Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions

Abstract

There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples’ responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.

Substantial promise and important new opportunities come about when health care providers integrate biopsychosocial management into their clinical practice. One such approach has been termed psychologically informed practice (PIP),¹ derived originally from a pain-management approach for people with high levels of pain-associated disability and distress appropriate for an intensive interdisciplinary approach.² A 2011 special issue ofPhysical Therapy focused on PIP, recommended that providers enhance their professional skills in the management of low back pain by including structured consideration of pain-associated psychosocial factors as potential obstacles to reactivation and by recognizing these pain beliefs, attitudes, emotions, and behaviors as worthwhile treatment targets.³ The overarching goal of PIP is to enhance secondary prevention of disability by providing a better understanding of the patient's pain, improved tailoring of interventions, enhanced adherence to treatment methods, and better outcomes at reduced costs. In the article by Main and George,¹ PIP was recommended as a “middle way” between traditional biomedically based, physical impairment–focused physical therapist practice and cognitive-behavioral approaches developed originally to treat mental illness (Fig.1). Since the 2011 special issue was published, there has been converging evidence of increased uptake of PIP, several examples of which are highlighted below.

Figure 1.

Conceptual framework for psychologically informed practice. The original framework for psychologically informed practice in the management of low back pain was proposed by Main and George.¹ Psychologically informed practice was described as the “middle way,” integrating traditional biomedically based, physical impairment–focused practice with cognitive-behavioral approaches. Adapted with permission of the American Physical Therapy Association from Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research.Phys Ther. 2011;91:820–824.

PIP in large trials

The Targeted Interventions to Prevent Chronic Low Back Pain in High Risk Patients (TARGET) trial is a large pragmatic study funded by the Patient-Centered Outcomes Research Institute. This multisite, cluster-randomized trial is comparing treatment for preventing transition to chronic low back pain via guideline-based primary care versus primary care plus timely referral to physical therapists trained in PIP.⁴ Another example is the Work Injury Screening and Early Intervention study in New South Wales, Australia—a randomized trial using multilevel interventions (some incorporating PIP) to facilitate return to work after injury for those at high risk for delayed return to work.⁵

Scientific conferences

The biopsychosocial framework has been featured regularly in the International Association for the Study of Pain world congresses and chapter meetings in North America, Europe, and Australia. This conceptual framework has been central to PIP-focused content delivered in refresher courses, keynote addresses, and workshops for several decades. Perhaps the strongest indication of broader acceptance of the biopsychosocial model, however, has been the North American Spine Society sponsorship of a 2-day meeting on PIP convened in October 2016.

Growing evidence base

In addition to these examples, there has been a burgeoning of research into specific PIP approaches that can be broadly classified into 5 intervention types, as summarized in Table1. Studies demonstrating the efficacy or effectiveness of PIP-focused interventions have been reported; they involved screening and referral in primary care⁶ and family practice⁷ settings or pragmatic delivery by physical therapists.⁸ There have been descriptions of PIP interventions for groups⁹ and tertiary rehabilitation,¹⁰ and there has been an extension from clinical to occupational contexts.⁵ Finally, alternate delivery modes for PIP,such as e-health¹¹and telephone-delivered care, have been described.¹²

Table 1.

Major Types of Interventions Used in Psychologically Informed Practice Approaches.

Intervention	Brief Description
Educational	Threat reduction and activation46
Behavioral change	Explicit focus on incorporating adaptive behaviors in response to pain47
Cognitive-behavioral	Principal focus on cognition and coping strategies48
Psychophysiological focus	Variants of stress reduction and mindfulness48,49
Contextual cognitive-behavioral therapy	Acceptance and commitment therapy10,50,51

Beyond the back

PIP to date has focused on patients with low back pain. However, PIP is not condition specific, and investigations of how it will be applied to other common musculoskeletal disorders (eg, neck, shoulder, and knee pain) have begun. For example, adaptation of a screening tool for low back pain has shown some promise in other anatomical regions for associations of pain and function.¹³ However, the groundwork in identifying prognostic factors for chronicity and developing condition-specific protocols is still at an early stage. Future research in clinical settings will identify how successful approaches for patients with low back pain (eg, stratified care models) can be adopted for other common pain conditions.

