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Psychologically Informed Practice: Let's Not Throw the Baby Out With the Bath Water Nicholls (1) offers an interesting lens on psychologically informed practice (PiP) and back pain using cardiac disease [...]

Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar. Keywords: Psychologically Informed Practice, Pain, Communication, Introduction A detailed description of psychologically informed practice (PiP) and its origins (1) is presented in the accompanying paper in this issue. (2) In brief, PiP's most distinctive features are [...]

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician--patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions. Keywords: Psychologically Informed Practice, Pain, Communication, Introduction This Perspective is centered on the nature of the clinical consultation in Psychologically Informed Practice (PiP) and focuses on how the use of communication skills can be used to [...]

There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined., Substantial promise and important new opportunities come about when health care providers integrate biopsychosocial management into their clinical practice. One such approach has been termed psychologically informed practice (PIP), (1) [...]

In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, termed 'psychologically informed practice,' is offered as a 'middle way' between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the 'flags' framework, with psychologically informed practice requiring routine and specific consideration of 'yellow flags' and 'blue flags' (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification--but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential 'black flags'). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that arc associated with outcome of treatment., In most health care systems, physical therapists are well placed to identify and address psychosocial risk factors for the development of chronic low back pain. However, a biomedical perspective persists [...]

There is mounting evidence that occupational factors influence the extent of sickness absence following an episode of low back pain, but there have been limited efforts to integrate the identification and management of occupational factors into the routine practice of physical therapists. Systematic reviews suggest that a client's report of heavy physical demands, inability to modify job tasks, work stress, lack of organizational support, job dissatisfaction, poor expectations for resuming usual work, and fear of reinjury are indications of significant barriers to returning to work. Recommended strategies for evaluating and addressing occupational factors are explored with respect to the physical therapist's role in client assessment, development of activity and lifestyle recommendations, therapeutic exercise, communication with other providers, and summary reports. Primary recommendations include: (1) administration of self-report questionnaires to assess a client's perspective of physical job demands, (2) client-centered interviewing to highlight individual return-to-work concerns, (3) early discussions with clients about possible job modifications, and (4) incorporation of clients' workplace concerns in progress reports and summaries. These strategies may improve low back pain outcomes by encouraging effective communication with key stakeholders and by developing clients' ability to resolve obstacles to returning to work., Low back pain (LBP) is a common health complaint and one of the most frequent reasons to be seen by a physical therapist. (1,2) For working-age adults with LBP, one [...]

Originally the term 'yellow flags' was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability., Kenndall and colleagues (1) coined the term 'yellow flags' to encompass psychological risk factors and social and environmental risk factors for prolonged disability and failure to return to work as [...]

The purpose of this special issue of PTJ is to present and integrate research evidence about the influence of psychosocial factors on presentation of symptoms of pain and disability (function) [...]

Musculoskeletal symptoms of various types (neck pain, limb pain, low back pain, joint pain, chronic widespread pain) are a major reason for consultation in primary care. This article uses the [...]

IMPORTANCE: Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care. OBJECTIVE: To determine the effectiveness of intensive patient education for patients with acute low back pain. DESIGN, SETTING, AND PARTICIPANTS: This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks’ duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education. INTERVENTIONS: All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). MAIN OUTCOMES AND MEASURES: The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months. RESULTS: Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, –0.3 [95% CI, –1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, –1.6 points on a 24-point scale [95% CI, –3.1 to –0.1]) and 3 months (mean difference, –1.7 points, [95% CI, –3.2 to –0.2]) but not at 6 or 12 months. CONCLUSIONS AND RELEVANCE: Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature. TRIAL REGISTRATION: Australian Clinical Trial Registration Number: 12612001180808

•Patient education is recommended in the primary care management of acute low back pain.•The PREVENT Trial is the first placebo-controlled randomized trial to evaluate the efficacy of patient education.•Statistical analysis plans increase the transparency around how researchers plan to estimate and interpret treatment effects from randomized trials.•This protocol describes the pre-specified principles, methods, and procedures to be adhered to in the statistical analysis of the PREVENT trial data.

Review was of little help in selecting treatment EDITOR--We have misgivings about the conclusions drawn by Guzman et al on multidisciplinary rehabilitation for chronic low back pain. (1) Low back [...]

