Psychologically Informed Practice: The Importance of Communication in Clinical Implementation

Abstract

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.

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 minimize the impact of chronic pain. Specifically, this paper focuses on the nature of clinical consultations, explores the nature of communication, and concludes with the presentation of a PiP Consultation Roadmap that comprises a structured, yet flexible treatment approach for non-mental health providers to incorporate key psychological principles into their treatment encounters. The accompanying paper discusses clinical implementation of the proposed Roadmap.¹

Psychologically Informed Practice: An Overview

PiP² has been suggested as a framework for interventions that include a specific focus on psychological factors and is advocated as a “middle way” between traditional biomedical or biomechanically focused care and mental health treatment. PiP offers an enhancement to musculoskeletal practice with the aim of restoring function and reengaging activity, rather than providing pain relief per se; with the goal of optimal self-management which, with appropriate training, can be delivered by musculoskeletal clinicians without the need for specialized mental health services. PiP is focused on the development of effective communication between clinicians and patients rather than on an “assess and educate” model in which the main focus is on the didactic provision of information rather than the development of patient-centeredness.³

Background to the Consultation

Before considering the PiP consultation directly, it is necessary to:

• Recognize the role of beliefs and coping strategies

• Identify appropriate outcomes

• Understand the type of education that is required

• Consider the use of standardized assessment

The influence of beliefs about the possibility of change and the role of pain coping strategies are central in the fear-avoidance model,^4,5 which offers a helpful way of understanding the influence of psychological factors on the development of chronicity. Lack of confidence in gaining control over pain or “self-efficacy”⁶ is consistently associated with impairment and disability, affective distress, and pain severity⁷; and improvements in self-efficacy have been associated with improved outcomes in integrated psychological and exercise interventions.⁸ Alignment of self-efficacy with fear-avoidance is depicted in the Figure, which shows how the experience of pain might lead to: (1) a negative activation cycle that increases associated disability or (2) a positive activation cycle that leads to recovery. Before considering the focus of the PiP consultation, it is necessary to consider the nature of consultations and the nature of communication.

Figure.

The influence of negative expectations (catastrophizing) and positive expectations (self-efficacy) on recovery.

Importantly, PiP focuses on addressing psychological factors associated with rehabilitative outcomes like pain and physical function, rather than on mental illness requiring specialist care. It promotes guided self-management with an emphasis on identifying and targeting risk factors for chronicity. For purposes of clinical management, the most influential psychological factors appear to be beliefs about the nature of pain; specific fears of hurting, harming/further injury; and beliefs/expectations about coping with pain.^9,10 PiP comprises a range of interventions that may require various levels of clinical expertise,¹¹ but in musculoskeletal management, the focus is primarily on reactivation, for which specialist mental health expertise is not required.

PiP differs from approaches such as pain neuroscience education (PNE¹²) in which a detailed understanding of pain neurophysiology is central. Although appropriate clarification about the nature of chronic pain and correction of misunderstandings is necessary, PiP deliberately attempts to shift attention from pain per se to its effects and the challenges of reactivation. In addition, while PiP can incorporate manualized treatments developed by clinical psychologists, such as Acceptance and Commitment Therapy (ACT) and Pain Coping Skills Training.¹³ PiP also offers a more flexible treatment approach that can be applied widely in a non-manualized way by other health care providers (eg, physical therapists, chiropractors, and athletic trainers).

During the past 4 to 5 decades, there has been a shift of focus in standardized assessment from aspects of pain perception, using validated instruments such as the McGill Pain Questionnaire,^14,15 to the identification of obstacles to reactivation (Yellow Flags) in terms of beliefs, emotional responses, and pain coping strategies¹⁶ that are associated with outcome and are potentially modifiable.¹⁷ The advantages and limitations of standardized assessment are discussed below, whereas Yellow Flags are described in more detail in Supplementary Material 1. In PiP, the nature of clinician–patient communication is of particular importance to the treatment encounter, and assessment tools provide a valuable resource to engage the patient in meaningful conversation.