Recently, chronic pain was identified by the US government as a priority, and 1 recommendation for patients includes population-based, biopsychosocial approaches to pain care that are tailored to an individual's needs.¹⁴ Another recommendation is for clinicians to receive better education and training on biopsychosocial characteristics and safe and appropriate management of pain.¹⁴ Furthermore, the current American College of Physicians’ pain clinical practice guidelines emphasize the importance of nonpharmacological approaches for frontline treatment of acute and chronic low back pain,¹⁵ directly in line with PIP.

The overall goal of this article is to meet the challenges of pain as a national priority by further informing readers on PIP as a nonpharmacological approach to pain management. The specific purposes of this article are to provide a description of PIP techniques that range in complexity, offer considerations for implementation in clinical practice, and outline future directions that hold promise for advancing the understanding of PIP.

Spectrum of PIP Techniques

PIP involves a range of specific techniques with which physical therapists have varied familiarity and experience. Some therapists may be aware of the general approach and have had some exposure to psychology, but have gaps in knowledge regarding the principles of behavior change. Other therapists may lack confidence in their own abilities to implement PIP techniques. Some physical therapists express doubt that the techniques will work or are valid. Still, others may hold unrealistically optimistic beliefs about how easy it is to implement these methods. Observations and training experiences have taught us that PIP application requires that clinicians hone their professional skills particularly in the areas described below.

Interview Methods

Interviewing is a key component of clinical practice^16,17 and is one of the most important skills that a physical therapist can develop. Traditionally, the core purpose of the interview has been information gathering for the purpose of determining a diagnosis, and it was assumed that relevant expertise was held by the health care professional. However, the advent of patient-centered medicine has fostered a growing interest in a different approach to patient interaction, which has led to a stronger focus on training health care professionals in patient-centered interview methods. Research has shown that the use of such interview methods is associated with higher satisfaction in the receivers of care and enhanced outcomes.^18,19 There is growing recognition that both verbal and nonverbal behaviors of the health care provider contribute to the effectiveness of interviewing and that interview skills can be taught and mastered.²⁰ Elements that can reinforce and heighten the impact of what was said in an interview include both verbal and nonverbal communication behaviors. Important verbal behaviors include the use of open-ended questions, acknowledging physical and emotional challenges, summarizing key points, clarifying areas of misunderstanding, and keeping the verbal focus of the conversation on the patient. Important nonverbal behaviors include maintaining an open and accepting body posture, making appropriate eye contact, responding with proper volume and tone of conversation, and using facial expressions to show interest and support. The 2 most important goals of the interview are to enhance communication and establish an effective working relationship between the patient and the provider.¹⁶ When these goals are met, there is an increased chance of establishing a better therapeutic alliance, which has been shown to be a precursor to better clinical outcomes.

Potential

The use of effective interview methods holds the promise of substantially improving the physical therapist's ability to understand and treat the patient. The judicious use of verbal and nonverbal skills can help patients convey their own stories and can help identify important topics that may affect the course of treatment and that otherwise might not be mentioned. These skills also serve to strengthen the therapeutic alliance in ways that can enhance treatment engagement and follow-through.

Challenges

Regular use and mastery of interview skills can be hindered by time pressure, patients who are discursive or overly talkative, and emotional issues that might arise. These challenges can lead some practitioners to stray away from a more patient-centered approach. Yet, learning to deal with such issues is a skill that can be mastered through formal training (eg, a workshop) or informal training (eg, supervision sessions with colleagues). Time spent reviewing best practices for interview methods, participating in role-playing, and receiving feedback can be well worth the time spent given the potential yield.

