Understanding Physiotherapists’ Intention to Counsel Clients with Chronic Pain on Exercise: A Focus on Psychosocial Factors

Abstract

Purpose: Twenty percent of Canadians experience chronic pain. Exercise is an effective management strategy, yet participation levels are low. Physiotherapists can be key to counselling clients to engage in long-term unsupervised exercise. Yet, investigations that identify psychosocial factors related to physiotherapists’ intention to counsel are lacking. The purpose of this study was to examine whether physiotherapists’ knowledge of chronic pain, beliefs about pain, and self-efficacy to counsel on exercise predicted their intention to counsel clients with chronic pain on exercise. Method: Practicing physiotherapists (N = 64) completed an online survey that assessed their knowledge of chronic pain, beliefs about pain, self-efficacy, and intention to counsel. A two-step hierarchical multiple regression predicted intention. Step 1 controlled for years of practice, and Step 2 included study variables significantly correlated with intention. Results: Beliefs about pain (r = –0.35, p < 0.01) and self-efficacy (r = 0.69, p < 0.01) were significantly correlated with intention. The overall regression model was significant, F_3,60 = 18.73; p < 0.001. Self-efficacy was the sole significant predictor, t₆₀ = 5.71, p < 0.0001, sr ² = 28%. Conclusions: Self-efficacy may facilitate physiotherapists’ intention to counsel on exercise for chronic pain. If shown to be a causal factor, interventions that target a change in physiotherapists’ self-efficacy should be pursued.

One in five adults experiences chronic pain, which is defined as pain lasting 3 months or longer, or beyond the expected healing time for a specific illness or injury, excluding cancer.¹–³ Chronic pain is a public health concern; it costs $43 billion in direct and indirect health care costs every year, an amount that exceeds the costs of treating heart disease, cancer, and HIV combined.³–⁴ Prescription opioids are one of the most commonly used chronic pain management strategies,⁵ yet concerns exist about their long-term effectiveness and risks for dependency, tolerance, and addiction.¹,⁶–⁸

Evidence-based nonpharmacological management strategies, including exercise, are recommended alternatives to opioids.¹,⁹ Multiple reviews support the beneficial effects of exercise, such as decreases in pain severity and improvements in physical functioning and quality of life.¹⁰–¹² However, participation levels are low.¹³–¹⁸ For example, Canadian adults without pain engage in 12–25 minutes of moderate to vigorous exercise each day, whereas adults with chronic widespread pain engage in only 10–19 minutes per day.¹⁷,¹⁸

Evidence-based strategies to help adults with chronic pain exercise more regularly are needed.¹⁵,¹⁹ Trained professionals are increasingly offering or promoting supervised exercise in health care settings and unsupervised exercise outside clinical settings.¹¹ Physiotherapists are well positioned to promote and educate clients on exercise through counselling.²⁰–²² Physiotherapy is a client-focused health profession that is dedicated to promoting quality of life through exercise, management of acute or chronic conditions, and maintenance or enhancement of physical performance.²³ Effective counselling by physiotherapists should include multiple components, such as giving instructions about exercise, including pain-related adaptations; providing education about pain management, which encompasses coping strategies; and teaching adherence-promoting self-regulatory skills (e.g., skills to overcome barriers caused by pain).¹,²⁴–²⁷ Prior research has shown that health care providers’ delivery of tailored integrated counselling has improved their clients’ exercise levels.¹⁵,²¹,²⁸

The focus of this study was on predicting physiotherapists’ intention to counsel clients with chronic pain on these components relative to performing unsupervised exercise. This behaviour occurs outside the clinical physiotherapy setting during leisure time and includes any planned, structured, and repetitive bodily movements that improve fitness (i.e., unsupervised leisure-based activities).²⁹,³⁰

Although unsupervised exercise can promote pain management, no theory-based research has examined physiotherapists’ intention to counsel clients on this behaviour. According to social cognitive theory, when counselling is a freely chosen, volitional behaviour for physiotherapists, their personal characteristics, including psychosocial factors, should predict their intention to counsel.³¹ Psychosocial factors are the most proximal predictors of individuals’ intention to perform volitional behaviours and are more easily modified than other personal and environmental determinants.³² The choice to counsel clients on exercise is not in the clinical mandate or practice of all physiotherapists, for example, those who practise in specialized settings or areas such as hospitals, oncology, and critical care.²⁰ However, social cognitive theory contentions would apply to physiotherapists who choose exercise as a treatment strategy. These physiotherapists would typically recommend exercise for the rehabilitation of an injury or joint replacement surgery or for the management of a chronic disease such as chronic pain. Moreover, these physiotherapists would typically supervise clients’ exercise in a clinical setting and prescribe long-term unsupervised exercise to maintain optimal health and functioning.