The Nature of Clinical Consultations

Effective patient–clinician communication, across a wide range of topics, has direct and positive consequences for patient care,¹⁸ including greater patient satisfaction, higher treatment adherence, and better clinical outcomes. Yet, interview and focus group studies have found that discussions about pain management are often frustrating and unproductive,¹⁹ and that patients and clinicians often prioritize different pain management goals.²⁰ Breakdown in the clinician–patient therapeutic relationship, termed “ruptures,”²¹ have been associated with increased dropout rates and poor clinical outcomes and only a limited operationalization of communication behavior has been found in physical therapist practice in chronic pain rehabilitation.²²

Goals of the Clinical Interview

The 2 overarching goals of a clinical interview are to facilitate communication and to establish an effective working relationship between the patient and the provider.²³ Research has shown that the use of such interview methods is associated with higher satisfaction in the receivers of care and enhanced outcomes.²⁴ Moreover, prior research has also suggested 2 strong predictors of patient-reported therapeutic alliance: (1) clinician attitudes and beliefs that are more aligned with a biopsychosocial approach and (2) sharing information and power with patients.²⁵

Interview Skills

Communication is of central importance to the interview. Both verbal and nonverbal behaviors of the health care provider (described in Keefe et al¹¹) contribute to the effectiveness of interviewing, and interview skills can be taught and mastered.²⁶ Training in interview skills using experiential methods, such as role-play and interviews with simulated patients, has been featured in the more extensive training programs delivered for research trials, but the training offered in pragmatic trials has been much less extensive and some physical therapists still tend to prefer dealing with the more mechanical aspects of low back pain (eg, restoring spinal stability).²⁷

What We Have Learned From Clinical Trials?

PiP has been featured in several clinical trials^28–30 and stimulated the development of workshops and training programs for health care practitioners, particularly for physical therapists, but also for other spinal practitioners. Several studies have detailed the training that has underpinned recent PiP trials.^31,32 However, adoption of PiP by physical therapists has shown mixed results. Physical therapists recognize the value of biopsychosocial interventions and consider using them in practice, but only partially recognize psychosocial challenges, frequently lack confidence in this approach, and do not feel adequately trained to deliver these interventions.^27,32–35 Although adequate training appears to improve confidence, we have little information as yet on how this translates directly into clinical practice (ie, what happened in the consultation).

Inadequate appreciation of the difficulty for clinicians firmly rooted in biomedical principles in adopting a PiP approach may be responsible in part for the disappointing outcomes in pragmatic trials. Attitudes and beliefs toward and adherence in principle to a biopsychosocial framework may be a necessary but insufficient building block for producing change in clinical practice. For example, when lacking confidence in dealing with the emotional impact of pain, clinicians may downplay the issues or even avoid them.²⁷ Nonetheless, managing both the patient’s response (and their own reaction) is an integral part of PiP management and is a core element in PiP training.

Finally, there are a range of both clinical and organizational or system challenges to implementing PiP in practice. For example, if treatment fidelity and adherence are not closely monitored, it could result in a lessening of the treatment effects observed.³⁶ Still, the focus of this perspective specifically is on the style and content of the clinical consultation itself, which we believe underpins all face-to-face therapeutic interventions.

Challenges in Clinical Evaluation

It is essential to reach agreement on the set way forward and there are 3 important challenges to be kept in mind when communicating with an individual in pain. First, the development of an effective therapeutic relationship needs to be built on trust and sensitivity in encouraging disclosure of potentially sensitive information. Second, it is important to appreciate that in people with complex chronic pain conditions, evaluation can be particularly challenging and when the cues are ambiguous, it may be difficult to obtain an accurate picture. Third, it must be borne in mind that pain complaints can be misinterpreted, and people may have become upset at suggestions of exaggeration. In the subsequent sections, strategies to address these challenges are briefly reviewed.

The Importance of the Clinician–Patient Relationship

The nature and role of assessment have been intensively investigated, but the dynamics of the consultation have often lacked a clear focus in pain management.

Therapeutic Alliance

Recent studies have supported the impact of the patient–physical therapist alliance on functional outcomes.^37,38 Positive therapeutic alliance ratings between physical therapists and patients not only are associated with improvements of outcomes in low back pain,³⁹ but are also important mediators of change. PiP, although clearly a derivative of cognitive behavior therapy (CBT), aligns well with the client-centered approach⁴⁰ with its emphasis on communication and has potential to enhance therapeutic alliance.

