’s box, you’re talking about things like setting off trauma or emotionally dysregulating someone during the session. The therapist may not have the tools to help negotiate that.
People were not maybe ready if somebody started talking about their depression or some traumatic experiences or stuff like that. They didn’t feel ready to sit with that and listen to those people and those stories.
It’s interesting because when I reflect back on my practice as a physiotherapist, a large percent of our patient population is struggling with depression. Most therapists recognize that, but yet they are a little bit cautious about treading into that area.
That’s a common question, but we’re not psychologists. We’re not supposed to do any therapy. That’s a barrier if we don’t see a role in that area.
It’s so interesting to me because one of the best interventions for depression is actually exercising, even above and beyond Cognitive Behavioral Therapy. We look at depression as this treatment that someone should see a mental health professional for Cognitive Behavioral Therapy. Of course, that’s important, but we should also fall back on our skills as physiotherapists that actually may be more effective for those types of conditions.
Quite often in case of pain, the depression is about that the person is not able to do the things they enjoy and their life circumstances have shrunken. Maybe somebody is sitting at home and not able to do anything. No wonder that you are not feeling so good. Maybe our goal would be to help people get back to those things and maybe we can help them with their mood as well.
One other question I did not ask you, the participants in the study, are they from all over the world, the United States, and other countries? Physiotherapy education has changed a little bit globally. There are different things that are happening in the United States as far as the doctor of physical therapy degree versus other countries that may be at a Bachelor’s level. The amount they’ve been introduced to cognitive and behavioral interventions may vary a little bit.
These studies were from the US, Australia, and different European and Western countries. Most of them were English speaking countries.
I’d imagine that would include bachelor level trained physical therapist, Master’s and probably DPTs or Doctors of Physical Therapy.
They had quite long work experience in most of the studies. The lowest was thirteen years of practice and the highest was 25 years.
They had no prior training in cognitive behavioral therapies before the studies?
That was not so well reported in many of the studies. A lot of the participants had previous training. That’s also a good question that what would be the situation if you start from zero, you have no background. Some of the studies reported that the physios who participated had an interest in this area That’s different from the study we did in Finland. That is not included in this review yet. We had participants who were told to participate in the study by their boss or something. They had no previous experience in this.
Back to the barriers. One barrier or challenge may be that a professional physiotherapist, a physical therapist may feel a little uneasy with certain types of patients that maybe have let’s say severe forms of anxiety or depression as you’re starting to implement these treatment techniques into practice. What other types of barriers should we be aware of?
It’s related that many physios reported that they see this a little bit outside the usual professional role of a physiotherapist. We are used to dealing with the physical side of things and it would be an interesting and important discussion. What is the scope of physiotherapy? What is actually physiotherapy nowadays? What does it mean? It’s not just exercise. We can’t avoid it when we’re working with people. We can’t avoid dealing with psychological and social issues.
In your opinion, the psychosocial aspects of care are inseparable from physiotherapy practice. Some therapists want to see that reflected in things like practice acts around the world. Some physiotherapist feels like, “This is what we do. It’s part of our profession, whether I’m learning it in school, whether I’m learning it in a consumer education course. This is part of a continuation of my professional development.”
One problem here is that we think of like a biopsychosocial approach as some intervention. It’s also quite a lot of philosophy from where we work. It’s not that we don’t have maybe that much evidence yet why psychosocial interventions. We have a lot of understanding about pain nowadays, how it works, how pain affects a person’s life. That’s something we can’t deny. The importance of communication and patient-centeredness and stuff like this. It’s about we’re getting things sometimes a little bit wrong.
Finally, the learning requirements. Because there are lots of different ways you can teach adult learners or teach professional learners new skills. Can you talk a little bit about that?
The ways that the physios were thought in these interventions that were either lot, but most of them seem to have some long-term training. Nine out of twelve studies reported using mentoring. The physiotherapists said that they liked to have a structured approach, which means that they would have some treatment manual and stuff like that. What I find interesting, even though they liked the manual, they were still rebelling against the protocol. They wanted some models and formulas, but then, in the end, they didn’t want to work according to them. They were mixing and matching their previous approaches. This reflects quite a lot what we see in practice when we’re teaching people. People want to have it clear. If something happens, then I need to do this. We want this formally and then it gets problematic if we can’t let go of that, individualize and take the patient into account. We start trading with our tools and not the person.
I want to clarify this point for everyone because it’s an important point. The participants in the studies that you looked at, they were enrolled as physiotherapists in a clinical study. They were provided with, let’s say, a formula or a protocol that they had to follow as part of this study. They found that beneficial because it provides a framework for them to follow. If I’m hearing what you’re saying correctly, I would imagine as they learn that protocol, then they start to develop their own cognitive flexibility with the models they’re learning to use it appropriately in different ways.
