Physical Therapy Treatment and the Impact of Behavioral Health Concerns
Physical therapists (PTs) and physical therapist assistants (PTAs) are involved in the treatment of people with movement dysfunction and pain and also provide services to promote health and wellness in order to prevent injury and the progression of symptoms, impairments, and activity limitations in a person with an illness or injury. Musculoskeletal conditions impact people of all ages at a higher incidence than any other medical condition. The prevalence of arthritis is expected to increase to 25% of the adult population by 2030 (Lezin N, Watkins-Castillo S. The impact of musculoskeletal disorders on Americans-opportunities for action, executive summary of the burden of musculoskeletal diseases in the United States: prevalence, societal and economic cost. Bone and Joint Initiative. www.boneandjointburden.org. Accessed 14 June 2017, 2016). Given the economic and human costs of musculoskeletal injuries and illness, it is important that physical therapy treatment be effective. Successful physical therapy treatment requires the participation of the person being treated, so biopsychosocial barriers to the individual’s participation need to be both recognized and addressed. The purpose of this chapter is to ascertain how PTs and PTAs can recognize when recovery is impacted by these psychological and behavioral conditions and identify treatment strategies to effectively address them during physical therapy treatment, including optimal communication to members of the healthcare team. Consideration is also given to how the clinician’s beliefs and approach can affect outcome. This exploration will include consideration of the multifactorial issues affecting both the PT and the individual’s approach and responses during treatment. Moreover, the discussion will address how these concerns may manifest during treatment and address methods available to the therapist to identify the individual’s perceived pain and function. Specific strategies for managing those individuals with pain-focused behavior, sometimes referred to as a cognitive behavioral approach, are addressed.
KeywordsPhysical therapy Physical therapist Physical therapist assistant Rehabilitation Cognitive functional training Therapeutic alliance Non-organic signs Delayed recovery Pain neuroscience education Pain
- American College of Occupational & Environmental Medicine. (2017). Chronic pain guideline. Beverly Farms: OEM Press.Google Scholar
- American Physical Therapy Association. (2014). Retrieved June 14, 2017, from http://guidetoptpractice.apta.org/content/1/SEC1.extract. https://doi.org/10.2522/ptguide3.0_1
- American Physical Therapy Association Board of Directors. Guidelines: Physical therapy documentation of patient/client management (BOD G03-05-16-41). Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/DocumentationPatientClientManagement.pdf. Accessed 18 July 17.
- Butler, D., & Moseley, L. (2013). Explain Pain. Adelaide: NOI Group Publications.Google Scholar
- Carriere, J. S., Thibault, P., Adams, H., Milioto, M., Ditto, B., & Sullivan, M. J. L. (2015). Expectancies mediate the relationship between perceived injustice and return to work following whiplash injury. Journal of Pain, 16, 1280–1287. https://doi.org/10.1016/j.jpain.2015.09.001 CrossRefPubMedGoogle Scholar
- Carriere, J. S., Thibault, P., Adams, H., Milioto, M., Ditto, B., & Sullivan, M. J. L. (2017). Expectancies mediate the relationship between perceived injustice and return to work following whiplash injury: A 1-year prospective study. European Journal of Pain. https://doi.org/10.1002/ejp.1023. Epub ahead of print.
- Childs, J. D., et al. (2008). Neck pain: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 38, A1–A34.CrossRefGoogle Scholar
- Darlow, B., Fullen, B. M., Dean, S., Hurley, D. A., Baxter, G. D., & Dowell, A. (2012). The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management and outcomes of patients with low back pain: A systematic review. European Journal of Pain, 16, 3–17.CrossRefGoogle Scholar
- Delitto, A., et al. (2012). Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 42, A1–A57. https://doi.org/10.2519/jospt.2012.42.4.A1 CrossRefGoogle Scholar
- Domenech, J., Sánchez-Zuriga, D., Segura-Ortí, E., Espejo-Tort, B., & Lisón, J. F. (2011). Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: A randomized clinical trial. Pain, 152, 2557–2563.CrossRefGoogle Scholar
- George, S. Z., Fritz, J. M., & Childs, J. D. (2008). Investigation of elevated fear-avoidance beliefs for patients with low back pain: A secondary analysis involving patients enrolled in physical therapy clinical trials. The Journal of Orthopaedic and Sports Physical Therapy, 38, 50–58.CrossRefGoogle Scholar
- George, S. Z., & Stryker, S. E. (2011). Fear-avoidance beliefs and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain conditions. Journal of Orthopaedic and Sports Physical Therapy, 41(4), 249–259. https://doi.org/10.2519/jospt.2011.3488 CrossRefPubMedGoogle Scholar
- Goldsmith, L. S., Suryaprakash, N., Randall, E., Shum, J., McDonald, V., Sawatzky, R., et al. (2017). The importance of informational, clinical and personal support in patient experience with total knee replacement: A qualitative investigation. BMC Musculoskeletal Disorders, 18, 127–140. https://doi.org/10.1186/212891-017-1474-8 CrossRefPubMedPubMedCentralGoogle Scholar