Empathy

The degree of empathy which a clinician feels toward a patient may affect the emotional climate of the consultation and subsequent decision-making. The topic has stimulated considerable neurophysiological and psychological interest.^41,42 There is MRI evidence to suggest that observing somebody in pain activates similar neurons as if the observer were feeling pain themselves.^43,44 Furthermore, empathy seems to be influenced not only by processes such as the appraisal of the observer, but also by “incoming” information, such as the facial expression of the person in pain, and the context in which the pain behavior is observed (eg, the relationship with the person in pain). A way to understand the nature of communication in the PiP consultation is provided by the integration of detailed analyses of how cognitive, affective, and behavioral components of empathy are elicited⁴¹; and also linkages among the 3 components as proposed in the Social Communication Model.⁴⁵ Viewed from a clinical perspective, empathy has also been conceptualized as the ability to take the perspective of another person, without confusing it with one’s own interests.⁴⁶ Indeed, the suspension of judgment until a full picture is obtained may act as a safeguard against underestimation of the intensity or significance of a patient’s pain.

Finally, if people show evidence of distress in describing previous encounters with health care professionals, it is important to offer the opportunity to discuss their experience, acknowledge its impact, and express appropriate empathy, and an attempt be made to “defuse” the distress and help the patient return to their present challenges. If it appears that treatment may have been negligent, the patient can be informed of actions they can take, but your role as their clinician should be clearly differentiated from legal assistance, which might be undertaken by others.

The Nature of Communication

The patient–clinician exchange of factual and perceived information is at the heart of all clinical consultations and is of special importance in PiP, not only in terms of what is transmitted but how it is expressed and understood. Rather than a “passive” 1-way education-only approach, communication within PiP is meant to encourage authentic “dynamic” 2-way communication so that the clinician can begin to understand each patients’ individualized pain experience as a precursor to beginning to discuss reactivation.

In PiP, reactivation requires a focus on the nature of behavior change and its determinants⁴⁷ with flexibility in the selection of strategies. Good patient–clinician communication has the potential to help regulate patients’ emotions, facilitate comprehension of medical information, and allow for better identification of patients’ needs, perceptions, and expectations.⁴⁸ Identified problems include non-disclosure of information, clinician’s avoidance of sensitive/difficult issues, ambivalence in addressing fear/avoidance, and lack of empathy.

There are many barriers to good communication in the patient–clinician relationship, including patients’ anxiety and fear, doctors’ burden of work, fear of litigation, fear of physical or verbal abuse, and unrealistic patient expectations. In PiP, these are best understood as obstacles to recovery, the significance of which requires appreciation of the context in which the behavior change is planned.^49–51

Context

Initially, a general focus on 4 key aspects of context has been recommended⁵²: (1) strategies and techniques (active ingredients); (2) how they function (causal mechanisms); (3) how they are delivered (mode of delivery); and (4) what they aim to change (intended targets). However, not all obstacles can be overcome, and if they cannot be circumvented, it may necessitate postponement or abandonment of the PiP intervention. The focus on PiP is on potentially modifiable obstacles to change which require identification of the determinants of behavior change in sufficient detail to tackle them in clinical practice. The Theoretical Domains Framework (TDF⁵³; see Suppl. Material 2) has been developed as a basis for identifying problems in clinical implementation, designing implementation interventions to enhance health care practice, and understanding behavior change processes. Its particular strengths are its theoretical coverage and its capacity to elicit beliefs that could signify key mediators of behavior change.⁵⁴ The PiP Consultation Roadmap (discussed below) is based on the theoretical underpinnings of the TDF.

Patient Perception

As aforementioned, the patient’s perception of their pain and its impact may be colored by high levels of distress, with little or no understanding or appreciation of chronic pain, and with disappointment, frustration, and even anger arising from previous encounters with clinicians. Hopefully, the recent recognition of chronic pain syndromes as a facet of general medicine rather than embedded in psychiatry^55,56 will prove helpful in encouraging people consulting about their chronic pain to focus primarily on the effects of pain on function and wellbeing and to tackle obstacles to recovery and reengagement.

Optimizing Communication: General Considerations

Establishing Appropriate Expectations

It is important to convey to patients that PiP is an approach with multiple benefits. First, it will empower patients to intervene when negative thoughts and feelings arise, and in doing so, improve the likelihood of healthy pain coping and behavior. Second, PiP may enhance the effectiveness of traditional PT interventions such as manual therapy or exercise. However, it is equally important to understand, acknowledge, and address a patient’s expectations. Simple clarification may not be sufficient to ameliorate expectation discord. Physical therapists must strive to understand past and current attempts in a patient’s pain management, ensure treatment goals are value-based and aligned, and include the patient in treatment decision making.