Therapist Reinforcement

Treatment sessions provide many opportunities for physical therapists to reinforce patient behavior, and the thoughtful use of reinforcement can have a major impact on the success of treatment.^20–22 Therapist reinforcement involves 2 basic steps: identifying a specific target behavior and delivering some type of reward contingent on the target behavior. There are several important principles to keep in mind when using therapist reinforcement. First, reinforcement should be delivered after the target behavior. For example, if one wishes to encourage a patient to engage in challenging exercises with rest periods, it is best to schedule the rest period after the exercise rather than have the patient rest beforehand. Second, immediate reinforcement works better than delayed reinforcement. For example, calling a patient several times during the first week of their exercise program to provide encouragement for exercise goals that they met is much more effective than waiting until the next treatment session. Third, it is important to phase down the rate of reinforcement over the course of treatment. During the early phase of treatment, a therapist might praise a patient each time they practice a pain-coping skill, such as relaxation. Later on, reinforcement might be provided for every fourth time the patient practices the skill, and still later on might be provided on a random decelerating schedule. Gradually reducing the frequency of therapist reinforcement reduces the patient's dependency on the therapist, making it much more likely the target behavior will be maintained.

Potential

Reinforcement is one of the most powerful methods for eliciting and maintaining changes in patient behavior, and it is considered a key component of behavioral-activation protocols.²³ Research shows that reinforcing patients’ statements about their experience and motivation in early treatment sessions can lead to higher levels of patient engagement and involvement in later sessions.²⁴ Prompting and reinforcing completion of tasks over the course of treatment also improves outcomes.²⁵ Reviews of the behavioral-activation literature demonstrate that such strategies are among the most effective ways of increasing activity in patients who are psychologically distressed.²³

Challenges

Although mastering such techniques might appear a little daunting, it can be accomplished with practice. In addition, to effectively use reinforcement, physical therapists need to be mindful of how they interact with patients in treatment sessions and pay particular attention to the behaviors they want to see increase. In particular, therapists should be careful not to unwittingly reinforce the wrong behaviors. For example, a patient with pain may come in concerned that they didn’t feel very motivated to complete their walking exercises that week; the patient might go on to report that they actually were able to do their walking program on 3 days. A therapist might be tempted to immediately focus on the problematic days. However, this adds attention, and likely reinforcement, to the problematic behavior rather than to the patient's successful experiences. A more effective strategy would be to focus on the successful days and then turn to an analysis of the problematic days.

Furthermore, the principle of shaping should be applied when reinforcement is used.^26,27 Shaping involves rewarding successive approximations to a desired longer-term goal. For example, a long-term goal might be for the patient to engage in a program of pain self-management that consists of daily record keeping, practice with relaxation methods, exercise, and pleasant activities goals. Therapist reinforcement might focus initially on the target behavior of keeping daily records and completing 2 elements of the program at least 3 days a week. Later on, reinforcement might be made contingent on completing all elements of the program 4 or 5 days a week, and so on. Finally, the goal of any reinforcement program is to help patients reach the point where their behavior is maintained by reinforcements available in the patient's immediate, natural environment.

Implementing a Treatment Technique or Protocol

One PIP treatment for persistent pain focuses on an individual technique and systematically teaches patients how to apply that technique to manage their pain. Frequently used individual techniques include relaxation training, guided imagery, problem solving, and goal setting. More complex types of PIP consist of formal treatment protocols that provide training in an array of techniques and skills that can be tailored to the particular pain-related challenges a patient is facing. A good example is a treatment protocol that provides training in cognitive (eg, cognitive restructuring and relapse prevention) and behavioral strategies (eg, self-monitoring, goal-setting, using reinforcement principles, and graded activation).