To explores the potential role of psychological treatments for older people who are affected by chronic pain.

One theoretical model suggests a pathway between pain and the development of depression through sleep problems. Here, we prospectively test the hypothesis that incident sleep problems, in those with persistent pain, increase risk of new onset probable depression, and investigate the role of "pain that interferes with daily life" (pain interference) on this pathway.

Social factors are widely acknowledged in behavioural models of pain and pain management, but incorporating these factors into general medical consultations for low back pain (LBP) can be challenging. While there is no compelling evidence that social factors contribute to LBP onset, these factors have been shown to influence functional limitation and disability, especially the effects of organisational support in the workplace, spousal support, family conflict and social disadvantage. A number of barriers exist to address such social factors in routine medical encounters for LBP, but there is emerging evidence that improving social and organisational support may be an effective strategy to reduce the negative lifestyle consequences of LBP. For clinicians to address these factors in LBP treatment requires a clearer psychosocial framework in assessment and screening, more individualised problem-solving efforts, more patient-centred interventions involving family, peers and workplace supports and a less biomechanical and diagnostic approach.

Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control).

To consider whether pain is a barrier to work and if so how this can be overcome.

In this article, we specifically focus on the identification and management of patient beliefs and expectations during consultations with health-care professionals (HCPs). In examination of the nature and purpose of communication during consultations, we evaluate the research relating to doctor–patient communication, present the Calgary–Cambridge framework and highlight the identification and management of the patient's beliefs and expectations as a key part of this process. Having identified what can go wrong, we identify the characteristics of effective consultations and consider strategies for improving communication. In recommending a clear and more focussed approach to the identification and management of patient beliefs and expectations, we consider not only the nature of the therapeutic climate, but also the style and content that could enhance the effectiveness of the communication. Having identified techniques for facilitating self-disclosure, we conclude by offering suggestions on how to ‘close down’ the consultation and hand over responsibility to the patient.

In this article, we provide an evidence-based review of pain beliefs and their influence on pain perception and response to treatment. We examine the nature of pain perception and the role of cognitive and emotional processes in the interpretation of pain signals, giving meaning to pain and shaping our response to it. We highlight three types of beliefs that have a particularly strong influence: fear-avoidance beliefs, pain self-efficacy beliefs and catastrophising. We examine the influence of beliefs, preferences and expectations on seeking consultation, interventions and treatment outcome from the perspective both of the patient and the health-care practitioner. We then adopt a broader societal perspective, considering secondary prevention and campaigns, which have attempted to change beliefs at a population level. The article concludes with a summary of the key messages for clinical management of patients presenting with painful conditions and suggestions for further research.

•Pain has a significant impact on work in terms of presenteeism, sickness absence, and long-term incapacity for work•A bio-psychosocial approach is required in understanding pain-related disability and incapacity for work•Long-term absence from work is associated with a number of negative outcomes including; poverty, social exclusion and poorer physical and psychosocial well-being•Return to work can improve recovery for people with musculoskeletal complaints and pain•Interventions to reduce the impact of pain on work can operate at clinical, worker, workplace, and wider systems levels•A broader whole systems approach to pain management needs to be adopted, with a greater focus on work retention as well as rehabilitation

ObjectiveTo develop and validate a tool that screens for back pain prognostic indicators relevant to initial decision making in primary care.MethodsThe setting was UK primary care adults with nonspecific back pain. Constructs that were independent prognostic indicators for persistence were identified from secondary analysis of 2 existing cohorts and published literature. Receiver operating characteristic curve analysis identified single screening questions for relevant constructs. Psychometric properties of the tool, including concurrent and discriminant validity, internal consistency, and repeatability, were assessed within a new development sample n 131 and tool score cutoffs were established to enable allocation to 3 subgroups low, medium, and high risk. Predictive and external validity were evaluated within an independent external sample n 500.ResultsThe tool included 9 items: referred leg pain, comorbid pain, disability 2 items, bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0–3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk.ConclusionWe validated a brief screening tool, which is a promising instrument for identifying subgroups of patients to guide the provision of early secondary prevention in primary care. Further work will establish whether allocation to treatment subgroups using the tool, linked with targeting treatment appropriately, improves patient outcomes.

