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Psychologically Informed Physical Therapy For Chronic Pain: Physiotherapists Leading The Way With Safe, Effective, Multimodal Treatment For Physical And Mental Wellbeing With Joe Tatta, PT, DPT, CNS
Psychologically informed physical therapy began with investigating safe and effective ways to prevent and treat chronic musculoskeletal pain. They blend psychological methods, strategies, and techniques within a physical therapist evaluation, treatment, and plan of care. What started with chronic pain has now evolved into a deep and global understanding that physical, behavioral, and mental health are inseparably interconnected with overall health and wellbeing.
This is important when you consider that 1 in 5 US adults lives with a mental illness and many more struggle with stress-related chronic illnesses such as chronic pain. If you are a physical therapist, understand that there are many studies out there that demonstrate that upwards of 75% of the patients that we see in clinical practice may be struggling with one or more mental health challenges. This means that the report of patient distress, things like anxiety, depression, and fear are no longer an optional invitation but a requirement for physical therapists and other licensed healthcare providers to address the cycle of mental illness and to promote mental wellbeing.
How can a physical therapist or another provider begin to develop, practice, and see their patients through this new psychologically informed lens? First, it requires that you study one or more psychological theories or methods. The most common are Cognitive Behavioral Therapy, acceptance and commitment therapy, motivational interviewing or mindfulness. The four just mentioned have the most research to support them and evidence that physical therapists can deliver this type of care effectively, it’s acceptable to patients, and that we can deliver this with high fidelity, meaning we stay faithful to the model.
Is there evidence supporting this type of care or psychologically informed care? The answer is yes. Physical therapists have treated back pain, neck pain, lower extremity osteoarthritis, specifically of the hip and the knee, as well as other conditions such as headache, fibromyalgia, and chronic regional pain syndrome. This type of care has been delivered within interdisciplinary pain centers, as well as by the solo private practitioner working in an outpatient setting.
There’s multiple high-powered quality metanalysis that demonstrates that psychologically informed physical therapy improves physical function and disability. As well as the psychological components, such as fear, pain catastrophizing, anxiety, depression, self-efficacy, mindfulness, acceptance, values, psychological flexibility, and promotes a faster and smoother return to function.
How do you begin to deliver this type of care? It starts with the initial evaluation. You have to have some type of validated patient self-report measure to measure the psychological components that are related to behavioral health. Once you have implemented this validated self-report into your initial evaluation or initial assessment, the next step is to discuss the outcomes with your patient during the initial visit and discuss how this is one component and not the cause of chronic pain. Always begin by addressing this during the first session.
One of the biggest challenges I see with practitioners when they first begin to use psychological care is that they wait until they notice that the patient is not doing so well, and then they insert a mindfulness exercise or a cognitive exercise. It leaves the patient confused, frustrated, and sometimes feeling stigmatized, for they have now felt that they are being told that pain is all in their head.
These interventions should be a consistent through-line from the initial evaluation, at most treatment sessions, all the way through to the end of the plan of care and any evaluation or reevaluation. This is the most beneficial care available for people living with chronic pain. Given the breadth of existing research, it’s time that we translate the evidence into practice as it relates to health promotion, prevention, and the treatment of chronic noncommunicable disease, as well as chronic pain. Now, I share with you voices from around the globe of physiotherapists that are using psychologically based tools and techniques to treat their patients with chronic pain. We will begin with the Physical Therapist, Zachary Stearns.
“We start with a standard screen. This is where ideally, there’s a screen either before the evaluation self or during the evaluation. From that initial screen, it can look different based on what setting you are in. From there, we engage in shared decision-making with the patient. This is important to me because we need to make sure that the patient is onboard with our plan and it thinks that it’s a good idea. That does include giving a rationale for asking these questions that we have 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. The shared decision-making aspect can, what we think, lead to four general pathways.”
“The standard physical therapy is hard to define that but what we mean is that we certainly know that exercise and physical activity are very helpful for those with musculoskeletal pain. There are specific exercises out there, as well as a general exercise that is 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 with particular musculoskeletal pain.”
“For many people, we don’t necessarily need to incorporate some different psychological interventions in our practice. Therefore, if someone were to present no positive screens in the O SPRO Yellow Flag Tool, we would say, “We don’t need to necessarily move forward with a progressive muscle relaxation or activity rest cycling, these other psychological skills. For some people, if they were to screen positive, we can consider one of a few different pathways and 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 clinical depression or an anxiety disorder.’ Therefore, we want to expand the team around the patient to make sure that we have professionals who specialize in treating their own respective specialties. That last category is an immediate referral for someone who’s in either a suicidal crisis or something very severe, and needs immediate intervention.”