Potential

There is now a large body of research supporting the efficacy of psychological treatments for patients with persistent arthritis, cancer, musculoskeletal (particularly back), migraine headache, and tension headache pain.²⁸ One of the most consistent findings is that psychological techniques provide statistically significant and modest reductions in pain and lead to improvements in other outcomes, such as pain-related interference and depressive symptoms.²⁸ There is evidence that psychological treatments can be successfully integrated in episodes of physical therapy for acute/subacute low back pain²⁹ and, when added to physical therapy for whiplash-associated disorder, accelerate return-to-work rates.³⁰

Challenges

In practice settings, there is often a lack of attention paid to training therapists.^31–33 This is particularly surprising given that physical therapists are often asked to treat a wide variety of patients, many of whom have entrenched and disabling problems in coping with pain. For the latter, a physical therapist who has little background and experience in PIP treatment techniques is likely to have little success. Many patients with longstanding pain problems have experienced multiple treatment failures, including medical and surgical interventions and even behavioral treatments, prior to seeing a physical therapist. Therefore, is it clinically responsible to have someone with minimal training treat such a patient? Moreover, is it ethically appropriate to offer a treatment that is delivered in a manner that is relatively uninformed and likely to fail?

A number of factors likely contribute to the lack of attention given to preparing therapists to deliver PIP treatment techniques or treatment protocols.^31,34 First, some may believe that systematic training is unnecessary; they believe telling therapists what they need to do once or twice is sufficient. Second, others may feel that more systematic training is somehow insulting or embarrassing for experienced therapists. Finally, the costs of more systematic therapist training is a major barrier.^34,35

Strategies for Training Therapists

Despites these obstacles, we recommend systematic training for physical therapists who are delivering PIP treatments. We suggest the following hierarchical 3-step training approach as an overall strategy: a treatment manual, an experiential workshop, and ongoing supervision with consultation and feedback (Fig.2). In this strategy, each step serves as a foundation for the next, and use of multicomponent training elements is more likely to result in positive training outcomes.³¹

Figure 2.

Systematic strategy for training physical therapists in psychologically informed practice. A hierarchy of psychologically informed intervention training should consist of a treatment manual, an experiential workshop, and supervision and monitoring. For the establishment of new training, feedback from mentors and consultants should be a structured part of the process.

Treatment manual

Fundamental to training is the use of a treatment manual that provides a detailed description of the treatment approach.³¹ Treatment manuals are recognized as one of the most important ways of teaching therapists how to integrate empirically validated protocols into clinical practice.³¹ They are usually comprehensive enough to enable practitioners to become familiar with the key components of a treatment. Manuals include a detailed outline or chapters that provide a description of the content of each treatment session; this may take the form of scripts or suggested wording that a therapist can draw from when introducing or implementing a technique. Manuals also usually provide guidelines regarding the amount of time the therapist should spend on each part of a session. Most manuals include clinical tips based on the authors’ experience. These tips can help therapists anticipate and better respond to common issues (eg, resistance to a particular technique, metaphors to help patients understand a concept, and ways to deal with common problems). Treatment manuals usually include handouts that can be used to assist the patient in the learning process. Finally, manuals are increasingly supplemented with video recordings that depict a skilled therapist delivering key components of the intervention (eg, a treatment rationale, guiding a patient through practice of a skill, and problem solving with a patient around challenging situations/difficulties that commonly arise during treatment). Observing a skilled therapist on videotape often conveys many of the subtleties and nuances of treatment delivery that are harder to fully describe in written form.