- Hall, A. M., Ferriera, P. H., Maher, C. G., Latimer, J., & Ferriera, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy, 90, 1099–1110. https://doi.org/10.2522/pt.20090245 CrossRefPubMedGoogle Scholar
- Harmon, K., MacRae, M., & Vallis, M. (2014). The development and testing of a checklist to study behavior change techniques used in a treatment programme for Canadian armed forces members with chronic non-specific low back pain. Physiotherapy Canada, 66, 313–321. https://doi.org/10.3138/ptc2013-55BC CrossRefGoogle Scholar
- Houben, R. M. A., Gijsen, A., Peterson, J., de Jong, P. J., & Vlaeyen, J. W. S. (2005). Do health care providers’ attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures. Pain, 114, 491–498.CrossRefGoogle Scholar
- Kendall, N., Linton, S., & Main, C. (1997). Guide to assessing psychosocial yellow flags in acute back pain: Risk factors for long term disability and work loss. Wellington: ACC.Google Scholar
- Lee, W.-Y. A., Lee, W.-C. E., Law, S.-W., Lau, W.-K. A., Leung, S.-M., & Sieh, K.-M. (2013). Managing psychosocial contributors in low back pain patients-a randomized controlled trial. Journal of Orthopaedics, Trauma and Rehabilitation, 17, 46–51. https://doi.org/10.1016/j.jotr.2012.12.002 CrossRefGoogle Scholar
- Lenz, T. A., Beneciuk, J. M., Bialosky, J. E., Zeppieri Jr., G., Dai, Y., Wu, S. S., et al. (2016). Development of a yellow flag assessment tool for orthopaedic physical therapists: results from the optimal screening for prediction of referral and outcome (OSPRO) cohort. Journal of Orthopaedic and Sports Physical Therapy, 46, 327–343. https://doi.org/10.2519/jospt.2016.6487. Epub 2016 Mar 21.CrossRefGoogle Scholar
- Lezin, N., & Watkins-Castillo, S. (2016). The impact of musculoskeletal disorders on Americans-opportunities for action, executive summary of the burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost. Bone and Joint Initiative. www.boneandjointburden.org. Accessed 14 June 2017.
- Lonsdale, C., Hall, A. M., Murray, A., Williams, G. C., McDonough, S. M., Ntoumanis, N., et al. (2017). Patient skills training for practitioners to increase patient adherence to home-based people rotation for chronic low back pain: results of the cluster randomized controlled trial. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2017.02.025
- Louw, A., & Puentedura, E. (2013). Therapeutic neuroscience education: Teaching patients about pain-a guide for clinicians. OPTP – Orthopaedic physical therapy products. Google Scholar
- Louw, A., Puentedura, E. J., Reese, D., Parker, P., Miller, T., & Mintken, P. E. (2017). Immediate effects of mirror therapy in patients with shoulder pain and decreased range of motion. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2017.03.031. [Epub ahead of print].
- Marchand, G. H., Myhre, K., Leivseth, G., Sandvik, L., Lau, B., Bautz-Holter, E., et al. (2015). Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: A randomized controlled trial. BMC Musculoskeletal Disorders, 16, 1–11. https://doi.org/10.1186/s12891-015-0553-y CrossRefGoogle Scholar
- Martinez-Cevera, F. V., Olteanu, T. E., Gil-Martinez, A. G., Diaz-Pulido, B., & Ferrer-Pena, R. (2017). Influence of expectations plus mobilization with movement in patients with lateral epicondylalgia: a pilot randomized controlled trial. Journal of Rehabilitation. https://doi.org/10.12965/jer.1732848.424
- Matthews, J., Hall, A. M., Hernon, M., Murray, A., Jackson, B., Taylor, I., et al. (2015). Brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: Face validity and feasibility of implementation. Biomedcentral Health Services Research, 15, 260. https://doi.org/10.1186/s12913-015-0921-1 CrossRefGoogle Scholar
- Murray, A., Hall, A. M., Williams, G. C., McDonough, S. M., Ntoumanis, N., Taylor, I. M., et al. (2015). Effect of self-determination theory-based communication skills training program on physiotherapists’ psychological support for their patients with chronic low back pain: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 96, 809–816.CrossRefGoogle Scholar
- Quicke, J. G., Foster, N. E., Ogollah, R. O., Croft, P. R., & Holden, M. A. (2017). The relationship between attitudes, beliefs and physical activity in older adults with knee pain: secondary analysis of a randomized controlled trial. Arthritis Care and Research. https://doi.org/10.1002/acr.23104. (accepted 9/27/2016).
- Smart, K. M., Wand, B. M., & O’Connell, N. E. (2016). Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochraine Database Systematic Review, 2.Google Scholar
- Stilwell, P., & Harman, K. (2017). Contemporary biopsychosocial exercise prescription for chronic low back pain: Questioning core stability programs and considering context. Journal of Canadian Chiropractic Association, 61, 6–17.Google Scholar
- Synnott, A., O’Keefe, M., Bunzli, S., Dankerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists Ms. statement ties were feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61, 68–75.CrossRefGoogle Scholar
- Synnott, A., O’Keefe, M., Bunzli, S., Dankerts, W., O’Sullivan, P., Robinson, K., et al. (2016). Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after cognitive functional training. Journal of Physiotherapy, 62, 215–221.CrossRefGoogle Scholar
- Vlaeyen, J. W., de Jong, J., Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: A replicated single-case experimental design in four patients with chronic low back pain. Behaviour Research and Therapy, 39, 151–166.CrossRefGoogle Scholar
- Waddell, G. (2004). Back pain revolution. London: Churchill Livingstone.Google Scholar