Physiotherapists’ views and experiences of assessing psychosocial factors in chronic low back pain: An opportunity to re-focus our clinical and educational priorities?

Psychosocial (PS) factors play an important role in the development and subsequent recovery of individuals suffering from chronic low back pain (CLBP) (O’Sullivan, 2011; Hayden et al, 2009, Wand and O’Connell, 2008). National clinical guidelines for low back pain (LBP) in the UK (NICE, 2016) and Italy (Negrini et al., 2004) recommend that PS factors should be considered in addition to biomedical/biological factors when managing patients with LBP (Negrini et al., 2004; NICE, 2016), and advocate that the biopsychosocial (BPS) model should be adopted by the practitioner when assessing and managing such patients.

Let’s start from the beginning… what is Pain?

Pain has been defined as:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 2018).


Looking at this definition (As of August 2019, the IASP are proposing a revised definition of pain as “An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury”), pain is considered a subjective experience and it is part of a complex process where social, psychological, cultural and contextual factors play a fundamental role in pain perception (Moseley, 2007). Patients presenting with PS factors (e.g. psychological distress, negative cognitions or poor social support) are associated with a higher likelihood of reporting chronic pain, playing an important role in the development and subsequent recovery of individuals suffering from CLBP (Maher et al., 2016). National clinical guidelines for LBP in the UK and Italy advocate that the BPS model should be adopted by the practitioner when assessing and managing such patients (Negrini et al., 2004; NICE, 2016).


The BPS model proposes that an illness or pain experience should be addressed through a multifactorial approach, looking at all the potential contributors that play a role on patient’s pain and disability experience (Waddell and Burton, 2001) and this contrasts with previous dualistic and reductionist definitions where the occurrence of pain linearly related to noxious stimuli via tissue damage (Stilwell & Harman, 2019).


However, as with other healthcare professions, physiotherapy has tended to consider the body from predominately biomechanical and physical perspectives (Thornquist, 2006) rather than from social and phenomenological perspectives (Nicholls and Gibson, 2010), and therefore the incorporation of PS factors into clinical practice has been challenging for some therapists. Despite growing evidence supporting the incorporation of PS factors into clinical assessment and management of patients with persistent musculoskeletal pain, research highlights that some physiotherapists continue to focus on the biological and biomedical factors in such patients (Zangoni & Thomson, 2017) emphasizing the necessity to improve practitioners’ skills, knowledge and understanding of the assessment and evaluation of PS factors (Pincus et al., 2002; Overmeer et al., 2004; Parsons et al., 2007; Singla et al., 2015).


Unfortunately, in Italy the situation is not so different. A study by Negrini et al. (2004) about the development and application of clinical guidelines for LBP in Italy showed there is resistance of general medical practitioners and physiotherapists in adopting a BPS model in their clinical practice, due to poor understanding and knowledge of the BPS approach and lack of standardisation in the teaching of PS factors assessment. There is currently little evidence to describe how physiotherapists in Italy assess PS factors in their patients experiencing CLBP.

In light of this, we decided to explore physiotherapists’ personal beliefs and knowledge about the BPS model and the different ways they assess and manage PS factors in patients presenting with CLBP in Italy.

We conducted the study adopting a qualitative approach employing semi-structured interviews with musculoskeletal physiotherapists in Italy, and analysed these data using grounded theory to develop the main themes. More details of the study and its methodological design can be found here. The study was able to answer the following research questions:


What are Italian physiotherapists’ awareness of the BPS model?

All participants demonstrated awareness on the importance of the BPS model in relation to CLBP and the influence of PS factors in pain and disability, recognising the importance to approach the PS aspects in their daily practice. Although general recognition of social factors (family, work, social relations), stress and negative attitudes were reported by all the participants, a comprehensive overview and explanation of these factors was not always reported. Moreover, lack of appropriate knowledge/understanding of the PS factors and limited clinical guidelines specific to Italy were reported by many participants.


Interview quote:

“The factors causing the chronicity in chronic low back pain are often psychosocial-so anxiety, depression, job-related factors, and expectations”


How do Italian physiotherapists apply the BPS model in the daily practice?

During the interviews a distinction between the BPS and the biomedical approach was perceived, rather than being part of the same model (Jeffrey and Foster, 2012). This fact could be related to the lack of adequate knowledge of the BPS model, as demonstrated via qualitative research from Portugal by Cruz et al. (2012), in Australia by Singla et al, (2015) and in New Zealand by Darlow et al (2014). When exploring how practitioners manage patients in the clinical setting, most participants demonstrated an informal and unstructured approach to PS assessment with the use of general questions and without a specific order, underlying lack of standardisation in this area within the Italian physiotherapy profession.


Interview quote:

“I do not use a set list of questions … I try to understand the openness of the patient”


What challenges do Italian physiotherapists face when managing patients with CLBP?

By exploring the main barriers Italian physiotherapists face when considering PS factors in CLBP patients, we noted frustration from some of the participants, often stemming from their patients’ consideration of physiotherapists as purely manual therapists and that an exploration non-physical factors were not part of their treatment expectations. This often tend to create an obstacle to create a therapeutic alliance, which then created further difficulties in applying a biopsychosocial approach.


Interview quote:

“If a person is reserved, trying to talk about those aspects or analyse them in-depth, could contribute to their suffering, and to distance them from you”


How is Italian physiotherapy education supporting the integration and use of the BPS model in the daily practice?

Standards of physiotherapy education in Italy emphasize the need to incorporate the assessment of PS factors into undergraduate training (Associazione Italiana Fisioterapisti, 2010). However, many participants reported limited education about PS aspects in their university training and expressed the need to receive additional specific training to improve their knowledge in the assessment of PS factors. Some physiotherapists felt partially underprepared to address PS factors due to their biomedically orientated physiotherapy education.


Interview quote:

“At university they do not train you [in psychosocial factors] enough … It would be interesting to have some courses with psychologists … however; unfortunately in Italy the collaboration does not exist”


In conclusion, from our research has emerged the need for Italian physiotherapists to improve their knowledge, understanding and skills in apply the PBPS model and shift their focus (which currently tends to be biomedically oriented) towards biopsychosocially oriented view of clinical practice. Dedicated curriculum content on the BPS model and how its enacted in the ‘real world’ from the university programmes is one way to address the skills deficit early on in pre-professional education. More experienced physiotherapists can be supported through postgraduate education and CPD which takes into account barriers which often impact clinicians’ decisions to prefer to embark on CPD which is biomedically and manual therapy skill orientated. Our qualitative findings concerning physiotherapists’ barriers to assessing PS factors are not intended to represent the entire Italian physiotherapy profession, but the findings may be considered as an instrument to reflect upon and highlight some of the challenges that are currently limiting the BPS practice in chronic LBP.



About the authors:


Giacomo Zangoni BSc, MSc

Giacomo is an Osteopath and Physiotherapist, practising in the north of Italy and UK (London). He is part of the research team and lecturer at Accademia Italiana di Medicina Osteopatica (Saronno, Italy) and he collaborates with the research team of the University College of Osteopathy (London, UK). His main research interests are in relation to the application of the biopsychosocial model in various physiotherapy and osteopathic clinical settings.


Dr Oliver Thomson

Oliver is a practicing osteopath and Associate Professor at the University College of Osteopathy, London, UK. His main research and clinical interests are the language, beliefs and attitudes held by healthcare professionals in relation to the biopsychosocial management of back pain and provides CPD courses to clinicians in these areas.


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