“The final step is an ongoing step of treatment monitoring in which cases 2 or 4 weeks go by. We are reconsidering how things are going, not just in terms of the range of motion, strength, physical or endurance but also in terms of the psychosocial profile of how someone is thinking, feeling or acting in their contexts living with pain. That can go back to inform our shared decision-making moving forward.”
Next up is Physical Therapist, Jeremy Fletcher. “This particular question about working with adults with chronic pain, from my perspective and experiences both personally and professionally, the value that the shift in perspective from what’s wrong with you. Let me go and evaluate someone from a docent-based perspective. In other words, I’m going to go through and collect a whole huge list of all these things that are wrong with you or impairment if we are using the ICF language and then we are going to develop this plan of care to address these impairments.”
“The fundamental shift that I have made in my personal clinical practice as a result of using the trauma-informed care guiding principles is that I want to recognize that your previous traumatic experiences may be influencing your ability to decrease the threat response and thereby decrease the amount and intensity of that pain that you are experiencing. That is a part of what we know is pain neuroscience education. We deliver this information about how the pain experience is. What is the nervous system doing? What I have found is everybody’s got this story. They need to feel heard and listened to.”
“If we are using the trauma-informed care perspective, what happened is what we want to listen for. What did happen? When we are hearing that, the essence of listening builds this therapeutic relationship to a greater degree than my previous experiences, where I was entering into this relationship, looking at someone from a deficit-based approach. Now I look at someone from a strength-based approach. I want to know how did you manage to overcome the adversity that you had before. What are the skills that you didn’t learn before to overcome these adverse experiences? How can we apply those nowadays?”
Let’s meet Canadian Physiotherapist, Carolyn Vandyken. “You have some evidence that people who are catastrophizing, which is a normal phenomenon. Let’s not make that pejorative or judgemental in any way, shape or form. I always say to my patients, ‘We all catastrophize.’ That’s normal. If I sprained my ankle, I’m going to start to freak out a little bit and go, ‘I’ve got to teach tomorrow. I’ve got to see patients the next day. How am I going to get through this?’ Catastrophization serves a function but when we get stuck in that mode, it is highly connected with persistent pain.”
“We do have research that catastrophizers, people who are freaking out about their pain, do much better with pain education or people who are fear-avoidance using the Tampa Scale of Kinesiophobia, for example, which isn’t a perfect scale. It’s the best one we have for fear now. I don’t use it because of the work component. I don’t see so many WSAB anymore. Workers’ comp. When we use a screening questionnaire, it helps us to tailor what the person in front of us needs. I always use the example of my daughter-in-law, who had chronic low back pain for about four years.”
“In COVID-19 at the beginning of 2020, she was suffering from this back pain. She had gone to see a chiropractor. She lives about three hours away. I had sent her to a couple of different clinicians and she wasn’t getting any better. Finally, I said to her, ‘Would you like me to take a look? I’m going to treat you like a patient.’ I gave her all the questionnaires and I started from scratch because we do what we do with a lot of friends and family. We jump in and give them a suggestion and leave again. We treated her like a patient this time.”
“She knows we have recorded her sessions. She’s okay with me talking about this. She’s a beautiful 26-year-old, vivacious, gregarious, outgoing Phys Ed teacher who was starting to become fearful about participating in her Phys Ed classes because of her back pain. Her catastrophization was at a severe level. She was convinced at this point, after four years that she needed surgery. What we had to do was a lot of pain education with her. I would never have guessed that her catastrophization was not severe unless I had measured it. When we use questionnaires to help us profile the person in front of us and figure out, are they fear avoidant, experiential avoidance of activity, catastrophizing, stressed or depressed?”
Over to Spain to meet Javier Martinez Calderon. “In my personal view, physical therapists have modulated conditions and emotions related to pain for decades. It states that our physical therapy educates the patients, beliefs, thoughts and emotions. Our model is incredible in how we try to promote self-management to our patients without altering cognitions and emotions related to pain because we need to create a therapeutic alliance firstly. We need our patients there during the intervention. In both steps, demolition of conditions and emotions are essential.”
