Physical Therapy Treatment and the Impact of Behavioral Health Concerns

  • Jill S. GalperEmail author


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. 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.


Physical therapy Physical therapist Physical therapist assistant Rehabilitation Cognitive functional training Therapeutic alliance Non-organic signs Delayed recovery Pain neuroscience education Pain 


  1. American College of Occupational & Environmental Medicine. (2017). Chronic pain guideline. Beverly Farms: OEM Press.Google Scholar
  2. American Physical Therapy Association. (2014). Retrieved June 14, 2017, from
  3. American Physical Therapy Association Board of Directors. Guidelines: Physical therapy documentation of patient/client management (BOD G03-05-16-41). Available at: Accessed 18 July 17.
  4. Beattie, P. F., Silfes, S. P., & Jordan, M. (2016). The evolving role of physical therapists in the long-term management of chronic low back pain: Longitudinal care using assisted self-management techniques. Brazilian Journal of Physical Therapy, 20, 580–591.CrossRefGoogle Scholar
  5. Blickenstaff, C., & Pearson, N. (2016). Reconciling movement and exercise with pain neuroscience education: A case for consistent education. Physiotherapy Theory and Practice, 32, 396–407.CrossRefGoogle Scholar
  6. Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., et al. (2013). The effects of graded motor imagery and its components on chronic pain: A systematic review and meta-analysis. Journal of Pain, 14, 3–13.CrossRefGoogle Scholar
  7. Bunzli, S., McEvoy, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2016). Patient perspectives on participation in cognitive functional therapy for low back pain. Physical Therapy, 96, 1397–1407. CrossRefPubMedGoogle Scholar
  8. Butler, D., & Moseley, L. (2013). Explain Pain. Adelaide: NOI Group Publications.Google Scholar
  9. Cairns, M. C., Foster, N. E., Wright, C. C., & Pennington, D. (2003). Level of distress in a recurrent low back pain population referred for physical therapy. Spine, 28(9), 953–959.PubMedGoogle Scholar
  10. 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. CrossRefPubMedGoogle Scholar
  11. 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. Epub ahead of print.
  12. 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
  13. Coudeyre, E., Rannou, F., Tuback, F., Baron, G., Coriat, F., Brin, S., et al. (2006). General Practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain, 124, 330–337.CrossRefGoogle Scholar
  14. Crombez, G., Eccleston, C. V. J. W., Vansteenwegen, D., & Lysens, R. E. P. (2002). Exposure to physical movements in low back pain patients: Restricted effects of generalization. Health Psychology, 21, 573–578.CrossRefGoogle Scholar
  15. 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
  16. 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. CrossRefGoogle Scholar
  17. Diener, L., Kargela, M., & Louw, A. (2016). Listening is therapy: Patient interviewing from a pain science perspective. Physiotherapy Theory and Practice, 32(5), 356–367. CrossRefPubMedGoogle Scholar
  18. 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
  19. Ebrahim, S., Malachowski, C., Kamal el Din, M., Mulla, S. M., Montoya, L., Bance, S., et al. (2015). Measures of patients’ expectations about recovery: A systematic review. Journal of Occupational Rehabilitation, 25, 240–255. CrossRefPubMedGoogle Scholar
  20. Fairbank, J. C. T., Davies, J. B., Couper, J., & O’Brien, J. P. (1980). The Oswestry low-back pain disability questionnaire. Physiotherapy, 66, 271–273.PubMedGoogle Scholar
  21. Ferreira, P. H., Ferreira, M. L., Maher, C., Reishauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical Therapy, 93, 470–478.CrossRefGoogle Scholar
  22. Fritz, J. M., George, S. Z., & Delitto, A. (2001). The role of fear-avoidance beliefs in acute low back pain: Relationships with current and future disability and work status. Pain, 94, 7–15.CrossRefGoogle Scholar
  23. Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S., et al. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle sensitivity in patients with chronic low back pain: An experimental controlled study. Physical Therapy, 94, 477–489.CrossRefGoogle Scholar
