The Role of Psychologically Informed Physical Therapy for Musculoskeletal Pain

Abstract

Purpose of Review

Psychologically informed physical therapy (PIPT) addresses physical and psychosocial factors, by integrating cognitive-behavioral techniques into conventional physical therapy. This review presents findings from randomized controlled trials to understand the benefits of PIPT and training needed to deliver PIPT programs.

Recent Findings

Pain coping strategies and exercise were effective for improving physical function in the short term for patients with knee pain; however, long-term clinical benefit depends on the comparison group. Conflicting findings were found in patients with neck pain. However, evidence supports the effectiveness of PIPT for patients with low back pain, particularly those with chronic pain.

Summary

PIPT, through one-on-one, group, and telephone formats, can achieve positive improvement in clinical outcomes. Graded activity, goal setting, and cognitive-restructuring are common components. Stratifying patients and applying targeted PIPT may improve treatment effectiveness. Future research should focus on replicating PIPT in clinical practice and understanding the cost-effectiveness of different delivery platforms.

This is a preview of subscription content, log in to check access.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    • Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research. Phys Ther. 2011;91(5):820–4. This paper presents a conceptual model for psychologically informed physical therapy (PIPT).

    Article  PubMed  Google Scholar 

  2. 2.

    • Ehde DM, Dilworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153–66. This review discusses the importance of cognitive-behavioral therapy (CBT) for chronic pain, directions for future research, and the use of CBT by providers other than psychologists.

    Article  PubMed  Google Scholar 

  3. 3.

    Turner JA, Romano JM. Cognitive-behavioral therapy for chronic pain. In: Loeser JD, editor. Bonica’s management of pain. Philadelphia: Lippincott Williams & Wilkins; 2001.

    Google Scholar 

  4. 4.

    Williams AC, McCracken LM. Cognitive-behavioral therapy for chronic pain: an overview with specific reference to fear and avoidance. In: Asmundson G, Vlaeyen JWS, Crombez G, editors. Understanding and treating fear of pain. London: Oxford University Press; 2004.

    Google Scholar 

  5. 5.

    Thorn BE. Cognitive therapy for chronic pain: a step-by-step guide. New York: Guilford Press; 2004.

    Google Scholar 

  6. 6.

    Thorn BE, Burns JW. Common and specific treatment mechanisms in psychosocial pain interventions: the need for a new research agenda. Pain. 2011;152:705–6.

    Article  PubMed  Google Scholar 

  7. 7.

    Jensen MP. Psychosocial approaches to pain management: an organizational framework. Pain. 2011;152(4):717–25.

    Article  PubMed  Google Scholar 

  8. 8.

    Riddle DL, Keefe FJ, Ang D, J K, Dumenci L, Jensen MP, et al. A phase III randomized three-arm trial of physical therapost delivered pain coping skills training for patients with total knee arthroplasty: the KASTPain protocol. BMC Musculoskelet Disord. 2012;13(1):149. https://doi.org/10.1186/1471-2474-13-149.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Archer KR, Coronado RA, Haug CM, Vanston SW, Devin CJ, Fonnesbeck CJ, et al. A comparative effectiveness trial of postoperative management for lumbar spine surgery: changing behavior through physical therapy study protocol. BMC Musculoskelet Disord. 2014;15(1):325. https://doi.org/10.1186/1471-2474-15-325.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Hunt MA, Keefe FJ, Bryant C, Metcalf BR, Ahamed Y, Nicholas MK, et al. A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study. Knee. 2013;20(2):106–12. https://doi.org/10.1016/j.knee.2012.07.008.

    Article  PubMed  Google Scholar 

  11. 11.

    •• Bennell KL, Ahamed Y, Jull G, Bryant C, Hunt MA, Forbes AB, et al. Physical therapist-delivered pain coping skills training and exercise for knee osteoarthritis: Randomized controlled trial. Arthritis Care Res (Hoboken). 2016;68(5):590–602. A 3-arm randomized trial of PIPT in 222 adults with knee osteoarthritis (OA).

    Article  Google Scholar 

  12. 12.

    • Hurley MV, Walsh NE, Mitchell H, Nicholas J, Patel A. Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: A pragmatic, cluster randomized, controlled trial. Arthritis Care Res (Hoboken). 2012;64(2):238–47. A pragmatic randomized, controlled trial in 418 people with chronic knee pain.

    CAS  Article  Google Scholar 

  13. 13.