Clinicians may be set in “fix the pain” mode, as may patients. While abolishing pain should be attempted wherever possible, it may be unrealistic for people in whom chronic pain has become firmly established. The overall tone should be one of cautious optimism (assuming that the therapist and patient have identified reasonable therapeutic objectives) with a focus on the next stage rather than eventual outcome. As mentioned above, communication is a 2-way process in which open-ended responses are encouraged and not over-constrained by a strict predetermined structure. Patient expectations may change soon after treatment is initiated, or due to external circumstances, and so it is important to maintain momentum. It is useful to reinforce positively any therapeutic gains, emphasize that the change is something the patient has achieved, and remind them that they can expect setbacks and flare-ups and if you have agreed upon targets with them, make these the initial focus of the next consultation.

The Use of Standardized Pain Assessment

There is a long history of attempts to standardize pain assessment, but there are both strengths and limitations of self-reported pain ratings,^15,57 and they must not be adopted uncritically. Modern approaches to assessment typically include assessment of function and psychosocial impact, many developed for the purpose of research or clinical audit and are not a realistic prospect in routine clinical practice. However, shorter tools such as the Örebro Musculoskeletal Pain Questionnaire,⁵⁸ the STarTBack tool,⁵⁹ or the OSPRO Yellow Flag Tool for Musculoskeletal Pain Conditions⁶⁰ are a more practical proposition and can be helpful in prioritizing potential treatment targets and can also be used as measures of change and/or to identify areas for open-ended engagement. Giving the patient an opportunity to quantify pain intensity and interference can serve as a catalyst for engaging in conversation about what the patient believes about their pain, its impact, and how they are attempting to cope with it. Appropriate questions such as “You noted that pain here was an 8/10, so your pain is clearly significantly troublesome”; and, “Can you tell me more about when this was and what was happening?” can be useful. However, despite these undoubted advantages, standardized assessment measures can impose a degree of patient and clinician burden and so it is particularly important to explain their purpose in simple terms, particularly if it is intended to repeat the assessment at a later date—and for clinicians to understand their value.

The Role of the Therapist in Facilitating Adaptive Behavior Change

Although the primary focus of this perspective paper is on the consultation as the “front end,” it may also pave the way for more complex interventions downstream. Keefe et al¹¹ identified 5 major types of PiP interventions including education, CBT, ACT, stress reduction, and mindfulness. In addressing reactivation and reengagement in chronic pain conditions, the primary goal and index of improvement in PiP is adaptive behavior change; offering appropriate encouragement for adaptive change allows unhelpful behaviors to “fizzle out.” It is important, therefore, to encourage and help the patient to identify the specific effects of their pain on themselves and others, the types of coping strategies which they habitually use, and to consider more adaptive alternatives (whether enacted by themselves or with involvement of others). A reason for structuring the interview is to help people understand that they need to focus on behavior change, and “reframing” their behavioral objectives is best achieved by concrete examples identified by themselves or illustrated by the ways in which other people have attempted to cope with pain. A number of techniques which can optimize such communication are shown in Table 1 and are discussed in more detail in Supplementary Material 3.

Table 1.

Optimizing Communication

Key Techniques	Description
Facilitating patient self-disclosure	● Patient discloses their pain experience, coping, and behavior
	● A prerequisite of clinical encounters
	● Requires establishing trust
	● Normalizing self-disclosure by describing other patient experiences often helpful
Shared decision making (SDM)	● Clinician and patient working together to determine treatment
	● Blends patient’s personal experience with therapist’s understanding of the condition
	● Supports patient self-determinism or autonomy
	● Patient involvement depends on factors such as comfort and health literacy
Motivational interviewing	● A counseling approach using behavioral change techniques
	● Contrasts with traditional “advice-giving”
	● Maximizes open-ended questions and affirmations
	● Goal is to have patient rather than clinician generate behavior change
Pain neuroscience education (PNE)	● Uses education about pain neurophysiology to help understand pain experience
	● Utilizes metaphors
	● Recognizes the need to correct misunderstandings
	● Offers as much detail as needed to overcome resistance to change
Use of the “guarded optimism”	● Importance of establishing cautious optimism
	● Guarding against promises of complete cures
	● Recognition that most chronic pain is recurrent
Development of a positive behavioral focus	● Pain management directed at patient goals and values, not generic outcomes
	● Helps patient to understand “realistic” vs “unrealistic,” “modifiable” vs “unmodifiable”
	● Stresses the importance of actual behavior change
	● Emphasizes adaptive pain coping strategies

