Abstract
Background The importance of the biopsychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically informed practice. Little is known about the process of physical therapists' learning and delivering of psychological interventions within the practice context.
Objective The aim of this study was to investigate physical therapists' experiences and perspectives of a cognitive-behavioral–informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis.
Design A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST).
Methods Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT period. Interviews were audiorecorded, transcribed verbatim into computer-readable files, and analyzed using Framework Analysis.
Results Thematic categories identified were: training, experience delivering PCST, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Physical therapists reported positive experiences with PCST and program delivery. They thought that their participation in the RCT had enhanced their general practice. Although some components of the PCST program were familiar, the therapists found delivering the program was quite different from regular practice. Physical therapists believed the PCST program, a 3- to 4-day workshop followed by formal mentoring and performance feedback from a psychologist for 3 to 6 months and during the RCT, was critical to their ability to effectively deliver the PCST intervention. They identified a number of challenges in delivering PCST in their normal practice.
Conclusion Physical therapists can be trained to confidently deliver a PCST program. The physical therapists in this study believed that training enhanced their clinical practice. Comprehensive training and mentoring by psychologists was crucial to ensure treatment fidelity.
There is increasing recognition of the benefits of incorporating the biopsychosocial model of health within physical therapist practice.1,2 This increasing recognition reflects growing understanding of the limitations of purely biomedical approaches in the treatment of chronic musculoskeletal conditions, particularly with regard to pain management.3 The biopsychosocial model acknowledges that a complex mix of biomedical and psychosocial variables can influence health experience and outcomes. Consequently, interventions that target single domains (eg, exercise or psychological treatment) may be less effective than those that target multiple factors. Application of the biopsychosocial model has led to increasing interest in interventions that combine exercise and psychological treatments, most commonly those based on principles of cognitive-behavioral therapy (CBT).4 While acknowledging the potential importance of underlying tissue pathology, the cognitive-behavioral model highlights the contribution of cognitive, emotional, and behavioral factors in the pain experience.4
A cognitive-behavioral–based pain coping skills intervention has 2 major goals. First, it seeks to enhance patients' understanding of how psychological, social, and environmental factors influence their daily pain, function, and quality of life. Second, it provides systematic training to increase the patient's ability to effectively cope with pain through learning, practicing, and applying a range of behavioral skills (eg, pleasant activity scheduling, activity pacing to achieve graded activation, problem solving, relaxation training) and cognitive skills (eg, cognitive restructuring, pleasant imagery, cognitive distraction techniques such as focal point and counting).4,5 There is growing evidence that such training programs are not only effective in decreasing pain but also in increasing activity level, decreasing psychological distress, and reducing health care utilization.6,7 In addition, by focusing on patient education and training, these programs aim to support patients' confidence and capacity to manage their health condition, a critical component of Wagner's chronic care model, which has been shown to reduce health care costs and lower use of health care services.8
Studies have investigated combined exercise and psychological interventions for a number of pain-related conditions, including back pain,9–11 knee pain,12 cancer,13 chronic fatigue syndrome,14 and fibromyalgia.15 In these studies, the psychological and exercise components were provided by different professional disciplines, with the exercise component most commonly provided by physical therapists, while the psychological components were implemented mainly by psychologists,10–14,16 but also by other health professionals, including social workers,11,13,17 occupational therapists,14 and nurses.14 Recently, the potential benefit of having one professional group deliver combined exercise and psychological interventions has been considered. Suggested advantages include time savings, with the ability to integrate exercises and psychological treatment into a single session, and cost savings.18 Although there is evidence that multidisciplinary pain treatment programs can be effective for people with chronic pain conditions,19,20 these services often have long waiting lists or may not be available in community practice settings.19–21 The potential for one professional group to deliver combined exercise and psychological treatment at the primary care level would provide opportunities to introduce CBT earlier in the rehabilitation process.22
