While musculoskeletal physiotherapists are generally well educated to assess and manage the physical and many environmental dimensions of the patient’s health condition, formal education and experience assessing, evaluating and managing psychological and social factors contributing to both acute and chronic pain are often less developed and less structured. In reality physiotherapists can often recognise significant psychosocial factors in their patients but due to a range of barriers many haven’t developed the practice skills to more thoroughly assess and manage psychosocial issues.
Barriers to psychosocial practice
Common concerns of physiotherapists regarding assessment and management of psychosocial factors include:
- Belief it’s not their role “I’m not a psychologist, I’m a physio”
- Belief psychosocial factors are only relevant to chronic pain
- Perceived lack of time
- Insufficient knowledge regarding what to assess
- Insufficient knowledge of how to use information gained either through interview or questionnaires
- Insufficient knowledge and skills in psychosocial factor management strategies
Whether you truly practice biopsychosocially and recognise that there are biological and psychosocial influences and interactions in ALL patients, or whether you practice biomedically with occasional recognition of patients with obvious negative psychosocial issues in their presentations, probably relates to your initial training and style of practice. Once physiotherapists get into the workforce with high workloads and often relatively short patient sessions, it becomes increasingly difficult to change your work style and habits of practice. Making changes to your practice requires motivation to change and the necessary knowledge and skills to apply the change.
The knowledge to practice biopsychosocially essentially requires understanding pain and disability and the biological, environmental and personal or psychosocial factors that influence and are influenced by pain and disability. Each of these factors and their reciprocal interactions are explained in the World Health Organisation ICF biopsychosocial framework and similar biopsychosocial-focussed publications. While psychosocial factors are usually considered with respect to their negative impact on pain, health and disability, it is important to recognise that psychosocial factors can also be positive and contribute positively to health and clinical outcomes. An example of a positive psychological factor is high self-efficacy in pain coping strategies and an example of a positive social factor is a supportive employer or partner.
There is increasing evidence that negative psychosocial factors are adversely influential in the transition from acute to chronic pain conditions. For example, a systematic review involving psychological factors as prognostic indicators for persistent pain and disability suggests there can be consistent relationships between depression, pain catastrophizing, pain intensity, and beliefs about pain with future clinical or occupational outcomes in patients with acute or subacute low back pain (Nicholas et al., 2011). A similar, yet separate systematic review involving predictors of poor clinical outcomes indicated that nonorganic signs, elevated maladaptive pain coping behaviours, elevated baseline LBP-related disability, the presence of psychiatric comorbidities, and low general health status were the strongest predictors of poor clinical outcomes at 1-year follow-up (Chou and Shekelle, 2010). Important knowledge to adopting a biopsychosocial approach to practice is recognition of the scope of adverse influences maladaptive or unhelpful thoughts, beliefs and emotions can have on patients (with the reverse being true for positive thoughts, beliefs and emotions).
Maladaptive Thoughts, Beliefs and Emotions
- Adversely influence sensitivity to mechanical and non-mechanical stimuli, pain intensity and pain tolerance
- Adversely influence function
- Adversely influence behaviours related to pain (e.g. avoidance, catastrophizing, overactivity) and behaviours related to care seeking (e.g. passive coping)
- Adversely influence self-concept and self-efficacy
- Adversely influence relationships
- Adversely influence quality of life
- Adversely influence participation in physiotherapy (e.g. acceptance, compliance)
Psychological factors, often labelled as “Yellow Flags” are not the same as psychiatric or psychopathology, labelled “Orange Flags” (e.g. clinical depression). Rather Yellow Flags are psychological reactions to symptoms and disability, although they can also be present before health problems develop. They exist along a continuum. At the lower end are those with pain and disability associated stress causing selective attention to sensory information, low levels of movement fear-avoidance and frustration with activity and participation restrictions. Many of these patients adjust themselves over time or respond well to education, behavioural interventions and graded activity. Greater pain and disability associated stress greater distress with emergence of catastrophizing cognitions, hypervigilance and broader fear avoidance. At the higher end of the continuum patients have higher levels distress where negative cognitions and emotions regarding pain and disability become enmeshed with negative self-concept and self-worth leading to emotions of helplessness, hopelessness, guilt and despair associated with depression. With training in explaining pain and cognitive-behavioural activity promotion and exercise physios can manage unhelpful/maladaptive cognitions and behaviours at lower end of continuums. In contrast, higher end (clinical depression) or stressors outside clinicians’ scope of practice (relationship breakdown) requires referral to more qualified health professionals. Even when referral, for example to a psychologist is necessary, optimal management involves integration of physiotherapy and psychology.