Experiential workshop

A treatment manual alone is insufficient to enable effective delivery of multicomponent treatment protocols. Thus, an important step in the hierarchy of training methods is an experiential workshop in which participants role-play sections of the manual that have been highlighted by workshop leaders. The workshop itself then focuses on experiential learning—that is, giving participants opportunities to practice key treatment components (eg, guiding a patient through an imagery exercise and providing rationales for the treatment techniques). Also, a behavioral rehearsal approach is used in which an experienced workshop leader briefly (5–10 minutes) models how a skilled therapist might deliver a treatment component by role-playing with an attendee. Attendees then pair off and practice what they just observed, taking turns as the therapist and patient (30 minutes). Workshop leaders circulate to role-players, taking notes. Afterward, workshop leaders and participants share feedback on how the role-plays went. It is important to start with positive feedback on helpful behaviors/strengths observed in the role-plays. Immediate positive reinforcement is one of the best ways to increase the likelihood that such behaviors will be repeated. Only after each dyad has received positive feedback should leaders provide corrective feedback, the initial goal of which is to help participants improve their behavior, not achieve mastery. To do this, workshop leaders often focus on small, achievable steps (eg, work on voice volume and eye contact) and model behaviors. (The principle of shaping is important not only when working with patients, but also when training therapists.) An experiential workshop also provides a useful venue for role-playing how a skilled therapist might deal with especially challenging scenarios (eg, an angry patient), and observing an experienced therapist handle such situations is a useful way of sharing lessons learned and best practices.

Ongoing supervision and consultation

To prevent drift and retain high fidelity, ongoing supervision by an experienced therapist is needed.³¹ As therapists master skills in delivering treatment, these supervision sessions can be reduced in frequency (eg, weekly to monthly to bimonthly). Therapists can attend in person, by phone, or by video. Ongoing supervision is most effective when it is based on direct observation (either by having the supervisor listen to audiotapes or observing segments of treatment sessions). Feedback can then focus on specific behaviors that worked well and areas in need of improvement. Problem-solving methods are used in supervision sessions to encourage therapists to use their own ideas and the resources of the group to brainstorm solutions for common problems. Supervision should emphasize experiential learning with extensive use of modeling and role-playing for challenging issues. Finally, having an experienced consultant available on an on-call basis is an especially valuable resource for clinicians using PIP treatment techniques.³²

Training Strategy Summary

Training models reported in the literature are for individuals participating in clinical trials, and there is growing interest in the best models for training practitioners in empirically validated behavioral treatments.^31,36,37 For example, in the United Kingdom, implementation of the STarT Back Screening Tool (SBST)³⁸ within clinical pathways has been much less of a problem compared with providing adequate therapist training in delivering psychologically informed care based on SBST risk status. Large-scale attempts at implementing the SBST in the United States are ongoing and face the same problem in that it is easier to develop clinical pathways to facilitate screening than it is to develop clinical pathways that deliver psychologically informed care. As we move toward implementation of PIP in practice, the best combination methods for training physical therapists and determining competence have yet to be determined. It is clear that existing educational models will have to change to be consistent with a biopsychosocial model.³⁹ Furthermore, existing training approaches have wide variability in the amount of time needed and in how therapist competence is determined, with no minimal standards established for either of these components. Challenges and opportunities for furthering implementation of PIP by physical therapists are highlighted in Table2. It is beyond the scope of this perspective to go into detail on these challenges and opportunities, but they are provided for readers interested in future directions for advancing PIP into routine clinical practice.

Table 2.

Challenges and Opportunities for Increasing Implementation of Psychologically Informed Practice (PIP) by Physical Therapists.

Area	Strategies
Professional education	Establish Commission on Accreditation in Physical Therapy Education curricular standards for adoption of biopsychosocial models, assessment of psychosocial factors, and treatment strategies
	Identify barriers to and facilitators for professional education from student and faculty perspectives
	Include psychologically informed principles and skills in existing curricula
	Develop faculty with expertise in PIP
	Identify best-practice interprofessional and clinical education models for PIP
Clinical practice and care pathways	Identify barriers to and facilitators for clinical practice from provider and patient perspectives
	Establish PIP certification or credentialing for physical therapists
	Determine appropriate method for providing training feedback sensitive to the scale needed (eg, feasible mentoring and feedback processes)
	Engage and enable clinicians interested in implementing quality improvement initiatives for delivery of PIP
	Develop processes that use electronic health record resources to identify “at-risk” patients and align care with providers who can deliver psychologically informed treatment
	Determine impact of psychologically informed treatment on the care episode (eg, length of individual session, number of sessions per episode, and patient outcomes)
Policy	Educate payers on delivery of PIP by physical therapists
	Develop reimbursement codes that allow for billing of psychologically informed treatment by physical therapists
	Create practice guidelines for PIP that can be used to define best-practice standards
	Determine how PIP patterns affect the value of care pathways for musculoskeletal pain
	Provide payers with data to support cost-effectiveness of PIP