“Many physical therapists are still uncomfortable using mental skills. For example, motivational interviewing went through the patient with persistent pain. Indeed, there are a lot of evidence supporting and health professionals who believe that things are always caused by tissue damage and difficult to return to their normal activities to their patients. I would like to increase different pain clinicians to investigate part of all the importance of the social model of chronic pain and how we can apply this model in our clinical practice.”
We will jet over to Ireland for Physiotherapist, Mary Grant. “Living with pain is a difficult concept, isn’t it for all of us, patients and conditions? It doesn’t sound right living was the same. The first step is to acknowledge the patient’s journey to date and know what they have tried already to get rid of pain and how this has worked or maybe not worked for them. What I love about the ACT is using measures like storytelling to try and help the patient to see that maybe there are other ways around this and that maybe it’s okay to drop the whole trying to control the pain or the pain agenda because that can be hard for people. That’s what they want to do. You have to go carefully with that with people.”
“The next thing is once you have thought that suggestion out there that may be controlling the pain is not the most beneficial way to go. They are ready to try something new. That’s where clarifying what values are for them as humans like what and who they care about most in their lives. That’s the next big thing that can help them to go on the path towards going back to what they want to do or it’s different.”
It’s an Italian Physiotherapist living in the UK, Davide Lanfranco. “Full suppression is about anything but allowing the full to be there. Distracting yourself, watching the movies, put in the music corner, trying to think positively, that belongs to these very toxic messages that are delivered by the society. You think positive, positive thoughts, positive vibes, put away everything that is scary, negative and is not nice. Replace it and change it with positive stuff.”
“These toxic messages lead us to the understanding that negative, scary or anxious thoughts are wrong and must be pushed away. When you push them away, you get their own equal effect. They come back even more and stronger. Research has shown us that suppressed thoughts are characterized by an increased return of the suppress content. You may be familiar with them in the polar bear experiment.”
“I don’t remember in which we showed people the polar bear, and then they told them to try to not think about the polar bear and it was impossible. When we tell our patients and it’s something I hear often from my colleagues, they are saying to the patients, “Try to be positive. Things will be alright. Don’t think too much about it. Don’t stress too much. Thank you.” If she or he could have done it, they would have done it already.”
“You don’t need to tell the person to think positive, don’t stress about it or don’t worry. Acceptance commitment therapy and cognitive diffusion teach us how to do this from another perspective and how to take a step back. Cognitive diffusion is something very powerful but as we said before, people who were at the eye level of cognitive fusion don’t even recognize were having folds in the first distance. I have a bed backer but this is the truth. It’s not even a thought that is passing through my mind. They think that is the truth. Before going using very fancy and nice techniques that acceptance commitment therapy offers, the first step with these patients is helping them be more aware of their cognition.”
From Finland, it’s Physiotherapist, Riikka Holopainen. “The physiotherapist reported that they have started seeing pain as more multidimensional, including also the psychological and social aspects. Some of the training interventions had thought physiotherapists to use questionnaires to identify these factors and the physios had started using the questionnaires. There were some breathing relaxation exercises that the physio started to use and they understood that the care needed to be patient-centered, unlike before some had been fixers and doers in their work. They started giving more responsibility for their patients.”
“A big theme was also that many physios reported that their therapeutic alliance and communication is starting to get better. Quite a lot of them also started using the approach wider, which means that 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 or stuff like that.”
From the United States, Physical Therapist, Matt Erb. “I’m going to preface what I’m going to say by suggesting that, I hope that at some point in the evolution in our co-creating and mutual learning around improving healthcare that labels will not be needed and that I have chosen and this can be loaded as well, too. As I’m sure, you know the word integrative, which is a derivative of the word integral.”
“When I look at the idea of bio-psycho-social, I see that if we can see that as a whole and potentially also acknowledge that there are spiritual facets to people’s lives, which could be added into the psychological compartments, for example. Cultural aspects of people’s health experience, which could be technically put into the social. That I believe as my personal preference that integral or integrative is more encompassing.”
“In this regard, we can look at the construct of body, mind, and environment. I know you have had Marlysa Sullivan on here. In her paper on the explanatory framework for yoga therapy, she introduced the abbreviation, BME, seeing that Body, Mind, and Environment are inseparably embedded into a living system. They can’t be removed from each other. The idea of using integrative is to look at bio-psycho-social but adding in other levels, as well as certain constructs.”