Psychosocial Factors

Identifying psychosocial factors that predict physiotherapists’ intention to counsel clients on exercise is a necessary first step in designing and testing interventions to help physiotherapists engage in counselling. Three key psychosocial factors may be knowledge of chronic pain, beliefs about pain, and self-efficacy to counsel on exercise. Limited knowledge of chronic pain, including knowledge of evidence-based treatments such as exercise, is a barrier to safe, effective chronic pain management counselling by health care providers.³³ With limited knowledge, providers are less likely to counsel clients that exercise can be a beneficial pain management strategy.²⁶,³⁴

Unfortunately, few opportunities exist for physiotherapists to learn about chronic pain.³⁵ Canadian physiotherapy students receive only about 41 hours of pain education while obtaining their degrees, whereas veterinarians receive 87 hours.³⁶ Physiotherapy students also report a limited understanding of pain mechanisms, opioid addiction risks, and the fact that chronic pain is incurable.³⁶ Practicing physiotherapists have reported that their licensure training and professional development opportunities did not provide them with the knowledge and skills to treat non-mechanical pain dimensions (e.g., psychological, social).³⁷ As a result, they focused only on treating mechanical pain dimensions.

Although many aspects of chronic pain knowledge exist,³³ in this study we focused on physiotherapists’ knowledge of pain neurophysiology. When providers use this type of knowledge to educate clients, pain and disability decrease and physical performance increases.³⁴ Physiotherapists who are knowledgeable about pain may better recognize that pain experiences are multidimensional and not always an accurate measure of the state of the direct tissue, which may have suffered trauma due to injury or harm.³⁸ They may also be more inclined to counsel clients to participate in evidence-based, guideline-consistent movement treatments, including exercise.²⁶,³⁴

Beliefs about pain may be another psychosocial factor that is important to physiotherapists’ intention to counsel. Negative beliefs that pain is invariably associated with impairment in functional abilities are inaccurate and act as a barrier to promoting guideline-consistent treatment practices among physiotherapy students and practitioners.³⁹–⁴³ Among students, 25% believed that individuals with chronic pain should avoid pain-inducing movement activities.³⁹ Moreover, physiotherapists who had more negative beliefs about pain were less likely to adhere to guideline-consistent exercise counselling.⁴⁰ Negative beliefs about pain among practicing physiotherapists were associated with increased counselling for clients with chronic pain to avoid returning to normal activities.⁴⁴

Self-efficacy is one of the strongest predictors of intentions to engage in volitional behaviors.³¹ Self-efficacy refers to individuals having the confidence to organize and execute actions to obtain a desired outcome, such as counselling clients to exercise. Individuals with high self-efficacy are more likely to intend to engage in volitional behaviour.⁴⁵ However, in prior research reviews practicing physiotherapists reported that they lack the skills and self-efficacy to treat the physical, psychological, and social dimensions of pain.³⁷,⁴⁴,⁴⁶ Physiotherapists also reported low self-efficacy to counsel clients with back pain on psychological and self-regulatory skills, as well as on long-term exercise self-management.⁴⁷

Purpose of this Study

Problematic levels of knowledge of chronic pain, beliefs about pain, and self-efficacy among physiotherapists have been demonstrated in prior research.³⁶,³⁷,³⁹,⁴⁰,⁴⁴,⁴⁶,⁴⁷ Physiotherapists with low knowledge of chronic pain, negative beliefs about pain, or low self-efficacy to counsel on exercise may be less likely or able to counsel clients to participate in evidence-based, guideline-consistent movement treatments, including exercise. To extend the existing evidence, we examined whether knowledge of chronic pain, beliefs about pain, and self-efficacy predicted practicing physiotherapists’ intention to counsel clients with chronic pain on exercise. Given the lack of research on intention to counsel, we did not advance any hypotheses.

Methods

Procedures

This cross-sectional online survey study received university behavioural ethics board approval. Individuals were recruited through Web-based study announcements posted by national and provincial physiotherapy associations and Canadian physiotherapy clinics. Each announcement contained a link to the online survey. Interested individuals who provided electronic informed consent had to satisfy the participant inclusion criteria. Participants had to (1) be adults aged 18 years or older; (2) be currently licensed physiotherapists practising in Canada; and (3) read and write English so that they could complete the survey. Eligible individuals then completed the survey, which assessed demographics, knowledge of chronic pain, beliefs about pain and self-efficacy, and intention to counsel on exercise. Participants took approximately 20 minutes to complete the survey.