Future Directions

Provider and Patient Receptiveness

What is the impact if a patient expects to receive an entirely physical treatment approach, but the provider wants to incorporate cognitive approaches into the treatment plan? Biopsychosocial treatment underpins modern pain management, and while this approach is acceptable to patients and providers in some cases,⁴⁰ it differs from traditional patient-provider interactions when seeking care for musculoskeletal pain. Mismatches in provider and patient expectations on what constitutes “acceptable” treatment of musculoskeletal pain could hamper the effective delivery of PIP.

Priority: First, clarify how patient and provider treatment expectations (including the interaction of the two) are important mediators of clinical outcomes. Second, develop a “front end” explanation for the clinical appraisal, which successfully paves the way for the PIP approach.

Trigger for Mental Health Referral

Awareness of psychological aspects of musculoskeletal pain naturally leads to questions as to when it is appropriate to include a mental health provider in the care episode, either by comanagement or referral. There is a small subset of patients receiving PIP for musculoskeletal pain that should have mental health provider involvement. There are 3 types of psychological contraindications to the use of PIP. First, the identification of a current mental disorder should trigger a referral for a mental health assessment. Examples include psychotic symptomatology, severe clinical depression, posttraumatic stress disorder, declared suicidal intent, or severe personality disorder (eg, ongoing drug abuse or forensic involvement). If a clinician is uncertain about the significance of psychological symptoms, psychiatric screening tools may be employed to aid clinical decision making. The second contraindication is a patient's inability to participate meaningfully in treatment, as a consequence of intellectual capacity, low health literacy, or marked cognitive dysfunction. Third is a stated unwillingness to participate and engage in self-management once it has been carefully explained. Such statements should be carefully investigated to identify the nature of any concerns about or difficulties in participation, such as fear, misunderstandings, or practical difficulties that might be overcome. The second and third examples should not trigger a referral for mental health assessment in most cases.

Priority: Develop clinical guidelines to clearly operationalize mental health referrals for a non-mental health provider delivering PIP.

Unanswered Questions in the Further Development of PIP

PIP requires consideration of the person's beliefs, expectations, and pain behavior as a template through which the management of pain and pain-associated dysfunction is understood. PIP is firmly based on an understanding of normal human functioning rather than psychopathology. Finally, the context of the intervention is particularly important, and this requires consideration of the determinants of behavior change that influence implementation.

PIP faces the same challenges as all multi-modal interventions, and questions arise not only as to whether it works but how it works. Issues such as treatment specification, influence of PIP on different outcomes, effectiveness, cost, and fidelity of interventions all require further appraisal. Perhapspro tem we could consider a number of specific issues to guide future PIP development.

Dosing of Psychologically Informed Approaches

PIP interventions are often difficult to quantify. This makes it difficult to communicate the amount of treatment delivered and to determine whether parameters for maintaining treatment fidelity have been met. In the aforementioned TARGET trial,⁴ study investigators have provided a conceptual framework on the expected PIP components for physical therapy delivered for acute back pain (Fig.3). For that trial, the psychologically informed physical therapy will consist of pain-coping skills, behavioral-based exercise approaches, traditional impairment-based treatment, and a home program. All of these components are provided within an overall model of patient-centered communication. This framework is helpful in establishing delivery of the PIP approach, but does not establish dosing parameters. There is insufficient information about how much treatment is required and, even more problematically, how to describe the associated duration, intensity, and frequency of PIP interventions.