As with all physiotherapy, management is guided by assessment and therefore physiotherapists need to integrate psychosocial assessment into the structured assessment they already conduct. Often the presence of negative psychosocial factors will emerge spontaneously as patients report their “behaviour of symptoms”, what aggravates their symptoms, what they have had to modify or possibly give up. Here the therapist simply needs to know what to listen for and to document these factors similar to how they would document the presence of physical factors found on examination. However, it is an error to assume that if the patient doesn’t volunteer the distress they are experiencing and the coping strategies they have tried, that there are no negative psychosocial factors affecting their presentation. Physiotherapists are generally familiar with “screening” to ensure information not spontaneously volunteered is not missed, for example screening for other types of symptoms, symptoms in other body areas, other aggravating factors, health co-morbidities, etc. Psychosocial factors can similarly be screened for through both the patient interview and through questionnaires. Below is a general outline of information that can be screened in the patient interview.
- What are the patient’s perspectives of their pain/disability experience?
- Understanding / beliefs regarding their problem, its diagnosis, about pain (for example, with respect to: Seriousness, changeability and controllability) AND what is the basis of those beliefs (i.e. why do they think that)?
- What are their expectations and beliefs about management and their role in management?
- How they are coping, emotionally (e.g., anger, depressive symptoms, feelings of vulnerability, etc.) and behaviorally? Do they have any specific coping strategies (e.g. medication, rest, alcohol, medication, exercise, avoidance), and if so, are they effective?
- What are the patient’s social circumstances (e.g. education, living, work, friends, etc.) and what is their perception of support:
- How does the patient think they are perceived by their partner, workmates and employer, and how does this affect how they feel about themselves?
- Is change important to the patient? What is their self-efficacy to positively contribute to change? What tasks do they currently believe they can perform? What tasks do they believe they will be able to return to following management?
Psychosocial screening in the patient interview may be sufficient or may highlight the need for more in-depth psychological assessment.
Multidimensional questionnaires, such as the STarT Back Screening Tool (SBT) or the Örebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) provide a measure of overall psychological distress. In contrast, unidimensional questionnaires assess specific psychological constructs, for example, below are examples of psychological factors that might be identified in the patient interview and a unidimensional questionnaire that could be used to explore those factors further:
- Expresses fear activity / exercise will make pathology / problem worse:
- Tampa Scale of Kinesiophobia
- Expresses often feeling anxious about their problem / pain:
- State-Trait Anxiety Inventory
- Expresses anger about injustice related to their problem:
- Injustice Experience questionnaire
- Expresses feelings of depression
- Patient Health Questionnaire-2 and nine-item PHQ-9
- Repeated negative statements about never getting better:
- Pain Catastrophising Scale
- Off work with doubts about ability to return:
- Örebro Musculoskeletal Pain Screening questionnaire
- Patient perceptions including understanding, expectations for care, self-efficacy and worrying:
- Brief Illness Perception questionnaire
- Report widespread pain with widespread alodynia and hyperalgesia:
- Central Sensitization Inventory
It is beyond the scope of this Blog to address management, however, physiotherapy management of psychosocial factors at the lower end of the continuum IS within our scope or practice providing we upskill ourselves in biopsychosocial theory, explaining pain (and other symptoms) and cognitive-behavioural management strategies. We can also learn how to screen for clinical depression and some psychiatric disorders (e.g. post-traumatic stress disorder) and stressors such as marital problems that are outside our scope of practice. Here, we need to expand our network of health professionals with whom we can consult and refer, often with the end result being collaborative management between the physio and a psychologist for these more difficult presentations.
Chou, R & Shekelle, P 2010, ‘Will this patient develop persistent disabling low back pain?’ Journal of the American Medical Association, vol. 303, pp. 1295-302.
Jones, MA & Rivett, DA in press Clinical reasoning in musculoskeletal practice. Elsevier.
Nicholas, MK & George, SZ 2011, ‘Psychologically informed interventions for low back pain: an update for physical therapists’, Physical Therapy, vol. 91, pp. 765-76.
World Health Organization 2001 International Classification of Functioning, Disability and Health, World Health Organization, Geneva.
Mark Jones has been a member of the academic teaching staff of the University of South Australia for 27 years. He is Program Director of the Master of Advanced Clinical Physiotherapy within the School of Health Sciences. He is internationally recognised as a key contributor in the physiotherapy practice and clinical reasoning.
You can find a spanish translation of this post here.