Measures

Knowledge of chronic pain

We used the Revised Neurophysiology of Pain Questionnaire to measure knowledge of pain neurophysiology.²⁶,⁴⁸ Participants rated 12 statements as true, false, or unsure. An example statement is “Chronic pain means that an injury hasn’t healed properly.” A percentage of correct responses, ranging from 0% to 100%, was calculated. Higher scores reflected greater knowledge. The reliability and validity of this measure have been demonstrated in samples with chronic spinal and low back pain.⁴⁸

Beliefs about pain

We used the 15-item Health Care Providers’ Pain and Impairment Relationship Scale to assess the participants’ beliefs about the relationship between pain and impairment.⁴⁹,⁵⁰ An example statement was “People living with chronic pain cannot go about normal life activities when they are in pain.” Participants responded on a scale ranging from 0 (completely disagree) to 6 (completely agree). A sum score ranging from 0 to 90 was calculated. Higher scores reflected stronger agreement with the inaccurate belief that pain and impairment are invariably linked. Strong agreement is associated with health care providers’ recommendations to limit physical activity.³⁴ The measure had acceptable internal consistency (Cronbach’s α = 0.69).⁵¹ Reliability and validity have been demonstrated in samples of community-based health care providers (e.g., physiotherapists, physicians, chiropractors).⁴⁹,⁵⁰

Self-efficacy to counsel on exercise

We measured self-efficacy to counsel clients with chronic pain to engage in unsupervised exercise outside the clinical physiotherapy context with 17 items that assessed physiotherapists’ confidence to counsel on chronic pain, exercise, and adherence-promoting self-regulatory skills (e.g., goal setting, overcoming barriers, scheduling exercise).²⁵ The measure was constructed in line with theory-based recommendations for assessing self-efficacy.³¹,⁵² Participants responded after reading the statement “At present, rate your confidence in your skills and abilities as a physiotherapist to do each of the following when working with an adult with chronic pain.” Example items are as follows: for chronic pain, “Educate clients that chronic pain is not always directly related to injury severity”; for exercise, “Educate clients with chronic pain about the benefits of exercise for people with chronic pain”; and for self-regulatory skills, “Teach clients with chronic pain to set appropriate exercise goals.” Participants responded on a scale ranging from 0 (not at all confident) to 10 (completely confident). An average score was calculated, with higher scores reflecting higher self-efficacy. The measure had acceptable internal consistency (Cronbach’s α = 0.96).⁵¹

Intention to counsel on exercise

We used three items to assess physiotherapists’ intention to counsel clients to exercise unsupervised outside the clinical physiotherapy context. The measure was constructed in line with theory-based recommendations.³¹ Participants rated their intention to educate clients on chronic pain, exercise, and adherence-promoting self-regulatory skills. Participants responded after reading the statement “At present, rate your willingness to do each of the following when working with an adult with chronic pain.” Items were as follows: for chronic pain, “Educate clients about their chronic pain”; for exercise, “Educate clients with chronic pain about exercising on their own”; and for adherence-related self-regulatory skills, “Educate clients with chronic pain about psychological skills to help them stick with exercising on their own (e.g., to overcome barriers, goal set, plan, and self-monitor exercise).” Participants responded on a scale ranging from 0 (definitely will not) to 10 (definitely will). A mean score was calculated. Higher scores reflected higher intention. The measure had acceptable internal consistency (Cronbach’s α = 0.93).⁵¹

Data analyses

We used IBM SPSS Statistics, version 24 (IBM Corporation, Armonk, NY), for data analyses. Missing data were replaced using recommended procedures.⁵¹ Missing values were replaced with a participant’s mean score on each measure. An exception was made for the knowledge of chronic pain measure, for which missing values were scored as incorrect responses. Missing data for each measure were random and minimal (i.e., < 10%),⁵¹ and none of the participants missed an entire measure. The absence of outliers and presence of normal distributions were confirmed before proceeding with the hierarchical multiple regression. All multiple regression assumptions were checked and satisfied.⁵¹

The results are presented in three sections: a summary of the study participants’ demographics, the descriptive statistics and correlations of the study variables, and the two-step hierarchical multiple regression results predicting intention to counsel. The first step of the hierarchical multiple regression controlled for the physiotherapists’ years of practice since licensure, thus capturing possible prior experiences working with clients with chronic pain, which may affect psychosocial factors.³¹ Prior research has also shown that less experienced physiotherapists are less comfortable working with clients with pain than more experienced physiotherapists.⁵³,⁵⁴ In the second step, primary study variables found to be significantly correlated with intention to counsel (e.g., beliefs about pain, self-efficacy) were entered.