Physical therapists are professionals with expertise in delivering exercise treatments. There is growing interest in this group's capacity to deliver interventions that integrate exercise and psychosocial components.1,23 Studies have investigated the provision of combined interventions by physical therapists for low back pain,24–29 neck pain,22,30–33 knee pain,18,34 musculoskeletal pain,35 and cancer.36 Most studies have shown some positive benefit in terms of patient outcomes. However, there is considerable heterogeneity in regard to the behavioral and cognitive components incorporated in the interventions. Likewise, there has been considerable variability in the training provided to physical therapists (equivalent 1–4 days training with or without ongoing mentoring),18,24,26,33 or details of training have not been reported.25,28,29,31,34 There has been variability in who delivered the training (psychologists or physical therapists)24,28,37 and procedures to determine treatment fidelity.24,26–28,33,35 Challenges in incorporating psychosocial factors in physical therapist practice also have been identified, including dominance of the biomedical perspective in physical therapy education and practice,1,2,38 possible lack of understanding of psychosocial factors39 and how to assess and manage these factors,1 and concerns with reimbursement and time constraints.1,39
The focus of most studies has been on whether combined interventions result in improvements in patients' physical and psychological outcomes, with conclusions that positive results demonstrate trained physical therapists can safely and effectively deliver cognitive-behavioral interventions to people with musculoskeletal conditions.18,22,29 However, Johnson et al24 questioned whether the adequacy of training might be a factor in some less impressive patient outcomes. Little is known about physical therapists' perspectives on being trained in cognitive-behavioral techniques or their experiences in implementing these techniques in practice, which might equally affect patient outcomes.
This article reports on a qualitative study that was conducted in parallel with a randomized controlled trial (RCT) that aimed to evaluate whether an intervention of exercise combined with CBT in the form of pain coping skills training (PCST) delivered by physical therapists was more effective than either an exercise-only or PCST-only intervention in people aged over 50 years with painful knee osteoarthritis. The study aimed to gain an in-depth understanding of physical therapists' perspectives on and experiences with PCST and the implementation process.
Method
Design
Details of the design of the RCT are reported elsewhere.40 The RCT was conducted at 2 sites (Melbourne and Brisbane, Australia). Patients were randomized to 1 of 3 intervention arms: exercise plus PCST, PCST alone, or exercise alone. Each intervention involved 10 weekly sessions with a physical therapist. Table 1 presents the PCST program components. The physical therapists delivering the PCST program attended a 3- or 4-day training course conducted by an expert psychologist in the field (F.J.K. or trial psychologist) to develop skills in delivering the PCST treatment strategies. The first program was delivered over 4 days. Subsequently, it was necessary to conduct a second program to train physical therapists to replace those who withdrew from the study (discussed in the next section). As the number of physical therapists in the second program was smaller, a 3-day training program was considered sufficient to cover the program content.
Description of the Pain Coping Skills Training (PCST) Interventiona
Initial training was followed by additional formal mentoring and instruction, role playing, and performance feedback from a psychologist at each trial site over the course of 3 to 6 months. Each physical therapist was required to submit audiotapes of training sessions for the purpose of rating and certification prior to delivery of trial treatments. Once deemed competent in delivery, the physical therapists received patients within the RCT. The psychologist continued to monitor and mentor physical therapist–patient interactions (audiorecordings and monthly discussion groups) for the 18-month duration of the RCT. Most physical therapists continued to regularly meet with the psychologist as a group throughout the study period.
For the current study, qualitative one-to-one semistructured telephone interviews were conducted with the physical therapists who delivered both the PCST alone and the exercise plus PCST arms of the trial. Interviews were conducted at 4 time points during the 12-month trial period. All participants provided informed consent.
Participants
Details of the physical therapist participants in this study are provided in Table 2. Physical therapists involved in the PCST alone and exercise plus PCST arms of the RCT were sent an invitation to participate in this study, an information sheet, and a consent form prior to commencing the training program. Of the initial 14 physical therapists, 3 were not included because they had previously been trained to deliver the PCST program, 1 did not meet the CBT certification standards required and did not progress to participate in the RCT, and 2 withdrew their participation in the RCT due to lack of time to participate fully. The results reported here are for the 8 physical therapists who completed all 4 telephone interviews. Five were located in Brisbane and 3 in Melbourne.