Much of the research into return to work following rehabilitation for low back pain in the literature reflects work done in those employed. Unemployment is a consequence of chronic low back pain which has considerable health and economic consequences for the individual and society. This paper describes an occupationally orientated rehabilitation programme for long-term unemployed people (mean duration of unemployment 38.9 months). The aim of the project was to identify factors which predict return to work and progress towards employment. Eight six subjects underwent a pain management rehabilitation programme incorporating vocational focussing and advice, subjects were followed up at 6 months to determine work status. At follow-up 38.4% of subjects were employed and another 23% were in voluntary work, or education/training. There were no significant differences on presenting characteristics between those who returned to work and those who did not. Subjects were divided into those who made positive progress (work, education/training or voluntary work) and those who did not (remained unemployed, dropped out of the programme or lost to follow up). Those who failed to make positive progress were characterised by longer duration of unemployment and higher scores on somatic anxiety and depression. A predictive model was able to identify 80% of those who failed to make progress but prediction of those achieving a positive outcome was poor (44% correct prediction). The factors predicting return to work in unemployed people with low back pain differs from the employed, the need for employment skills training and a vocational focus to rehabilitation are highlighted.

Prospective study on individuals with asymptomatic lumbar disc abnormalities detected in magnetic resonance imaging.

Objectives. To investigate the cognitive model of psoriasis held by patients and to explore its relationship with pathological worrying, and with the clinical severity and anatomical location of the patients' psoriasis. Design. Correlational design. Methods. A total of 140 patients with psoriasis attending the University of Manchester's Psoriasis SpecialityClinic at Hope Hospital, Salford underwent a medical examination where the clinical severity of their psoriasis and medical history were assessed by their dermatologist. The Penn State Worry Questionnaire (PSWQ) and the Illness Perception Questionnaire (IPQ)were used to assess worry and illness representations, respectively. Results. Clinical severity of psoriasis was not associated with illness perceptions nor with pathological worry. A logistic regression analysis indicated that pathological worry was associated with stronger beliefs in psoriasis having serious consequences, and stronger beliefs in an emotionalcause. Women were also significantly more likely to be members of the pathological worry group. It was found that 38%of the sample scored within one standard deviation of the worry score for patients diagnosed with Generalized Anxiety Disorder. Conclusions. A considerable number of patients with psoriasis experience high levels of worrying thoughts that are linkedmore to personal and social evaluative concerns than to the pathophysiology or course of their disease.

The ability of three new methods of scoring the Pain Drawing to predict psychological distress in two cohorts of 100 patients with chronic low back pain was investigated.

A prospective survey of patients seeking primary care for low back pain. Clinical and psychosocial data, available at presentation, were explored for predictors of outcome at 1 year.

A 1-year prospective study in industry, assessing effects of an educational pamphlet on various psychosocial parameters and absenteeism resulting from low back trouble.

Background:Patients’ beliefs about their disease have been shown to be of fundamental importance in adjustment to their condition. Objective:We investigated patients’ beliefs about their psoriasis and examined the relationship between these beliefs and clinical severity, symptom report, and other clinical and demographic variables. Methods:A total of 162 patients with psoriasis (84 male, 78 female) completed the illness perception questionnaire that provides a standardized assessment of beliefs about causes, consequences, chronicity or recurrence, controllability, and symptoms of the condition. Results:The most commonly reported agents of causation were stress (60.1%) and genetic factors (55.5%)—the latter group being significantly more likely to have a family history of psoriasis (P= .0001). Forty-six percent of patients believed that their behavior could improve or worsen their psoriasis, whereas 32% believed that treatment would be curative. Desquamation and pruritus were experienced “frequently” or “all the time” by 80% and 76% of patients respectively. Overall clinical severity was not associated with any of the beliefs held by patients or with symptom report. Conclusion:The beliefs held and symptoms experienced by patients with psoriasis are not governed by overall clinical severity of the disease. (J Am Acad Dermatol 1998;39:196-201.)