    Thompson DP, Oldham JA, Woby SR. Does adding cognitive-behavioral physiotherapy to exercise improve outcome in patients with chronic neck pain? A randomised controlled trial. Physiotherapy. 2016;102(2):170–7. https://doi.org/10.1016/j.physio.2015.04.008.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Monticone M, Baiardi P, Vanti C, Ferrari S, Nava T, Montironi C, et al. Chronic neck pain and treatment of cognitive and behavioral factors: results of a randomised controlled clinical trial. Eur Spine J. 2012;21(8):1558–66. https://doi.org/10.1007/s00586-012-2287-y.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    •• Archer KR, Devin CJ, Vanston SW, Koyama T, Phillips SE, George SZ, et al. Cognitive-behavioral-based physical therapy for patients with chronic pain undergoing lumbar spine surgery: A randomized controlled trial. J Pain. 2016;17(1):76–89. A randomized trial of a telephone-based PIPT intervention in 86 adults with chronic pain undergoing lumbar spine surgery for a degenerative condition.

    Article  PubMed  Google Scholar 

  16. 16.

    Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine (Phila Pa 1976). 2014;39(18):1449–57.

    Article  Google Scholar 

  17. 17.

    Walti P, Kool J, Luomajoki H. Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial. BMC Musculoskelet Disord. 2015;16(1):83. https://doi.org/10.1186/s12891-015-0533-2.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    •• Hall A, Richmond H, Copsey B, Hansen Z, Williamson E, Jones G, et al. Physiotherapist-delivere cognitive-behavioral interventions are effective for low back pain, but can be replicated in clinical practice? A systematic review. Disabil Rehabil. 2016;21:1–9. A systematic review of PIPT randomized controlled trials in patients with non-specific low back pain of any duratuion. Five studies were included in the review.

    Google Scholar 

  19. 19.

    Brunner E, De Herdt A, Minguet P, Baldew S, Probst M. Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Disabil Rehabil. 2013;35(1):1–10.

    Article  PubMed  Google Scholar 

  20. 20.

    Jacobs CM, Guilford BJ, Travers W, Davies M, McCracken LM. Brief psychologically informed physiotherapy training is associated with changes in physiotherapists’ attitudes and beliefs toward working with people with chronic pain. Br J Pain. 2016;10(1):38–45. https://doi.org/10.1177/2049463715600460.

    Article  PubMed  Google Scholar 

  21. 21.

    •• Bryant C, Lewis P, Bennell KL, Ahamed Y, Crough D, Jull GA, et al. Can physical therapists deliver a pain coping skills program? An examination of training processes and outcomes. Phys Ther. 2014;94(10):144–54. This qualitative paper describes the PIPT training process for the randomized trial of Bennell et al.

    Article  Google Scholar 

  22. 22.

    •• Nielsen M, Keefe FJ, Bennell K, Jull GA. Physical therapist-delivered cognitive-behavioral therapy: a qualitative study of physical therapists’ perceptions and experiences. Phys Ther. 2014;94(2):197–209. Eight physical therapists describe their experiences with PIPT training and delivering a PIPT treatment. https://doi.org/10.2522/ptj.20130047.

    Article  PubMed  Google Scholar 

  23. 23.

    Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain. 1983;17(1):33–44. https://doi.org/10.1016/0304-3959(83)90125-2.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Lorig K, Chastain RL, Ung E, Shoor S, Holman HR. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32(1):37–44. https://doi.org/10.1002/anr.1780320107.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15(12):1833–40.

    CAS  PubMed  Google Scholar 

  26. 26.

    Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Patel A, Williamson E, et al. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial. Arthritis Rheum. 2007;57(7):1211–9. https://doi.org/10.1002/art.22995.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Williamson E, Jones RH, et al. Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain. Arthritis Rheum. 2007;57(7):1220–9. https://doi.org/10.1002/art.23011.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Woby SR, Roach NK, Urmston M, Watson PJ. Outcome following a physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes. Physiotherapy. 2008;94(2):115–24. https://doi.org/10.1016/j.physio.2007.08.008.

    Article  Google Scholar 

  29. 29.

    Leak AM, Cooper J, Dyer S, Williams KA, Turner-Stokes L, Frank O. The Northwick Park pain questionnaire, devised to measure neck painand disability. Br J Rheumatol. 1994;33(5):469–74. https://doi.org/10.1093/rheumatology/33.5.469.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Sullivan MJL, Bishop SR. The pain catastrophizing scale: develop-ment and validation. Psychol Assess. 1995;7(4):524–32. https://doi.org/10.1037/1040-3590.7.4.524.