Site-Specific Characteristic Information of Project Physical Therapists Who Participated in This Study
Procedure
All interviews were conducted by the same investigator (M.N.) to ensure consistency and reliability of information collection. The physical therapists were interviewed at 4 time points: prior to attending the PCST workshop, immediately following the workshop, and at 3 and 12 months following the workshop. Semistructured interview guides were used for each interview (Appendix). Interview topics included previous experience with CBT, reasons for participating in the study, expectations and concerns regarding participation, the experience of the PCST program, reflections on the program delivery, and perspectives on the potential for PCST to be used in clinical physical therapist practice. Interviews were audiorecorded and transcribed verbatim into computer-readable files.
Data Analysis
Transcripts were analysed using Framework Analysis, a matrix-based method for ordering and synthesizing qualitative data.41 This method involves a number of sequential and inter-related stages, including familiarization, identifying initial themes, indexing, charting, and synthesizing the data. NVivo version 9 (QRS International Pty Ltd, Doncaster, Victoria, Australia), a qualitative data analysis program that includes a Framework Matrix component, was used for data management and analysis.
Familiarization involved an initial reading of all transcripts as the study progressed and noting salient issues and potential patterns within the data. At the completion of the fourth interview, a draft conceptual framework was developed by reviewing the transcripts of interviews with 3 participants, 2 from Brisbane and 1 from Melbourne. This framework was initially deductive, drawing on topic areas covered by the 4 interview schedules, as these were identified areas of interest of the researchers. Where indicated, additional thematic categories were added to the framework. A manageable index was constructed by identifying links among categories, grouping them thematically, and sorting them so that the index had a hierarchy of main themes and subthemes. Data indexing and synthesis were largely conducted by 1 investigator (M.N.). To improve trustworthiness, an independent researcher was commissioned to review the interview transcripts and develop a separate index. Discussion between the 2 researchers resulted in a refined index that was applied to all interview transcripts.
After indexing, the data were charted in framework matrices, using the index categories, with data referred back to, in an iterative process, for further refining. Finally, data were summarized and synthesized into a set of descriptive categories that adequately reflected the content of the data.
Role of the Funding Source
This study was supported by an Australian Health Management grant. Dr Bennell is partly supported by an Australian Research Council Future Fellowship.
Results
Results are discussed under the 4 descriptive categories identified by analysis: training, experience of delivering the PCST program, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Representative quotes are used to illustrate the findings, with substantial quotes being attributed to participants using their study identifier (eg, P2, P3).
Training
Most physical therapist participants had limited experience in CBT. Although 2 participants had worked with other health professionals who used CBT in practice and 1 participant had some previous CBT training, for most the PCST program was their first exposure to CBT-based training. Prior to training, physical therapists' concerns centered on their capacity to learn the skills and fulfill the study expectations. After the training workshop, physical therapists commented favorably on the training as a good introduction to the content and process of delivering the PCST program. However, most also believed the weekly group interaction and input from the supervising psychologist were crucial to being able to deliver the intervention effectively and to problem-solve issues that arose during the study period: “[The workshop] was the tip of the iceberg…it set the groundwork or sort of gave us a taste of it, but then it was the weekly meetings we had with the psychologist that really concreted everything for us.” [P6] Even with ongoing input from the psychologist, some physical therapists did not feel they had the skills or expertise to deal with some more challenging patients encountered during the study or to teach the more “cognitive skills” such as challenging negative thinking: “It depends on how much we wander into the territory of emotions, because the more that we go in that direction, the bigger player that is, the less qualified I feel to be there.” [P11]
All physical therapists indicated that acquiring the skills to deliver the program took time and required a combination of theoretical input and role playing or practice in delivering the skills in “real-life” clinical scenarios. Some said they would have liked more role-playing experience prior to beginning trial treatments:
…because it's not a straightforward competency of just a performer's skill. It's a skill that has to adapt under the pressure of doing the interview. And that's a far more advanced skill than simply learning to be able to—I don't know—take a foot through a movement. If I learn that skill, then I've got that, and I can go on, whereas this sort of skill, I walk in and the client throws me a curve ball, and I've got to adapt and make it all work. [P11]
Experience of Delivering the PCST Program
Content.