Results

Study participants

Participants were recruited over a 3-month period, and 64 licensed, practicing Canadian physiotherapists (mean age 40.58 [SD 13.46] y) completed the online survey. Most participants were female (n = 50), White (n= 54), and married (n = 41). Participants represented the Canadian physiotherapist population: an average of 42 years old and 75% female.⁵⁵ Participants had been practising physiotherapy for 15.72 (SD 13.95) years since licensure and had received some licensure or professional development education on chronic pain (n = 53), exercise recommendations (n = 56), and exercise adherence self-regulatory skills (n= 41). Table 1 shows full participant demographics.

Table 1.

Participant Demographic Characteristics (N = 64)

Characteristic	n (%)
Gender
Male	14(21.88)
Female	50(78.13)
Race/ethnicity
White	54 (84.38)
Chinese	1 (1.56)
Southeast Asian	2(3.13)
South Asian	3 (4.69)
Other	4 (6.25)
Marital status*
Married	41 (64.06)
Not married but living with my partner	9(14.06)
In a relationship but not married or living with my partner	4 (6.25)
Divorced	2(3.13)
Single	7(10.94)
Education
University certificate or diploma below bachelor's level	1 (1.56)
University certificate or diploma above bachelor's level	5(7.81)
Bachelor's degree	21 (32.81)
Master's degree	36 (56.25)
Eamed doctorate	1 (1.56)
Practising as a licensed physiotherapist, y
<1	7(10.94)
1-5	18(28.13)
6-10	5(7.81)
11-25	14(21.88)
>25	20(31.25)

Note: Percentages may not total 100 because of rounding.

^*One participant did not report marital status.

Descriptive statistics: means and correlations

As seen in Table 2, participants reported having a moderately high amount of knowledge of chronic pain and more positive beliefs about pain, disagreeing that pain and impairment were invariably linked. Participants reported moderately high self-efficacy and intention to counsel on exercise. Table 3 contains the Pearson bivariate correlations. Beliefs about pain, self-efficacy, and years of practice were significantly correlated with intention to counsel, whereas knowledge of chronic pain was not. Self-efficacy was significantly correlated with knowledge of chronic pain, beliefs about pain, and years of practice.

Table 2.

Means and SDs of Study Variables

Variable	Mean (SD)	Response range, minmax
Knowledge of chronic pain*	83.07 (12.77)	0–100
Beliefs about pain†	34.22 (8.49)	0–90
Self-efficacy to counsel*	7.21 (1.64)	0–10
Intention to counsel on exercise*	8.37 (1.85)	0–10

^*Higher scores represent greater knowledge of pain, self-efficacy, and intention.

^†Higher scores represent stronger agreement that pain and impairment are invariably linked.

Table 3.

Pearson Bivariate Correlations

Variable	1	2	3	4	5
1. Intention to counsel on exercise	-
2. Practice, y	0.33*	-
3. Knowledge of chronic pain	0.21	−0.01	-
4. Beliefs about pain	−0.35*	−0.15	−0.16	-
5. Self-efficacy to counsel	0.69†	0.39†	0.27*	−0.51†	-

^*p < 0.05.

^†p < 0.001.

Predicting intention to counsel on exercise

The overall hierarchical multiple regression model was significant, accounting for 46% of the variance in physiotherapists’ intention to counsel,F_3,60 = 18.73, p < 0.001. As seen in Table 4, in the full model nonsignificant predictors included years of practice, t₆₀ = 0.71, p> 0.05, and beliefs about pain, t₆₀ = –0.04, p > 0.05. However, self-efficacy was a significant predictor, t₆₀ = 5.71, p < 0.0001, accounting for 28% of the variance in intention; this is a large effect size.⁵¹

Table 4.

Predicting Intention to Counsel on Exercise

Predictor	R2adj	ΔR2	β	Sr2
Step 1	0.10*	0.11*	-	-
Physiotherapy practice, y	-	-	0.33*	0.11*
Step 2	0.46†	0.37†	-	-
Physiotherapy practice, y	-	-	0.07	0.00
Beliefs about pain	-	-	−0.01	0.00
Self-efficacy to counsel	-	-	0.66†	0.28†

^*p < 0.05.