Clinical Implementation Into Day to Day Practice

Clinical implementation presents a number of challenges. As aforementioned, some clinicians have difficulty in shifting from a “fix the pain” mode and broadening their focus to incorporate the identification (and management) of yellow flags in clinical practice, but a number of strategies may help. The move toward patient-centered communication,^3,61 with its increased flexibility and focus on experiential learning by the patient, allows for consideration of a wide range of issues. There are clear implications for training.

Implications for Training

PIP can be taught at the professional level,⁶² and different combinations of didactic and experiential learning methods have also been included in clinical trials. However, the relatively small treatment effects of PiP interventions in recent pragmatic clinical trials may be a consequence, in part, of insufficient training in implementation of the stratified approach required for PiP. According to Beneciuk et al,²⁵ physical therapists are aware of the potential benefits of PiP but feel insufficiently trained to successfully implement such skills in clinical practice, with specific barriers including lack of knowledge and resources, time constraints, and insufficient role clarity. This finding is in accord with training in management of high-risk patients in which both competence and confidence had to be addressed as part of the training.³¹ Further research supporting the development of training for, and mentoring of, physical therapists, to promote competence and confidence in delivering psychologically informed interventions has been recommended.^63,64

Examples of how PiP training has been delivered for selected clinical trials are shown in Ballengee et al, Table 2.⁶³ Explanatory trials are often resourced to focus on treatment fidelity through many different means, including protocol standardization and a dedicated provider pool, using evaluations that cannot generally be built into the funding or implementation in routine clinical practice. Although there seems to be convergence around the core components of a PiP training program, there is no consensus on how training should be delivered. In addition, there is little evidence as yet regarding the most effective intensity of training on how to increase uptake of PiP into an existing health system or clinic, or on how to sustain PiP in a workforce after initial training attempts are completed.

Table 2.

Roadmap Stages: Purpose, Techniques, and Mechanisms

	Stage	Purpose	Behavioral Change Theory	Mechanism of Action
1	Initiating the conversation	To establish a patient-centered approach to reactivation and the recovery of function prior to eliciting a detailed pain history.	Social support Credible source	Social influences Social role/professional identity General attitudes/beliefs
2	The starting point	To clarify the context of the consultation as a precursor to facilitating patient-centered management.	Action planning Problem solving Information about social and environmental consequences	Behavioral regulation Beliefs about capabilities and consequences Environmental context and resources Skills Knowledge Attitudes toward the behavior
3	Route-finding	To invite the patient to develop an initial plan from which a strategy can be developed.	Action planning	Behavioral regulation
4	Vehicle check	To clarify the route that has been selected and the challenges which may need to be overcome, as well as the involvement of others.	Problem solving Social support Goal setting Commitment	Beliefs about capabilities Environmental context and resources Skills Social influences Behavioral regulation
5	Checking fitness to drive	To ensure that the learner has both the competence and the competence to set off on their own.	Demonstration of the behavior Feedback on behavior Behavioral practice/rehearsal Framing/reframing	Beliefs about capabilities/skills Subjective norms Knowledge Skills Attitude toward behavior
6	The handover	To support their plans, reinforce ownership of the decision-making process, and embed self-management.	Self-monitoring of behavior Focus on past-success Verbal persuasion about capabilities Commitment Feedback on outcomes of behavior	Behavioral regulation Beliefs about capabilities Values Feedback processes
7	Continuing the journey	To remind trainee that temporary setbacks are expected and that it is important to learn from them and potentially settle for interim targets.	Problem-solving Self-monitoring of behavior Focus on past success Habit formation	Beliefs about capabilities Skills Environmental context and resources Behavioral regulation/cueing