Overall, the physical therapists commented favorably on the program content: “I think it works. I feel it's a very positive way to help people be proactive about their pain, manage their pain…. It just enriches your skills as a physio [physical therapist] and what you can give a client.” [P6] Most said they were familiar with some of the PCST skills, with progressive muscle relaxation being most frequently mentioned as a skill learned in physical therapy school. Involvement in the study had provided an opportunity to review these skills and learn more structured and deliberate ways of incorporating these skills into practice: “We did relaxation way back when I graduated in the '70s, and I hadn't incorporated that very much through my career. And I realized what a great tool it was.” [P8] Some physical therapists noted the requirements of an RCT potentially created a barrier to responding to “where the client was,” but this was an understandable restriction in the research context: “The focus was very much on delivering all the elements, going through that sort of system, when some of them may not be relevant to a certain client…. I think mix and matching is definitely very important.” [P7]
All physical therapists found some modules of the program worked better than others in practice because they found them easier to deliver, easier for the patients to understand, or were more accepted by patients. There was also variation among patients, as “different people found different modules helpful,” so the choice of which component would be helpful depended, in part, on the individual patient and context.
However, all physical therapists commented on the “identifying and challenging negative thoughts, developing calming self-statements” components of the program, which focused on cognitive restructuring techniques. They thought this was an important component, with 1 participant identifying it as “the crux of the whole thing” and “life changing” for some patients. However, comments also indicated that this was the component with which patients had the most difficulty: “They're the sessions where people came unstuck. If they were going to leave, it was about session 5, which is starting to deal with thinking.” [P2]
Physical therapists' comments suggested a number of possible reasons for this difficulty. For example, patients had difficulty understanding the meaning of the concept: “A lot of people just found it really hard to identify negative thoughts and to change them. They also found it hard to differentiate between thoughts and feelings.” [P4] There was also the possibility that people did not want to think of themselves as “negative”: “I would say 10 out of 10 people, as soon as you mention the words ‘negative thinking,’ the shutters come down…for them negative thinking meant, oh, I'm creating my problems…that's kind of like a societal failure, and those people weren't willing to go there.” [P11] Some physical therapists thought they did not have sufficient skills to present the component effectively: “…probably a more expert area than the small amount of training that we had…. I don't think I had the skills to do a really good job of it.” [P8] Some participants expressed concern over the use of the term “negative” and had agreed in their groups early in the program to substitute the term “unhelpful.”
Process.
Physical therapists thought the structure of the PCST sessions, consisting of an overview, home practice review, covering the new skill, and home practice planning, worked well. Having a consistent process with which patients became familiar was viewed as a positive. The process of asking patients to document their home practice and checking the documentation weekly was thought to encourage people to do the home practice, as well as demonstrate that the physical therapist valued the home practice component. In addition, the weekly review session provided an avenue for people to see their progress and for the physical therapist to acknowledge their progress. Furthermore, the previous session could be reviewed, with patients having an opportunity to discuss any difficulties they had encountered.
Most physical therapists thought the process skills, such as encouraging active patient participation, pacing the session appropriately, adjusting content when needed, and expressing support and acceptance, were not dissimilar to their pre-existing clinical communication skills, with the main difference being the content being delivered. The exceptions were the skills of asking open-ended questions and encouraging patient-directed problem solving. Most said they found these challenging skills to use. While acknowledging the benefits of this approach, therapists said this was very different from their regular practice: “…from a physio [physical therapist's] point of view, [it] is probably not the way we're trained; we're trained to get information quickly, whereas the open-ended questions were inviting the clients to explore more and do their own problem solving.” [P6]
Value of peer support and supervising psychologist input.