^†p < 0.001.

Discussion

This study provides the first evidence on whether psychosocial factors predict physiotherapists’ intention to counsel clients with chronic pain on exercise. Our findings contribute new knowledge that a modifiable psychosocial factor, self-efficacy, may be a key factor in facilitating intention to counsel. This finding supports theoretical contentions that efficacy is a strong, proximal predictor of intentions to perform volitional behaviours.³¹

Our findings also suggest that self-efficacy may mediate relationships between years of practice and intention, as well as between beliefs about pain and intention. Recall that significant bivariate correlations were found among years of practice, self-efficacy, and intention, as well as among beliefs about pain, self-efficacy, and intention. Although these significant correlation patterns suggest mediation,⁵⁶ the cross-sectional design did not allow mediation analyses to be conducted.⁵⁷

Reflecting on the mean findings, participants reported high levels of knowledge of chronic pain, moderately high self-efficacy to counsel, and positive beliefs about pain. All these findings contrasted with prior research. For example, physiotherapy students and practicing physiotherapists have reported deficient knowledge of chronic pain and treatment guidelines.⁴³,⁴⁶,⁴⁷,⁵⁸ Physiotherapists have also reported low self-efficacy to work with clients who were living with chronic pain.³⁷,⁴⁴,⁴⁶,⁴⁷ Among physiotherapy students and practicing physiotherapists, negative beliefs about pain are prevalent, and they hinder attempts to implement guidelines for treating chronic pain that encourage movement.³⁹,⁴⁰,⁴⁴

One explanation for why the study findings contrasted with prior research may be the experienced sample. Participants had been practising physiotherapy, on average, for nearly 16 years, and most had received some training in chronic pain, exercise recommendations, and self-regulatory skills. Given this experience and education, participants may have experientially learned about chronic pain and exercise; this could have resulted in enhanced knowledge, more accurate beliefs about pain, and favourable self-efficacy to work with clients living with chronic pain.³¹

Our study has a few limitations. First, the findings may not be generalizable beyond practicing, experienced physiotherapists who are White, are female, and have received some licensure or professional development education on chronic pain, exercise recommendations, or adherence-promoting self-regulatory skills. Second, our findings may not apply to physiotherapists who cannot choose to counsel clients on unsupervised exercise because of their specialization, clinical mandate, or setting. Finally, although appropriate for the stage of research, the cross-sectional study design did not allow for any cause-and-effect conclusions.

Conclusion

Given our novel finding that self-efficacy was a significant predictor of intention, future research is warranted. Researchers should determine whether self-efficacy is a reliable predictor, and whether other psychosocial factors are consistently predictive, of physiotherapists’ intention to counsel. Because this study found that years of practice and beliefs about pain were significantly correlated with self-efficacy and intention, researchers should conduct longitudinal studies to examine whether self-efficacy mediates the relationships between these variables and intention to counsel.

Theory contends that self-efficacy may bolster physiotherapists’ intention to counsel and that this should promote actual counselling.³¹ Investigations are needed of whether physiotherapists’ self-efficacy and intention to counsel predict actual counselling of clients and of factors that interfere with the intention–counseling relationship. Future research that examines whether clients who receive counselling increase and maintain their participation in exercise is also needed. If research confirms that hypothesis, researchers could proceed with conducting interventions targeting change in key psychosocial factors among physiotherapists that may result in higher intention and actual counselling, as well as exercise participation among counselled clients.

Key Messages

What is already known on this topic

Chronic pain is a public health issue.⁴,⁵⁹ Exercise is a proven alternative to using opioids to manage pain,¹,⁷,²⁴ but participation levels are low.¹⁷ Physiotherapists can be key social influencers of their clients’ unsupervised exercise.¹,¹¹,²⁰ To date, no research has identified modifiable psychosocial factors that can predict physiotherapists’ intention to counsel clients with chronic pain on exercise.

What this study adds

Our study is the first to examine whether three psychosocial factors – knowledge of chronic pain, beliefs about pain, and self-efficacy – predicted physiotherapists’ intention to counsel clients with chronic pain on exercise. Our findings show that self-efficacy may be a key psychosocial factor that predicts physiotherapists’ intention. If this finding can be replicated, and if future research shows that intention leads to actual counselling, which in turn has a positive impact on clients’ participation in exercise, interventions targeting change in physiotherapists’ self-efficacy should be pursued.