Objectives.To identify painful stressor-induced surface electromyography [sEMG] responses in chronic low back pain [CLBP] patients and pain-free controls to experimental noxious stimulation, the cold pressor test [CPT] and investigate potential differences in pain report.Methods.Fourteen CLBP patients and 12 age/gender matched controls underwent an identical sEMG recording protocol in six stages: baseline, hand in 15°C cool water, a recovery period, a CPT, a second recovery phase and a post-test evaluation. Surface electromyography was recorded at bilateral trapezius, and paraspinal sites at L5.Results.Across all stages of the experiment there was no statistically significant difference in pain report. However, following the experiment patients reported significantly higher retrospective pain ratings than the controls using the Short Form-McGill Pain Questionnaire [SF-MPQ]. During baseline conditions, no differences in sEMG were noted between the groups. During the cool water condition, patients showed increased L5 sEMG in the left side compared to controls. Patients' elevated sEMG persisted after the hand was taken out of the cool water and increased further during the CPT. These group differences occurred for both sides and were most marked on the contralateral side to hand immersion. The increases on the ipsilateral side failed to reach significance. In contrast, the control subjects demonstrated increased sEMG activity in the trapezius muscles across the testing stages but this only reached significance for the right side.Conclusions.These results suggest a preferential activation of the lumbar paraspinal muscle activation in CLBP patients during painful hand stimuli. In addition retrospective rating of experimental pain by CLBP patients, using the SF-MPQ may be unrepresentative of the experimental condition.

Objectives:The aim of this study was to investigate the role of physical and psychological factors on changes in surface electromyography [sEMG] during static and dynamic activity of the lumbar paraspinal muscles in a group of chronic low back pain [CLBP] patients following a pain management program.Methods:Surface electromyographic recordings of the lumbar paraspinal muscle activity of 36 patients attending a pain management program were made during static and dynamic activity prior to the program and immediately afterwards. A measure of abnormality, the Flexion Relaxation Ratio [FRR] was calculated to observe the effect on the Flexion Relaxation Phenomenon [FRP]. Patients were assessed for current back pain and on a range of physical and psychological variables.Results:There were no significant correlations between current pain or disability and the FRRs. Significant correlations were identified between fear avoidance beliefs and low FRRs prior to the Pain Management Program.Following the program, significant correlations were identified between reductions in fear avoidance beliefs, increases in pain self efficacy beliefs and increased FRRs on movement. No such relationships were observed between sEMG measures and changes in range of movement, pain report or disability.Conclusion:The results of this study suggest that the absence or reduction of the FRP, measured by the FRR, in patients with CLBP is influenced by fear of injury and low self efficacy beliefs and changes in FRRs were independent of the range of motion and pain report in the group studied. Therapists should consider the role of psychological factors in the development and resolution of abnormal recruitment in patients with low back pain.

Despite increasing advances in medical technology, the cost of musculoskeletal incapacity, particularly low-back pain, in terms of sickness benefits, invalidity benefits and associated allowances has led to a fundamental reconsideration of the nature of chronic incapacity. Recent reports from the United Kingdom and the United States of America, in their recommendations for a comprehensive multidisciplinary assessment for patients still symptomatic at six weeks, are based on the clear assumption that a significant proportion of chronic incapacity is preventable. Such a proposition represents a fundamental challenge to much of current medical practice.

Waddell et al in 1980 developed a standardized assessment of behavioral responses to examination. The signs were associated with other clinical measures of illness behavior and distress, and are not simply a feature of medicolegal presentations. Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medicolegally. Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding. Isolated signs should not be overinterpreted. Multiple signs suggest that the patient does not have a straightforward physical problem, but that psychological factors also need to be considered. Some patients may require both physical management of their physical pathology and more careful management of the psychosocial and behavioral aspects of their illness. Behavioral signs should be understood as responses affected by fear in the context of recovery from injury and the development of chronic incapacity. They offer only a psychological "yellowflag" and not a complete psychological assessment. Behavioral signs are not on their own a test of credibility or faking.

Prospective comparative study of pain drawings with findings on lumbar spine magnetic resonance imaging.

Poor compliance with treatment advice in chronic conditions, such as psoriasis, represents a major challenge to health care professionals. Previous research suggests that the rate of noncompliance in chronic conditions may be as high as 40%.

The behaviour of the therapist may play an important part in determining the amount and type of speech observed during activity therapy. In this study, one aspect of the therapist's behaviour (prompting) was systematically altered and resulted in specific changes in the patients' speech to each other and to the therapist.