Recent Developments in Clinical Consultations

The Nature of Consultations

At the heart of the PiP Consultation is direct contact between the therapist and the patient (usually seen individually but sometimes in groups). In face-to-face contact, the clinician is able to gage quickly if rapport is being established and tackle any apparent difficulties. However, the health care landscape is changing. There have been significant advances in eHealth over the last decade,^65,66 including the provision not only of information, but also of case management and self-care,⁶⁷ and the use of patient-related outcome measures.⁶⁸ There is evidence for the effectiveness of e-health supplemented by “on-demand” clinical support,⁶⁹ but there is considerable variation within the eHealth-mediated self-management support intervention literature.⁷⁰

Continuity of care is important in all health care settings,⁷¹ but although e-health offers significant potential benefit in terms of management continuity, it carries the risk of significantly damaging relationship continuity and thus has important implications for management of patients with conditions, such as chronic pain, for whom communication with health care professionals can be a particular challenge and who have difficulty in managing their condition.⁷²

The Content of Consultations

There have also been important changes in the content of consultations. Positive health at a societal level is increasingly acknowledged and is supportive of self-management approaches such as PiP, not as second-best, but as a positive way forward in the management of chronic illness such as chronic pain and its effects.⁷³ There are sometimes difficulties in introducing the PiP perspective to patients (particularly with the sensitive undercurrent of personal responsibility) who may have had a very different expectation of the consultation. There have been transitions from pain relief to pain management, from prescribed treatment to guided self-management, from function to work capability and social participation, and most recently from illness to wellness.

The PiP Consultation “Roadmap:” A New Approach to the Consultation

In the present paper, we have offered a focus specifically on the clinical consultation. As part of the training for PiP interventions, training content (particularly for the management of the patient who is “high risk” or more complex) has been progressively developed and although trainees have demonstrated mastery of the educational content, they have reported difficulties in embedding the new approach in clinical consultations and in structuring the consultation effectively within an overall framework.

We offer The PiP Consultation Roadmap as a structured, yet flexible approach to consultation. Although it is recognized that clinicians new to PiP may need more structure in the beginning of their learning journey, it is to be expected that as clinicians gain more confidence in their use of the Roadmap, more flexibility will be built in as their expertise develops. The Roadmap is suggested as a clinical implementation strategy which incorporates a series of stages to provide structure to an effective PiP approach, while at the same time providing the flexibility to accommodate differing therapeutic communication styles and levels of experience. The proposed stages in the Roadmap stages are presented in Table 2, as are the purpose, typical behavior change techniques, and associated mechanisms of action for each stage. These are grounded in specific behavior change techniques and the modes of action which might be employed.⁷⁴

However, 2 specific caveats must be appreciated. First, the table is offered only as attempt to illuminate the stages in the roadmap. Second, since patient-centeredness rather than rigid prescription is fundamental in PiP, a change in the way care is delivered may be required and how the stages are implemented will depend on the way the individual has been affected by the chronic pain. A detailed discussion of the use of the roadmap in practice is given in the accompanying paper.

Summary and Conclusion

Effective communication is the cornerstone for PiP and begins within a clinical consultation; however, it is important to be aware of the challenges in putting PiP into routine practice. Certainly, trained physical therapists can adopt collaborative and responsive styles of verbal and nonverbal communication.⁷⁵ Nevertheless, some therapists have difficulty in shifting from a biomedical “pain relief” mode to broadening their focus to incorporate the identification (and management) of psychosocial risk factors/obstacles (yellow flags) in their clinics. Recognition of a number of specific features of PiP may help with this difficulty in transitioning to incorporating key biopsychosocial factors into clinical practice.⁶³ Research that incorporates direct observation of patient–clinician communication is critical to elucidate possible pathways through which communication is related to treatment decisions, patients’ and clinicians’ of consultations, and patient outcomes. Finally, we introduce a new clinical implementation strategy known as “The PiP Consultation Roadmap” as a way to address the above challenges and optimize communication.

Author Contributions

Concept/idea/research design: C.J. Main, L.A. Ballengee, S.Z. George, J.M. Beneciuk, C.M. Greco, C.B. Simon

Writing: C.J. Main, L.A. Ballengee, S.Z. George, J.M. Beneciuk, C.M. Greco, C.B. Simon

Data collection: C.J. Main, L.A. Ballengee

Project management: C.B. Simon.

Consultation (including review of manuscript before submitting): C.J. Main, S.Z. George

Funding

Preparation of this perspective was funded in part by the National Institute on Aging of the National Institutes of Health (K76AG074943). The funder played no role in the writing of this Perspective.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.