On “Fragility and Back Pain: Lessons From the Frontiers of Biopsychosocial Practice.” Nicholls DA. Phys Ther. 2023; 103:pzad040. https://doi.org/10.1093/ptj/pzad040

Psychologically Informed Practice: Let’s Not Throw the Baby Out With the Bath Water

Nicholls¹ offers an interesting lens on psychologically informed practice (PiP) and back pain using cardiac disease management as a historical comparison. Although Nicholls addresses the implication of shifting treatment paradigms from a physical therapist perspective, the changes he identifies are consistent with a broad reconsideration of health care and, in particular, the core competencies required for professional accreditation and reimbursement. However, in responding to Nicholls’ essay, we note several concerns, including: (1) conceptualizing “change” in the physical therapist profession; (2) suggesting that much of the “physical” from physical therapy has been removed with such change; and (3) purported future implications for the profession.

Physical Therapy Is Responding to the Public Health Problem of Chronic Pain

Although our understanding of pain processing has not fundamentally changed over the past half century, we do have a clearer picture of factors that influence chronic pain development and its impact on function, quality of life, and work capability. Our understanding of low back pain has shifted from a narrow biomedical or biomechanical model toward a broader biobehavioral patient-centered model. Nonetheless, legions of health care professionals are poorly equipped to implement PiP. One reasonable response to this change is to ensure that physical therapists gain exposure to PiP principles and strategies to better optimize patient engagement.

Although it is tempting to call for a complete realignment of physical therapist training and coverage, PiP has always resisted such a doomed enterprise. Stemming from early pain management literature,² multidisciplinary care for low back pain has remained grounded on a solid clinical foundation, with early dissemination efforts presenting PiP as an updated framework for physical therapist practice. Cardiology has historically relied on life-saving surgical procedures and risk-reducing medications and only recently has recognized the role of the patient in secondary prevention. By contrast, patient behaviors have long been recognized as pertinent in the management of low back pain, especially as it relates to secondary prevention.

Physical Therapist Management of People With Low Back Pain Is Not Currently, and Was Never Intended to Be, Only Physical

With respect, Nicholls’ lament for the loss of the “physical” aspect of physical therapy suggests a misunderstanding of PiP and of current strategies based on modern pain theories (eg, Melzack neuromatrix theory of pain³) that reject dualistic (physical vs psychological) sources of pain. Newer pain management strategies focus not only on identifying physical impairments and biomechanical abnormalities but also on contextual factors (anxiety, depression, poor social support) that adversely impact function and patient-directed reactivation. Accordingly, recent physical therapist clinical practice guidelines recommend manual and other directed interventions to address a broader range of biological and behavioral factors influencing low back pain.⁴ Therefore, referring to physical therapists as “hands-off facilitator and enablers” perpetuates a dualistic mindset that is inconsistent with our current understanding of pain management. Furthermore, it is inconsistent with current evidence that does not support the use of “hands-off” treatments alone (eg, patient education) but instead supports their use as adjuncts to “physical” treatments such as exercise and manual therapy.

In many respects, physical therapists have always delivered interventions with psychological inputs, whether through education about prognosis that helps reduce anxiety or by instilling self-confidence with challenging new exercises. The term “PiP” was introduced into the physical therapy mainstream via a 2011 PTJ special issue,⁵ which proposed PiP as a method for integrating management of unhelpful psychological responses to pain (particularly patient attitudes, beliefs, emotional responses, and pain coping strategies) into standard practice.

Indeed, the PiP framework introduced in that special issue never advocated for separate lanes of “physical” and “psychological” practices, instead striving for one practice in which those were integrated when patients may benefit from such an approach. We fully acknowledge that work prior to 2011 inspired the PiP term.² However, the special issue provided an opportunity to label a management approach that—though clearly related to cognitive behavioral therapy—also had important distinctions, namely the use of “physical” treatments with evidence of the potential for pain relief.

Future Implications of PiP Should Be Viewed as Data-Informed Evolution in Clinical Practice That Will Benefit the Physical Therapist Profession and Patients Who Seek Our Care

We note Nicholls’ concerns about the potential for “over-correction” in clinical practice. Our concerns, however, surround reluctance to evolve toward a broader biobehavioral patient-centered treatment approach when evidence supports the benefits of such an approach. To minimize both types of concerns, future PiP training needs to intentionally model care that integrates traditional treatments (eg, exercise and manual therapy) with interventions that address patient attitudes, beliefs, emotional responses, and pain coping strategies. To reiterate, PiP maintains exercise and manual therapy as its cornerstone, while integrating psychologically focused interventions as needed to best engage patients in their care and optimize outcomes.

Evidence supports the benefits of patient-centered approaches that fit under the PiP umbrella. For example, cognitive functional therapy, which shares many principles and treatment strategies with PiP (emphasizing patient beliefs, motivation, pain-related emotions, and behavioral-based exercise) has shown large treatment effects when compared to usual care.⁶ Perhaps more importantly, PiP creates opportunities to facilitate cooperative care around issues that are important to patients—such as reducing pain-related anxiety and improving confidence in performing desired activities despite pain—yet these aspects are not commonly evaluated or addressed by other musculoskeletal providers. For example, the PiP Consultation Roadmap⁷ promotes establishing a therapeutic relationship, developing patient-centered communication, and guiding effective pain self-management while also accommodating individual patient differences. Empowering patients to play an active role in their pursuit of optimal function might be more beneficial for patients as compared to typical directive or prescriptive care approaches.

In closing, we echo Nicholls’ sentiment about being at a critical juncture in the physical therapist professional evolution. However, rather than holding on to the prescriptive, biomechanically focused approaches to low back pain management of the past, we continue to advocate for and recognize the positive impact that physical therapists offer health systems and patients through their expanded use of psychologically informed treatments.

Author Contributions

All authors contributed to the concept, idea, and writing of this letter to the editor.

Funding

Jason M. Beneciuk receives research funding from the National Institutes of Health (NIH) (R01AT012229) and fellowship funding from the Center on Health Services Training and Research. Steven Z. George receives research funding from the NIH (UH3AT009790, R21AR082657, R01AR075399, U24NS114416, U24 AT010961, and U24 AT009676) and Department of Defense (HU00011920011 (S-11021-21-01). Corey B. Simon receives research funding from the NIH (K76AG074943, UH3AT009790, R01AG071585). Dr Lentz receives research funding from the NIH (R34AT012082, R21AR082657, UH3AT009790), Duke Claude D. Pepper Older Americans Independence Center, and ATI Holdings, LLC. Carol M. Greco receives research funding from the National Science Foundation (2100040), the Department of Defense (W81XWH-18-2-0007), and the NIH (R01AT009539, UH3AT008769, U19AR076725, R01DK128114, UH3AT010621, R01MH127021). Francis J. Keefe receives research funding from the following NIH grants: 5UH3-AT009790; 239631/1-R01AG064947; 60062239/5R01-CA271220; 5R01-CA249959; 5R01-CA237892; 5R01-CA229425; 5UH3-AR077360–04; 5UH3-AG067493; 5R21-DA052729; U01-DK123813; 5UG3-NR019196.

Disclosures

Jason M. Beneciuk was a PTJ Editorial Board member, and Steven Z. George was a deputy editor at the time this letter to the editor was written. They are currently associate editor and editor-in-chief, respectively. Corey B. Simon, Lindsay A. Ballengee, Carol M. Greco, Chris J. Main, and Francis J. Keefe have developed and provided clinician training courses for physical therapists. These training courses were supported by research grants and provided in conjunction with conducting clinical trials. All authors have published on the topic of PiP.

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