That happened and it looks like that. Also, for some physios what happened was, they abandon some parts, some techniques right in the beginning. They didn’t see them fit their way of working.
This is very normal, in my practice, for example, McKenzie fits better but Mulligan’s concepts don’t fit as well. Someone may say, “I like these concepts from Cognitive Functional Therapy, but these other ones more from traditional Cognitive Behavioral Therapy don’t quite fit where my perception is of treating someone with pain.”
Some reported they would pick some easier techniques and start using them and then they would forget about the more difficult ones and wouldn’t start practicing.
That’s perfectly normal. It’s a learning curve that’s happening. As people are implementing new skills and technologies into practice, there’s a bit of a learning curve. They’re trying different things, increasing their confidence and their competence, and then as they work, they become more skillful.
Some of the training approaches that would be more strict, I assume, as some would be more flexible. What do you expect the physios to do? This is interesting in the research context. Actually, if the physios don’t do what they’re supposed to do, then it raises the question of what would they measure when we study something? If somebody is supposed to do ACT in an RCT and they are doing something else. What are the results telling us? That’s an interesting question here.
Tell me about mentoring. You mentioned mentoring and I find it important for new therapists who are coming out of school. It’s a nice transition from the classroom and an internship to their first job. The other place I’ve found mentoring to be important is when you’re learning a completely new skillset like this, which could be ACT or a Cognitive Functional Therapy. Talk to us about mentoring. What does that look like in the studies that you identified?
That’s one thing that is a little bit problematic. The training is not usually described in much detail there, so we don’t know much. What it looks like is that they have had different kinds of approaches. They have had group meetings where they go through some patient cases and then somebody would have support from a psychologist where they have one-on-one or group meetings. They would get feedback from their supervisors. Somebody comes and watches you work or you provide a video and you get feedback. There was also some self-feedback and also some peer support. They would mentor each other in a group, so different approaches. Some had practice patients that they should report and then they got feedback from them.
There are lots of different ways to mentor people.
We don’t know what is the best way. I haven’t seen any research on in our field at least how to even train mentors and what would be the optimal way.
I haven’t either. I’ve actually looked high and dry for it. I have not found anything. It’s interesting because, in my perspective, I don’t believe we’ll ever find the perfect way to train or mentor someone with regard to pain because ultimately pain is contextual. Whether you’re training pain in the didactic setting or whether you’re training these things in a more case-based approach to learning, both are important, but ultimately pain is contextual. You have to obviously get into the clinic with real people. Even then, it’s like a rainbow. There are many hues and different colors of everyone who has pain and what their pain experience is like. It’s an interesting topic to talk about, but there’s no research on it and I’m not quite sure we’ll ever be able to put a clear indicator of exactly how we should be training and mentoring. Along those lines, how many hours of training did you find were available in these studies for the participants? I’m sure there’s a range.
The lowest was ten hours and the highest was 150 hours if I understood correctly from the papers I read. That’s quite a big range. One study used internet-based training, but the others were face-to-face.
You can train over the internet with an asynchronous, meaning there is no interaction, or obviously you can have live workshops. You mentioned somewhere between 10 to 150. That’s quite a spread.
In the highest number of hours. They were having a lot of mentoring and support afterward, even for one year after the training.
Was there a mean or a median that stuck out to you as you looked at those numbers or was it hard to identify based on what was provided in the previous research?
Those studies that had the workshop, so that would be like 10 to 15 hours or something like that. If there was some mentoring, so then it would go over twenty hours. There were a couple of studies with 100 or 150 hours. There were a couple of outliers both ends. Some studies, I assume they would have had more because they reported they had mentoring, but it was not clear how much that was, so I’m not sure.
What I’m finding in my practice is that around twenty hours is good to deliver the information and then you need a couple of touchpoints, usually about three mentoring sessions to get people a chance to implement it and to work on some case studies into, of course, have some time for question and answer. People oftentimes have questions about places they bump into as they start to implement it into practice.
What is important is that we should actually train people until competency. We shouldn’t set that exact number that this is going to be the twenty hours of training. Some people are going to probably need more and some people are going to need less based on their background on ways of learning and learning possibilities.