    Article  Google Scholar 

  31. 31.

    Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric propertiesof the TSK-11: a shortened version of the Tampa scale for Kinesiopho-bia. Pain. 2005;117(1):137–44. https://doi.org/10.1016/j.pain.2005.05.029.

    Article  PubMed  Google Scholar 

  32. 32.

    Anderson KO, Dowds BN, Pelletz RE, Edward WT. Development and initial validation of a scale to measure self efficacy beliefs in patientswith chronic pain. Pain. 1995;63(1):77–84. https://doi.org/10.1016/0304-3959(95)00021-J.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Monticone M, Baiardi P, Nido N, Righini C, Tomba A, Giovanazzi E. Development of the Italian version of the neck pain and disability scale. NPDS-I Spine (Phila Pa 1976). 2008;33(13):E429–34. https://doi.org/10.1097/BRS.0b013e318175c2b0.

    Article  Google Scholar 

  34. 34.

    Archer KR, Wegener ST, Seebach C, Song Y, Skolasky RS, Thornton C, et al. The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine. 2011;36(19):1554–62. https://doi.org/10.1097/BRS.0b013e3181f8c6f4.

    Article  PubMed  Google Scholar 

  35. 35.

    Archer KR, Seebach CL, Mathis S, Riley LH, Wegener ST. Early postoperative fear of movement predicts pain, disability, and physical health 6 months after spinal surgery for degenerative conditions. Spine J. 2014;14(5):759–67. https://doi.org/10.1016/j.spinee.2013.06.087.

    Article  PubMed  Google Scholar 

  36. 36.

    Mannion AF, Elfering A, Staerkle R, Junge A, Grob D, Dvorak J, et al. Predictors of multidimensional outcome after spinal surgery. Eur Spine J. 2007;16(6):777–86. https://doi.org/10.1007/s00586-006-0255-0.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    den Boer JJ, Oostendorp R, Beems T, Mummeke M, Oerlemans M, Evers A. A systematic review of bio- psychosocial risk factors for an unfavorable outcome after lumbar disc surgery. Eur Spine J. 2006;15(5):527–36. https://doi.org/10.1007/s00586-005-0910-x.

    Article  Google Scholar 

  38. 38.

    Archer KR, Motzny N, Abraham CM, Yaffe D, Seebach CL, Devin CJ, et al. Cognitive-behavioral based physical therapy to improve surgical spine outcomes: a case series. Phys Ther. 2013;93(8):1130–9. https://doi.org/10.2522/ptj.20120426.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Cleeland CS, Ryan KM. Pain assessment: global use of the brief pain inventory. Ann Acad Med Singap. 1994;23:129–38.

    CAS  PubMed  Google Scholar 

  40. 40.

    Fairbank JC, Pynsent PB. The Oswestry disability index. Spine. 2000;25(22):2940–52. https://doi.org/10.1097/00007632-200011150-00017.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain. 2007;11(2):153–63. https://doi.org/10.1016/j.ejpain.2005.12.008.

    Article  PubMed  Google Scholar 

  42. 42.

    Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT back): a randomised controlled trial. Lancet. 2011;378(9802):1560–71. https://doi.org/10.1016/S0140-6736(11)60937-9.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Critchley DJ, Ratcliffe J, Noonan S, Jones RH, Hurley MV. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine. 2007;32(14):1474–81. https://doi.org/10.1097/BRS.0b013e318067dc26.

    Article  PubMed  Google Scholar 

  44. 44.

    Johnson RE, Jones GT, Wiles NJ, Chaddock C, Potter RG, Roberts C. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine. 2007;32(15):1578–85. https://doi.org/10.1097/BRS.0b013e318074f890.

    Article  PubMed  Google Scholar 

  45. 45.

    Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, et al. Group cognitive behavioral treatment for low-back pain in primary care: a randomized controlled trial and cost-effectiveness analysis. Lancet. 2010;375(9718):916–23. https://doi.org/10.1016/S0140-6736(09)62164-4.

    Article  PubMed  Google Scholar 

  46. 46.

    Johnstone R, Donaghy M, Martin D. A pilot study of a cognitive-behavioral therapy approach to physiotherapy, for acute low back pain patients, who show signs of developing chronic pain. Adv Physiother. 2002;4(4):182–8. https://doi.org/10.1080/14038190260501622.

    Article  Google Scholar 

  47. 47.

    Turner JA, Macl L, Aaron LA. Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized controlled trial. Pain. 2006;121(3):181–94.