  24. George, S. Z., Bialosky, J. E., & Fritz, J. M. (2004). Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs. Physical Therapy, 84, 538–549.PubMedGoogle Scholar
  25. George, S. Z., Fritz, J. M., Bialosky, J. E., & Donald, D. A. (2003). The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: Results of a randomized clinical trial. Spine, 28, 2551–2560.CrossRefGoogle Scholar
  26. 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
  27. 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. CrossRefPubMedGoogle Scholar
  28. George, S. Z., Valencia, C., Zeppieri Jr., G., & Robinson, M. E. (2009). Development of a self-report measure of fearful activities for patients with low back pain: The fear of daily activities questionnaire. Physical Therapy, 89, 969–979.CrossRefGoogle Scholar
  29. 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. CrossRefPubMedPubMedCentralGoogle Scholar
  30. Gross, D. P., & Battié, M. P. (2005). Work-related recovery expectations and the prognosis of chronic low back pain within a worker’s compensation setting. Journal of Occupational and Environmental Medicine, 47, 428–433.CrossRefGoogle Scholar
  31. 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. CrossRefPubMedGoogle Scholar
  32. 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. CrossRefGoogle Scholar
  33. 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
  34. Jack, K., McLean, S. M., Moffet, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy, 15, 220–228. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 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
  36. Kolt, G. S., & Andersen, M. B. (2004). Using psychology in the physical and manual therapies. In G. S. Kolt & M. B. Andersen (Eds.), Psychology in the physical and manual therapies. Edinburgh: Churchill Livingstone.CrossRefGoogle Scholar
  37. Lakke, S. E., Soer, R., Krijnen, W. P., van der Schans, C. P., Reneman, M. F., & Geertzen, J. H. B. (2015). Influence of physical therapists’ kinesiophobic beliefs on lifting capacity in healthy adults. Physical Therapy, 95, 1224–1233.CrossRefGoogle Scholar
  38. 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. CrossRefGoogle Scholar
  39. 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. Epub 2016 Mar 21.CrossRefGoogle Scholar
  40. 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. Accessed 14 June 2017.
  41. Linton, S. J., & Shaw, W. S. (2011). Impact of psychosocial factors in the experience of pain. Physical Therapy, 91, 700–711.CrossRefGoogle Scholar
  42. 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.
  43. Louw, A., & Puentedura, E. (2013). Therapeutic neuroscience education: Teaching patients about pain-a guide for clinicians. OPTP – Orthopaedic physical therapy products. Google Scholar
  44. Louw, A., Puentedura, E. J., & Zimney, K. (2016). Teaching patients about pain. It works, but what should we call it? Physiotherapy Theory and Practice, 32(5), 328–331. Scholar
  45. 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. [Epub ahead of print].
  46. 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. CrossRefGoogle Scholar
  47. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Counseling and Clinical Psychology, 68, 438–450.CrossRefGoogle Scholar
  48. 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.
  49. 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. CrossRefGoogle Scholar
  50. Moseley, G. L. (2004). Graded motor imagery is effective for long-standing complex regional pain syndrome: A randomized controlled trial. Pain, 108, 192–198.CrossRefGoogle Scholar
  51. 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
  52. Nicholas, M. K., Linton, S. J., Watson, P. J., & Main, C. J. (2011). “Decade of the flags” working group-early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain a reappraisal. Physical Therapy, 91, 737–753.CrossRefGoogle Scholar
  53. Nijs, J., Roussel, N., & Wilgen, C. P. (2013). Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy, 18, 96–102.CrossRefGoogle Scholar
  54. Nijs, J., Van Houdenhove, B., & Oostendorp, R. A. (2015). Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Manual Therapy, 15, 135–141.CrossRefGoogle Scholar