The regular group meetings throughout the RCT were considered by many physical therapists to be a very important, if not essential, aspect of delivery of the PCST program. The value of group meetings was commented on in terms of providing interpersonal support and a regular avenue for consolidating understanding program content as well as problem solving implementation issues as the program progressed: “We did role playing. We did lots of problem solving. We also discussed difficult patients or interesting things that had come up and how would I handle this, and it gave us a lot more information to play with, rather than having to…sort it out by yourself.” [P6]
Many physical therapists also commented on the value of having a psychologist involved throughout the program. Professional input from the psychologists was considered helpful in supporting group processes, consolidating understanding of program material, and providing feedback on physical therapists' skills and strategies for difficulties encountered throughout the RCT: “I think if we hadn't had that, we would not have been anywhere near as effective as we were. Because we did bump up against things and we were able to go to her and say, ‘What do we do about this?’ And she was able to give us really good strategies to help.” [P2]
Impact on Clinical Practice
At all 4 interview points, physical therapists were asked their thoughts on the potential to utilize PCST in their general clinical work as a physical therapist, beyond the study. At all stages, all physical therapists indicated they did expect to do this. Prior to training, some said they were already using aspects of PCST in practice, although there was recognition that their practice could be improved: “I recognize parts that I have already been using just intuitively and also recognize other bits that you could certainly apply to many or most situations, in a more deliberate sense, rather than just in an accidental or incidental sort of sense.” [P2]
At the time of the final interview, all physical therapists said they were integrating aspects of the PCST program into their general clinical practice and expected to continue to do so. The most frequent components identified were relaxation and identifying negative thoughts/developing coping thoughts. Most physical therapists indicated they would choose to integrate specific PCST components in response to individual patient need and context rather than present a stand-alone PCST program in the format presented in the study: “…probably not as formally as it is presented in this study, but the principles and some of the techniques, definitely.” [P10] Although the physical therapists acknowledged the need for a consistent approach as a requirement of the RCT, they believed a more flexible approach responsive to patient needs was required in their practice: “I'd be ready to mix and match and just change it, depending on what's going on, ensuring you still cover it at some stage.” [P7]
Physical therapists referred to increasing confidence in using PCST skills over the course of the study. Most said being involved had altered the way they managed general clinical patients, in terms of formalizing or improving the PCST-related skills they had been using previously, and adding to their clinical skill set overall: “Professionally, it certainly has enhanced the way that I practice…. I'm much more alert to incorporating CBT aspects in my general physio [physical therapy] treatment when it's indicated…and it's actually made a lot of treatments more effective.” [P2]
Many physical therapists also referred to improved interpersonal skills with their general clinical patients as a result of participating in the study, particularly in relation to encouraging patients to take a more active role in their rehabilitation: “I certainly treat some of my patients differently. Now, if they come back and say, ‘Look, I haven't done my exercises’ instead of saying, ‘Oh, naughty patient, you should do your exercises,’ I'll say, ‘So why do you think that is or what do you think you can do to be able to do these exercises?’” [P4]
Perspectives on PCST and Physical Therapist Practice
All physical therapists thought, in theory, that PCST is appropriate and relevant for physical therapist practice. As has been noted previously, most believed that physical therapists already used some of the PCST skills in practice. One therapist highlighted the value of increasing the profession's explicit understanding and use of PCST skills:
[W]e [already] use CBT in negative and positive ways. We use CBT to accidentally reinforce that someone's disk is a real problem, they're going to cause more harm to themselves if they move, accidentally, by some of the things that we say or do. We use it already, so I think using it in a smart way is really valuable…. I think it needs to happen more. [P7]
A few physical therapists suggested that using PCST in practice may require the development of a practice model specific to the physical therapy context, as delivering PCST in this context was “a bit different from how a psychologist works…I'd like to use it a bit better and perhaps try to combine what I already do in my own practice with what has been offered in [this program], and it's really tricky…. I'm still working on that.” [P11]
A number of potential barriers to the use of PCST in physical therapist practice also were identified. These barriers related to aspects of the practice environment and public expectations of the physical therapy role and are outlined below.
Practice environment.
Most physical therapists commented on aspects of the practice environment that present barriers to incorporating PCST into practice. Most frequently identified was the time required to teach PCST skills to patients: “In theory, it's a great idea. In practice, you don't have time to do it properly.” [P2] Related to this issue was concern about the capacity to recover the cost of incorporating CBT into practice: “It's just a matter of fee structure and that sort of thing and whether…we are in a position to offer that as a skill.” [P6]
Incorporating selected PCST components on an as-needed basis with individual patients was considered the most practical way of incorporating PCST within current practice environments: “I think if you can work it into a physio [physical therapy] session, then it's got relevance, but I don't know how people would see that, just a CBT session from a physio [physical therapist].” [P6]
Physical therapists also commented on a lack of knowledge about CBT among physical therapists as a barrier to implementation in practice: “Most physios [physical therapists] have no idea of the CBT approach and then also don't refer out to, say, a psychologist either…unless someone's really sort of suicidal or in a really bad way.” [P7] Several physical therapists noted a “catch-22” element in that even though they had previously been interested in the CBT approach, it had been necessary to participate in the training and the RCT to fully appreciate the value of CBT to their practice: “…the thing is I couldn't incorporate [CBT] unless I've been through what I've been through.” [P2]
Public expectations of the physical therapy role.