    Article  PubMed  Google Scholar 

  48. 48.

    Williams DA, Cary M, Groner K, Chaplin W, Glazer L, Rodriguez A, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive-behavioral intervention. J Rheumatol. 2002;29(6):1280–6.

    PubMed  Google Scholar 

  49. 49.

    Von Korff M, Balderson BH, Saunders K, Miglioretti DL, Lin EH, Berry S, et al. A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. Pain. 2005;113(3):323–30. https://doi.org/10.1016/j.pain.2004.11.007.

    Article  Google Scholar 

  50. 50.

    Slater MA, Weickgenant AL, Greenberg MA, Wahlgren DR, Williams RA, Carter C, et al. Preventing progression to chronicity in first onset, subacute low back pain: an exploratory study. Arch Phys Med Rehabil. 2009;90(4):545–52. https://doi.org/10.1016/j.apmr.2008.10.032.

    Article  PubMed  Google Scholar 

  51. 51.

    Litt MD, Shafer DM, Kreutzer DL. Brief cognitive-behavioral treatment for TMD pain: long-term outcomes and moderators of treatment. Pain. 2010;151(1):110–6. https://doi.org/10.1016/j.pain.2010.06.030.

    Article  PubMed  PubMed Central  Google Scholar 

  52. 52.

    Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive behavioral intervention and two forms of information for patients with spinal pain. Spine. 2000;25(21):2825–31. https://doi.org/10.1097/00007632-200011010-00017.

    CAS  Article  PubMed  Google Scholar 

  53. 53.

    Gatchel RJ, Polatin PB, Noe C, Gardea M, Pulliam C, Thompson J. Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study. J Occup Rehabil. 2003;13(1):1–9. https://doi.org/10.1023/A:1021823505774.

    Article  PubMed  Google Scholar 

  54. 54.

    Storheim K, Brox JI, Holm I, Koller AK, Bø K. Intensive group training versus cognitive intervention in sub-acute low back pain: short-term results of a single-blind randomized controlled trial. J Rehabil Med. 2003;35(3):132–40. https://doi.org/10.1080/16501970310010484.

    Article  PubMed  Google Scholar 

  55. 55.

    Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P, et al. Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice. Lancet. 2005;365(9476):2024–30. https://doi.org/10.1016/S0140-6736(05)66696-2.

    CAS  Article  PubMed  Google Scholar 

  56. 56.

    Steenstra IA, Anema JR, van Tulder MW, Bongers PM, de Vet HC, van Mechelen W. Economic evaluation of a multi-stage return to work program for workers on sick-leave due to low back pain. J Occup Rehabil. 2006;16(4):557–78. https://doi.org/10.1007/s10926-006-9053-0.

    Article  PubMed  Google Scholar 

  57. 57.

    Newcomer KL, Vickers Douglas KS, Shelerud RA, Long KH, Crawford B. Is a videotape to change beliefs and behaviors superior to a standard videotape in acute low back pain? A randomized controlled trial. Spine J. 2008;8(6):940–7.

    Article  PubMed  Google Scholar 

  58. 58.

    Rogerson MD, Gatchel RJ, Bierner SM. A cost utility analysis of interdisciplinary early intervention versus treatment as usual for high-risk acute low back pain patients. Pain Pract. 2010;10(5):382–95. https://doi.org/10.1111/j.1533-2500.2009.00344.x.

    Article  PubMed  Google Scholar 

  59. 59.

    Whitfill T, Haggard R, Bierner SM, Pransky G, Hassett RG, Gatchel RJ. Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes. J Occup Rehabil. 2010;20(2):256–63.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The statements in this publication are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.

Funding

Research reported in this publication was partially funded through a Patient-Centered Outcomes Research Institute (PCORI) award (CER-1306-01970).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kristin R. Archer.

Ethics declarations

Conflict of Interest

Kristin R. Archer has served as a consultant for Pacira and has had travel/accomodation expenses covered or reimbursed by APTA.

Rogelio A. Coronado and Stephen T. Wegener declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Musculoskeletal Rehabilitation

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Archer, K.R., Coronado, R.A. & Wegener, S.T. The Role of Psychologically Informed Physical Therapy for Musculoskeletal Pain. Curr Phys Med Rehabil Rep 6, 15–25 (2018). https://doi.org/10.1007/s40141-018-0169-x

Download citation

Keywords

  • Biopsychosocial
  • Cognitive therapy
  • Musculoskeletal diseases
  • Pain management
  • Physical therapy
  • Psychological