Priority: Develop ways to systematically define and record common PIP treatment parameters, so that dosing parameters can be appropriately described.

Figure 3.

Overview of key components of psychologically informed physical therapy for the Targeted Interventions to Prevent Chronic Low Back Pain in High Risk Patients trial. With the use of patient-centered communication as the overall model, psychologically informed physical therapy can consist of pain-coping skills, behavioral-based exercise approaches, traditional impairment-based treatment, and a home program. The response to this approach should be monitored and used to determine whether the composition of the psychologically informed physical therapy should be changed.

Treatment Monitoring: When and How Often?

Psychological assessments are often done only at initial encounter and prior to the commencement of treatment with no consideration of how the early response to treatment may impact clinical decision making. There are some data suggesting that additional assessment of pain-associated distress (ie, treatment monitoring) may refine outcome prediction.^41,42 An assessment strategy that includes treatment monitoring of pain-associated distress would allow for changes in treatment approaches if needed. With treatment monitoring, patient responses determine whether the composition of physical therapy should be changed (Fig.3).

Priority: Determine how treatment monitoring can inform clinical decision making not only for outcome prediction, but also for adjustment of PIP treatment approaches to improve the chances of better outcomes.

Role of Treatment Modifiers

Identifying robust treatment modifiers for low back pain has been a challenging exercise.⁴³ Factors, other than pain-associated distress, that increase or decrease the chance of PIP resulting in successful outcomes have only begun to be explored. In a secondary analysis of the SBST trial, investigators found that socioeconomic status, education level, and use of pain medication potentially impacted the chance of responding favorably to the psychologically informed treatment component.⁴⁴ Very little work has been done in this area specific to PIP, and in moving the field forward, it will be important to know which moderating factors limit its overall effectiveness and whether treatments can be adjusted to account for these moderating factors.

Priority: Develop strategies to tailor PIP so that it is responsive to key treatment moderators. As part of this process, a focus on identifying who is likely to benefit may also include consideration of treatment outcome mediators specific to the modifier of interest.

Updated Care Delivery Models

How can PIP be efficiently delivered in existing clinical environments? Current practice guidelines stress nonpharmacological approaches as frontline treatment for low back¹⁵ and chronic pain,⁴⁵ which make PIP a guideline-adherent option. However, structuring care so that these approaches are received early in a care episode can be challenging for many health care systems. Although progress has been made in embedding PIP into treatment pathways in the United Kingdom, the United States model is particularly problematic since many payers do not provide physical therapists or other providers with reimbursement incentives for applying PIP during routine visits.

Priorities: Disseminate information from health care systems and payers that have piloted successful demonstration projects or established best-practice models resulting in the efficient delivery of PIP, and develop a strategy for enabling appropriate reimbursement of PIP as a matter of urgency to better align funding with evidence-based practice.

Conclusion

In this perspective article, we have provided a description of PIP techniques that could be used in routine clinical practice, and we have outlined future directions to advance understanding of PIP as a treatment approach for musculoskeletal pain conditions. We have advocated for PIP as an approach in which optimal pain management is incorporated within a patient-centered model that considers beliefs, expectations, and emotional concerns to inform the design of a reactivation strategy. Such an approach is built around the skills already possessed by physical therapists and is intended to enhance and not supplant existing skills. PIP is supported by the existing evidence we have on the predictors of outcome, and although several challenges remain in its implementation (eg, in terms of training and funding of care), it is sufficiently focused to be able to warrant further research into its application, implementation, and development to improve our ability to provide effective care for musculoskeletal pain conditions.

Author Contributions

Concept/idea/research design: S.Z. George, F.J. Keefe, C.J. Main

Writing: S.Z. George, F.J. Keefe, C.J. Main

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

Funding

While working on this article, Steven Z. George was supported by a grant from the National Institute for Arthritis and Musculoskeletal and Skin Diseases (ref. no. AR055899). The funder played no role in the writing of this Perspective.

Disclosure

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