Physiotherapists’ confidence implementing a biopsychosocial approach to managing CLBP

CLBP treatment guidelines generally acknowledge a shift toward a biopsychosocial management approach in which the cognitive, psychological and social dimensions of CLBP are considered in addition to the physical and path anatomical dimensions of pain. However, with this said, currently available research indicates that while physiotherapists theoretically endorse the proposed biopsychosocial approach to treatment, very few are adopting this approach in clinical practice despite training in cognitive behavioural principles.

A recent systematic review found physiotherapists lacked confidence in their ability to identify, communicate about and manage cognitive, psychological and social dimensions of CLBP in practice. Physiotherapists reported feeling neither equipped by their initial training, nor currently available professional development courses, to successfully deal with these factors in practice. The Physiotherapists emphasised a need for training on integrating these factors into patient management.

Cognitive Functional Therapy (CFT) is a novel, multidimensional, patient-centred intervention which directly explores and manages cognitive, psychological and social factors deemed to be barriers to recovery in CLBP. While we know that CFT is efficacious in improving patient outcomes, physiotherapists’ experiences after completing such training have not yet been qualitatively explored. Such perspectives are important to establish as while CFT may be beneficial to patients, if therapists are no wiling or confident in its administration it will not be an approach incorporated regularly or with ease in the clinical setting.

Therefore as part of this study we explored physiotherapists’ perspectives on treating the biopsychosocial dimensions of CLBP after receiving intensive biopsychosocial training through semi-structured interviews. This training included both workshop attendance in which they observed CFT trainers assessing and treating live patients and supervision given by trainers in the administration of CFT in the clinical setting.

After our analysis four main themes emerged from the data these included

A: self-reported changes in understanding and attitudes,

B: self-reported changes in professional practice,

C: altered scope of practice

D: and increased confidence and satisfaction.

Some of the specific self-reported changes described by physiotherapists are described below:

Participants described increased understanding of the nature of pain,

“ but the cognitive part has been the greatest change…understanding the influence of  sleeping poorly, being stressed… I mean back then (before training) I probably realised it somewhere in the back of my head but I didn’t act on it.” (P6)

the role of patient beliefs

“There is a belief that manipulating their back is the only thing that can help, and then it’s quite difficult to introduce this biopsychosocial model because they kind of deny the presence of these psychosocial factors” (P13)

and a new appreciation of the therapeutic alliance.

“There is a belief that manipulating their back is the only thing that can help, and then it’s quite difficult to introduce this biopsychosocial model because they kind of deny the presence of these psychosocial factors” (P13)

Changes in practice included use of new assessments, changes in communication and adoption of a functional approach.

“Now I think I’m much more open-ended, so I  kind of ask open-ended questions like what’s your story you  know, or what brings you here …” (P1)

For many participants, the results of these screening tools informed their route of questioning during patient interviews.

“I might use the question to explore a particular problem…so you can go “well look you answered this in such a way, tell me a little bit more about it” (P1)

Since undertaking CFT training participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors.

As physios we can put our hands on patients and assure them nothing is physically wrong… and with the training we can complement our hands on  and exercise expertise to treat things like anxiety” (P12)

In considering their scope of practice in these situations, participants acknowledged these issues and their relevance for the patient’s pain, yet described their understanding that they were not appropriately qualified to treat these issues in practice.

“I can identify it, I can talk with the patient and help them consider the relevance of it to their pain, but when it is really traumatic for the patient then I am not capable enough of addressing this problem… it is because I am not trained in it.” (P13)


Overall, after intensive biopsychosocial training physiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of CLBP after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case.

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