UK Physiotherapist now living in Canada, Tom Young. “Some of what we do more traditionally, there’s something seductively complex about it like regional independent models. I’m going to watch you walk. You’ve got shoulder pain while your ankle is pronating ten degrees, and if we fix that and I saw it, accepting maybe that, A) It doesn’t have the best evidence, to begin with. B) Letting go of that sense of maybe I’m not quite as clever as I think and that’s a challenge. You acknowledge your own sense of intellectual vanity almost. Letting go of that a little bit can be a challenge and answering what you expect a patient needs. You encourage the patient to do something and in the session, they buy it. They were like, ‘This is important to me. This is awesome.’”
“They have a big pain flare and there’s that sense of you can either swoop back in, try and save the day and say, “Here’s what we are going to do. We are going to control this and back off.” That robs people of agency. Part of that is trying to muddle up oldness about pain and, ‘You have pain but what else came up for you. Was that some excitement when you did that thing? Was that some joy at the moment? What else was there room for at that moment?’ The more I have done that, the less of a win-loss there is a frame for me. That’s what’s freeing.”
“Trying to fix chronic pain is like banging your head against the wall. I talk a lot about patients letting go of that fight but for me, as a practitioner, also have to do that. If I’m still secretly like but all of this is to make you have a less painful experience, then I keep on feeling lost and that’s not a battle I’m winning. To truly let go of that control for myself as well and be willing to model boldness about pain is quite liberating too, and always bring it back to, ‘That happened.’ What else, what’s important to you?”
Australian Physiotherapist, Samantha Bunzli. “This model helps these guys to understand how we can play a role. Often, physiotherapists are worried to use that line with maybe the pain psychologists and feeling like maybe we don’t have a role to play in managing those emotional responses to pain and that’s distressed. This model shows that it helps physios understand that we do play a role in addressing those emotional responses by helping people make sense of their pain.”
“This is something that is well within our scope of practice. We also play an important role as far as belief change going hand in hand. Any question that has a patient coming to see them with pain, it’s important that we know how that individual is representing their pain. We need to tap into these five belief dimensions.”
“How do they make sense of their pain experience? We can ask them questions about that identity domain. Do you have a diagnosis for your pain? Can you explain to me what that means so that problematic interpretation of the jargon? Have you had any scans? You said you are trying to look around with those beliefs. Around the cause domain, do you know what causes your pain and how predictable is your pain?”
“Is there always a cause and effect? How predictable are that cause and effect? What do you think are the consequences of your pain or your diagnosis aside? Can you prevent your pain from flaring up around that control domain and can you control the pain once it’s split up? Patients often distinguish between those two control factors and then the timeline beliefs.”
“How long do you expect your pain will last? How hopefully for the future and what do you think it’s going to take to get your pain better? As clinicians, we should be listening for any gaps and understanding that we need to help fill or any incorrect belief set that we need to try to adjust. That’s where behavioral techniques are important because I have done a lot of work with patients CFT, and that puts a lot of emphasis on exposure to feared movements and activities as a mechanism to disconfirm beliefs.”
To round out, we have a Brazilian Physiotherapist now living in Australia, JP Caneiro. “Ask any grandmother and any mother around the neighborhood, everyone will tell you that round back is a bad thing for you. There is this belief in posture. We are probably tapping into the information that is most readily available in our society. That is quite interesting because you give us an idea that, for instance, I have been working for dollars. He’s got an extraordinary work around capturing people’s explicit beliefs and of self-report. There is this idea that the back is easy to harm and hard to heal.”
“We looked at this population and implicitly are making the same associations that creates what we think is this strong schema that you might be going on about your life and everything is fine and then you experienced pain. Once you have experienced pain, your brain is probably going to tap into that schema and go, ‘I have back pain. What should I do? I shouldn’t bend because that’s what my implicit schema is telling me.’”
“You go in and talk to your friend, neighbor, healthcare professionals and they reinforce the schema and what we think potentially happens. That speculation on our data is that you have this update of the schema that goes from bending the back is dangerous to protect the back from now on, especially if your pain is related to bending. You have bent forward and you think you are on your back, which reinforces that skim. You get caught up in that idea. That ideation has a behavioral response. There may get people trapped.”
Important Links:
- Zachary Stearns – LinkedIn
- Jeremy Fletcher – LinkedIn
- Carolyn Vandyken
- Javier Martinez Calderon – Instagram
- Mary Grant – LinkedIn
- Davide Lanfranco
- Riikka Holopainen
- Matt Erb – LinkedIn
- Tom Young – LinkedIn
- Samantha Bunzli
- JP Caneiro – Twitter
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