A second barrier was public expectation of what physical therapy treatment should be: “There would be a barrier, I think, in people thinking, well, I didn't really come to have my thinking challenged or changed or anything, I just came to get the exercises.” [P8] Physical therapists discussed the value of incorporating aspects of the PCST “mind-set” into professional (entry-level) training as one way of changing public expectations of physical therapists, particularly the aspects of encouraging active patient participation in the rehabilitation process and psychosocial influences on the pain experience: “I guess if it's coming through from everybody, then there's more chance that people will be better informed or better understand.” [P11] This approach also would address the lack of understanding of CBT in the physical therapy profession, although training to the level of effectively delivering CBT in practice was considered to be more appropriate at the postgraduate level, perhaps in the form of a specialist practice area: “I think you could bring it in at an undergrad level, but I don't know how much relevance it has until you're out there doing it…so undergrad maybe, but postgrad is probably more relevant, and to do it well, it's got to be intensive, I think.” [P6] In addition, many physical therapists considered a certain amount of clinical practice experience to be a valuable background: “I don't know if you can do it without experience. I mean, I've been a physio [physical therapist] 33 years, so there's a lot of talking to people in there, and there's a lot of building confidence and skills and just knowing how to deal with people…it doesn't happen overnight.” [P6]
Discussion
This study explored physical therapists' perspectives and experiences of training and delivery of a PCST program for people aged over 50 years with painful knee osteoarthritis. Overall, the physical therapists who participated in the study reported positive experiences of both the training and delivery of the program and believed participation in the study had enhanced their general clinical practice. Although some elements of the PCST content, such as relaxation and pacing, were identified as similar to their existing skill set, the physical therapists found the process of delivering PCST to be quite different from their regular physical therapist practice, particularly asking open-ended questions and encouraging patient-directed problem solving. Most highlighted the value of having ongoing mentoring in the form of psychologist-supervised group meetings throughout the study in addition to the initial training workshop, citing the mentoring process as critical to developing their skills to the point where they felt they could deliver the PCST program effectively. In addition, being able to consult with the psychologist supervisor as the study progressed, particularly when they encountered difficult or novel practice situations, was considered a valuable component of the program.
Although physical therapists reported their confidence to deliver the program increased as the study progressed, some also acknowledged a continuing level of discomfort when patients ventured into what were identified as more psychological areas of concern. Although most therapists, therefore, felt better able to identify and respond to psychosocial issues in their practice, they also believed there were limits to their PCST skills and that there could be instances where referral to a psychological health practitioner would be warranted. This finding suggests that some consideration needs to be given to identifying the boundaries of PCST in the physical therapy context. For example, further exploration of the difficulty patients had with the “challenging negative thoughts, developing coping thoughts” skill is needed to determine whether this part of the PCST program for physical therapists should be retained or whether more ongoing training and experience with this particular skill are required. In addition, physical therapists who incorporate PCST into their practice should consider appropriate referral pathways to psychological health professionals before opening up what Foster and Delitto1 referred to as the “black box” of patient cognitive evaluations and emotional responses to musculoskeletal pain.