  55. O’Sullivan, K., Dankaerts, W., O’Sullivan, L., & O’Sullivan, P. B. (2015). Cognitive functional therapy for disabling nonspecific chronic low back pain: Multiple case-cohort study. Physical Therapy, 95, 1478–1488.CrossRefGoogle Scholar
  56. Overmeer, T., Boersmak, K., Main, C. J., & Linton, S. J. (2009). Do physical therapists change their beliefs, attitudes, knowledge, skills and behavior after a biopsychosocially oriented university course? Journal of Evaluation in Clinical Practice, 15, 724–732.CrossRefGoogle Scholar
  57. Parry, R. H., & Brown, K. (2009). Teaching and learning communication skills and physiotherapy: What is done and how is it done? Physiotherapy, 95, 294–301.CrossRefGoogle Scholar
  58. 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. (accepted 9/27/2016).
  59. Sanders, T., Foster, N. E., Bishop, A., & Ong, B. N. (2013). Biopsychosocial care and the physiotherapy encounter: Physiotherapists’ accounts of back pain consultations. BMC Musculoskeletal Disorders, 14, 65. CrossRefGoogle Scholar
  60. Schmidt, S. G. (2016). Recognizing potential barriers to setting and achieving effective rehabilitation goals for patients with persistent pain. Physiotherapy Theory and Practice, 32, 415–426.CrossRefGoogle Scholar
  61. Slade, S. C., Molloy, E., & Keating, J. L. (2009). Listen to me, tell me: A qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation, 23, 270–280.CrossRefGoogle Scholar
  62. 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
  63. 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
  64. Sullivan, M. J., Adams, H., Rhodenizer, T., & Stanish, W. D. (2006). A psychosocial risk factor-targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy, 86, 8–18.CrossRefGoogle Scholar
  65. Sullivan, M. J., Stanishn, W., Waite, H., Sullivan, M., & Tripp, D. A. (1998). Catastrophizing, pain and disability in patients with soft-tisse injuries. Pain, 77, 253–260.CrossRefGoogle Scholar
  66. Sullivan, M. J. L., Adams, H., Horan, S., Mahar, D., Boland, D., & Gross, R. (2008). The role of perceived injustice in the experience of chronic pain and disability: Scale development and validation. Journal of Occupational Rehabilitation, 18, 249–261.CrossRefGoogle Scholar
  67. Sullivan, M. J. L., Scott, W., & Trost, Z. (2012). Perceived injustice: A risk factor for problematic pain outcomes. Clinical Journal of Pain, 28, 383–488.CrossRefGoogle Scholar
  68. 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
  69. 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
  70. Van Wilgen, P., Beetsma, A., Neels, H., Roussel, N., & Nijs, J. (2014). Physical therapists should integrate illness perceptions in their assessment in patients with chronic musculoskeletal pain: A qualitative analysis. Manual Therapy, 19, 229–234.CrossRefGoogle Scholar
  71. Vernon, H., & Mior, S. (1991). The neck disability index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics, 14, 409–415.PubMedGoogle Scholar
  72. 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
  73. Vlaeyen, J. W., Kole-Snijders, A. M., Boeren, R. G., & van Eek, H. (1995). Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain, 62(3), 363–372.CrossRefGoogle Scholar
  74. Vlaeyen, J. W., & Linton, S. J. (2006). Are we fear-avoidant? Pain, 124, 240–241.CrossRefGoogle Scholar
  75. Waddell, G. (2004). Back pain revolution. London: Churchill Livingstone.Google Scholar
  76. Waddell, G., McCulloch, J. A., & Kummel, E. (1980). Nonorganic physical signs in low-back pain. Spine, 5, 117–125.CrossRefGoogle Scholar
  77. Waddell, G., Newton, M., Henderson, I., Somerville, D., & Main, C. J. (1993). A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain, 52, 157–168.CrossRefGoogle Scholar
  78. Wijma, A. J., van Wilgen, C. P., Meeus, M., & Nijs, J. (2016). Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiotherapy Theory and Practice, 32, 368–384.CrossRefGoogle Scholar
  79. Woolf, C. J. (2007). Central sensitization: Uncovering the relation between pain and plasticity. Anesthesiology, 106(4), 864–867.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.VP, Occupational Health ServicesMalvernUSA

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