There are some very fast adopters and then there are some people that take a little bit longer. One of the things that I’m discovering as I’m starting to train clinicians in different biopsychosocial techniques is some professionals have a difficult time being flexible, meaning moving from let’s say a pain science education intervention into Cognitive Functional Therapy or into ACT. As physical therapists, we’re often trained on different types of manual techniques. I mentioned before McKenzie and Mulligan and we implement those wonderfully. I’m seeing some therapists able to implement the biopsychosocial interventions and I’m seeing some therapists starting to struggle with competing theories along with the psychosocial realm. Did anything like that pop up in your literature review?
It’s not that I could say from these studies, but that’s an irrelevant issue. It’s interesting that quite a lot of these approaches like Cognitive Behavioral Therapy or ACT or something would have a lot more in common than different. It’s interesting because of course everybody wants to make their trademark. We’re starting to have more and more different names for different approaches. That’s when we start to get in trouble. We are renaming things that are combining old stuff.
We have lots of new names and flavors of the same ice cream almost. What you’re saying is that therapists are learning these different types of theories and they can all intermingle with each other in practice. As a therapy, we should hold theories lightly and not grasp too tight onto one theory as this being the best, most evidenced way to treat someone.
From the point of view of Cognitive Functional Therapy, I can say that the idea is more of like having an evidence-based practice that is evolving all the time. It’s like a collection of the best ways to help our patients. It’s not a fixed approach. That’s a problem. When we create a treatment approach that is like, “This is method X and it’s not evolving.” If we are flexible, taking on the new evidence and changing our practice based on that, things would be much easier.
Was there something surprising that came up in the research that surprised you at the end when you looked at all the data and when you wrote the paper up?
After interviewing the physiotherapists in our own study in Finland, the results were quite similar to those that we saw in Finland. The thing that struck me most was maybe the treatment fidelity thing that I mentioned. The dilemma between wanting a structure and then again, rebelling against that. Those were something that I hadn’t thought about in that sense before. Also, like with the treatment fidelity and mixing and matching, that would be perfect in that sense that we want to individualize. Also, these approaches the physios were trading were a person-centered approach and probably also wanted to individualize. There is a little bit of dilemma that I don’t know what would be the best way to fix that in the training but that was interesting.
What have some of the feedback been from the professional community, from researchers about your paper?
I haven’t had any negative feedback so far. I don’t know how to say whether anybody has yet read the paper, but a lot of people have been sharing it and being thankful for us to do this study. I’m still waiting for the real discussion around this topic. It’s because this is experiences from the physiotherapist, so you can’t argue with that. That’s the reason for not having so much opinions towards one and/or others.
Do you have plans to follow this up? Would you have other studies coming out that are similar or piggyback off the information that’s here?
In our own study from Finland, we interviewed physiotherapists who had participated in CFT training as part of our project. Now, what I’m doing is I’m asking the patients who were happy being treated by physios who have undergone the training. I’m analyzing the data. It’s also interesting to see what is their perception of this approach because I already know that it’s different from what they’re used to.
The work you’re doing is super important for physiotherapists and other health professionals. Of course, we’ll be following your work, Riikka, as it develops. As we close, I want to thank you for joining us and let us know how we can follow you and stay abreast of all the work you’re doing.
Maybe the best way to follow me is on Twitter. Our research group, a wonderful group from Curtin University, and the CFT team. We have the website Pain-Ed, which is worth following. For the readers, we have a company named MoveDoc, but we are publishing only in Finnish, so sorry to the others. We’re sharing a lot of information there. We are on Twitter, Facebook, and Instagram.
We know everyone’s work, Peter O’Sullivan, who’s done great work with Cognitive Functional Therapy, and your work piggybacking off of that. I want to thank you again Riikka for being here talking about biopsychosocial interventions for a physical therapists. Make sure you share this information out with your friends, family, and colleagues on Facebook, Twitter, LinkedIn, wherever you are talking about physical therapy safe and effective ways to treat pain. I’ll see you next time.
- Riikka Holopainen
- Physiotherapists’ Perceptions of Learning and Implementing a Biopsychosocial Intervention to Treat Musculoskeletal Pain Conditions: A Systematic Review and Meta Synthesis of Qualitative Studies
- Integrative Pain Science Institute courses
- Twitter – Riikka Holopainen
- Twitter – MoveDoc
- Facebook – MoveDoc
- Instagram – MoveDoc
About Riikka Holopainen, PT, MSc
Riikka is a physiotherapist and physiotherapy educator from Finland. She is currently a PhD student at University of Jyväskylä, and the aim of her PhD project is to explore patients’ and physiotherapists’ perspectives of biopsychosocial approach in management of musculoskeletal conditions, especially low back pain using qualitative research methods. Her thesis is part of a research project related to feasibility of Cognitive Functional Therapy in Finnish health care system.