Throughout the study, physical therapists expressed interest in incorporating PCST skills they were learning into their general clinical practice, and all thought they were successfully doing this to a certain extent by the end of the study. They believed their general practice had been enhanced by improvements in their interpersonal skills and by the focus on encouraging patients to take a more active role in their rehabilitation. Rather than deliver PCST as a stand-alone program, however, physical therapists thought a “mix and match” approach in relation to individual patient circumstances, integrated with appropriate physical therapy treatments, was more appropriate in their practice context. They also identified challenges in using the complete PCST program in their practice environment that went beyond practitioner preferences. These challenges included time pressures, fee structure, and public expectations of the “hands-on” nature of physical therapy. Similar challenges have been identified by other authors, including Foster and Delitto1 in their consideration of embedding psychosocial perspectives within physical therapist practice for patients with low back pain and Beissner and colleagues in their study of physical therapists' use of CBT for older adults with chronic pain.39
The findings of the current study support Foster and Delitto's view that changes to reimbursement systems and service priorities may be needed to enable increased use of psychosocial assessments and interventions in physical therapist practice.1 Although patients may benefit from combined exercise and psychological treatment delivered by physical therapists within primary care, our findings also indicate that change needs to occur beyond the patient-therapist interaction, targeted at systemic barriers, such as health care organization and delivery system design, to ensure the full potential of combined interventions is realised.42,43
Physical therapists in the current study also cited lack of knowledge about psychosocial issues and interventions as a barrier to wider implementation of this perspective in physical therapist practice. This issue also has been identified by other authors,1,38,39 with the continuing dominance of a biomedical orientation within physical therapy education suggested as a significant factor in the maintenance of this.1,38 Suggested remedies include integrating biopsychosocial training and pain education within entry-level programs.1
Feedback from participants in our study supported this approach, with physical therapists suggesting that inclusion of the biopsychosocial model of pain within undergraduate physical therapy programs, in addition to teaching a practice approach that encourages active participation of patients in the treatment process, would be a good starting point to increase therapists' and public understanding of the biopsychosocial approach to rehabilitation. However, the physical therapist participants in our study believed that training therapists to the point where they could deliver targeted cognitive-behavioral–based interventions would be more appropriate at the postgraduate level, such as an extended scope practice program. This finding was due to the amount of training the physical therapists believed was necessary to become competent to deliver a PCST program in practice. The initial training course, followed by additional mentoring, role playing, and performance feedback from an appropriately trained supervisor, was considered to be the minimum requirement for competency in this area. In addition, some participants believed that a certain amount of postgraduate experience is necessary to build confidence and basic skills prior to adding the complexity of the PCST approach to physical therapist practice.
Limitations, Strengths, and Future Directions
This study has considered the experiences and perspectives of physical therapists trained to deliver a PCST program as part of an RCT involving adults with knee osteoarthritis. The necessarily small sample size and qualitative method used mean the results cannot be generalized. In addition, the study is limited to the experiences of physical therapists in 2 states in Australia. However, to our knowledge, this is one of the first studies to consider the physical therapist perspective of cognitive-behavioral training and practice in such depth. As such, a number of salient issues have been identified regarding the integration of psychological interventions within physical therapist practice, particularly in terms of training requirements and scope of practice issues. Future studies should investigate how best to integrate traditional physical therapy methods with psychologically informed practice in a way that is realistic and sustainable in the contemporary practice context. In addition, qualitative analysis of transcripts of those sessions identified by physical therapists as problematic, such as those pertaining to cognitive restructuring, would provide insight into the reasons for the difficulty experienced.
Conclusion
Increasing interest in applying the biopsychosocial model of health to chronic musculoskeletal conditions such as knee osteoarthritis has been accompanied by an awareness of the potential for physical therapists to deliver integrated physical and psychological interventions. The findings of this study demonstrate that physical therapists can be trained to confidently deliver a psychological intervention that educates patients in pain coping skills. In addition, physical therapists believe training in these skills enhanced their clinical practice overall. Comprehensive training, involving skill acquisition, mentoring, and guidance by appropriately trained personnel, is crucial to ensure treatment fidelity and provide support to physical therapists in practice.
Appendix.
Interview Guidesa
a CBT=cognitive-behavioral therapy, RCT=randomized controlled trial.
Footnotes
All authors provided concept/idea/research design and writing. Dr Nielsen provided data collection. Dr Nielsen, Dr Keefe, and Dr Jull provided data analysis. Dr Bennell and Dr Jull provided project management and fund procurement.
Ethical approval for the study was granted by the relevant University Ethics Committee.
This study was supported by an Australian Health Management grant. Dr Bennell is partly supported by an Australian Research Council Future Fellowship.
- Received February 18, 2013.
- Accepted September 4, 2013.
- © 2014 American Physical Therapy Association
References
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