Use of Mental Health Interventions by Physiotherapists to Treat Individuals with Chronic Conditions: A Systematic Scoping Review

Abstract

Purpose: Physiotherapists work with people with chronic conditions and can act as catalysts for behavioural change. Physiotherapy has also seen a shift to a bio-psychosocial model of health management and interdisciplinary care, which is important in the context of chronic conditions. This scoping review addressed the research question “How do physiotherapists use mental health–based interventions in their treatment of individuals with chronic conditions?” Method: The Embase, MEDLINE, PsycINFO, and CINAHL databases were searched, and a variety of study designs were included. Data were categorized and descriptively analyzed. Results: Data were extracted from 103 articles. Low back pain (43; 41.7%) and non-specified pain (16; 15.5%) were the most commonly researched chronic conditions, but other chronic conditions were also represented. Outpatient facilities were the most common setting for intervention (68; 73.1%). A total of 73 (70.9%) of the articles involved cognitive–behavioural therapy, and 41 (40.0%) included graded exercise or graded activity as a mental health intervention. Conclusions: Physiotherapists can use a variety of mental health interventions in the treatment of chronic conditions. More detailed descriptions of treatment and training protocols would be helpful for incorporating these techniques into clinical practice.

Physiotherapists are primary health care providers who play an important role in preventing and managing chronic diseases in Canada. As experts in exercise and education, they are able to increase individuals’ confidence in their ability to be physically active, leading to positive health outcomes such as decreased pain and shortness of breath and increased health-related quality of life in people with chronic diseases.¹

Although physiotherapists are typically trained to look at physical conditions from an anatomical or structural perspective, there has been a recent shift in approach to one that applies the bio-psychosocial model of management, which stresses the importance of psychosocial factors in developing and maintaining physical pathologies.² For example, research has shown that psychosocial factors such as stress, anxiety, poor cognitive functioning, and negative mood or emotions are risk factors for the development and chronicity of low back pain.³ Research has also supported the impact of psychosocial factors on physiotherapy practice and outcomes.² For example, implementing psychologically based behavioural change programmes has been shown to be effective in increasing patients’ adherence to exercise programmes.⁴

Given that exercise programmes are an integral part of physiotherapists’ practice, incorporating these psychologically based behavioural change programmes into their management plans may be an effective treatment strategy.⁴ In addition, psychosocial factors such as fear avoidance, catastrophizing, depression, and anxiety, as well as confidence and self-efficacy, have proved to correlate with the pain and disability outcomes of individuals treated by physiotherapists for low back pain.⁵ Therefore, incorporating both physical and psychological treatment components would contribute to effectively managing chronic conditions using physiotherapy.⁵

These findings have led to research investigating the effectiveness of using mental health interventions, such as cognitive–behavioural therapy (CBT), along with physiotherapy to treat conditions such as chronic low back pain and chronic musculoskeletal pain.^6,7 Several of these studies have shown positive effects on treatment outcomes.^6,8 These interventions are typically delivered in two main models of care. The first is an interdisciplinary team, in which mental health practitioners work with physiotherapists and other team members, such as nurses and physicians, to manage chronic conditions.⁹ The second is a more direct method of delivery in which physiotherapists administer the mental health intervention themselves.⁶

Although the body of literature on the use of mental health interventions alongside physiotherapy is growing, several areas remain to be investigated. The main focus of the literature has been on chronic low back pain and chronic musculoskeletal pain. However, there is also evidence for the importance of psychosocial factors in other chronic conditions commonly treated by physiotherapists, such as post-concussion syndrome and heart disease, but there has been little to no research on how physiotherapists can address these factors.^10,11

In addition, much of the literature lacks the depth of explanation of the treatment protocol that is required to implement treatment techniques that address psychosocial factors in clinical practice. This is reflected in literature investigating the barriers to physiotherapists using bio-psychosocial techniques in practice. For instance, a study by Beissner and colleagues, surveying the use of CBT strategies to manage chronic pain in older adults, found that, although physiotherapists in the United States were interested in implementing CBT strategies, one of the main barriers was insufficient knowledge of the techniques.⁷ In addition, a systematic review by Gray and Howe identified that most physiotherapists accepted the need to identify psychosocial variables, but they did not adequately manage these factors in individuals with back pain.¹² These authors also found that physiotherapists who had more extensive training in managing psychosocial factors were more likely to be practising these strategies.¹² These findings support the need for knowledge translation: moving this research into the hands of physiotherapists so that they can address psychosocial factors in practice.

In summary, we identified two important gaps in the literature on incorporating mental health practices into physiotherapy for chronic conditions: (1) the lack of research into chronic conditions other than low back pain and chronic musculoskeletal pain and (2) the disconnect for physiotherapists between knowing that psychosocial factors play an important role in chronic conditions and not understanding how to address them in physiotherapy interventions. As a result, this scoping review aimed to answer the research question “How do physiotherapists use mental health-based interventions to treat individuals with chronic conditions?”

No ethics approval was sought for this study because the data were publicly available.

Methods

We conducted a scoping review to describe the relevant scientific literature on how physiotherapists incorporate mental health strategies into clinical practice when treating people with chronic conditions. Scoping reviews allow researchers to find gaps in the literature, and they give an overview of a topic in a particular research area by incorporating a wide range of study designs.^13,14 A scoping review can also provide a method of analytically reinterpreting a research topic; mapping key concepts about a research topic; and providing findings to interested consumers, practitioners, and policy-makers who can use information to make decisions.¹³

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines.¹⁵

Identification and selection of articles

We searched the Embase, MEDLINE, PsycINFO, and CINAHL databases using the following search terms: (physiotherap* OR physical therap* OR exercise therap*) AND (mental health OR cognitive therap* OR behavioural therap* OR behavioral therap* OR cognitive behavioural therap* OR cognitive behavioral therap* OR CBT or Psych*) AND (intervention* OR treatment* OR therap* OR program* OR promotion OR prevention) AND (chronic OR persistent OR long-term OR lingering OR recurrent) AND (condition OR pain OR dysfunction OR function OR disability OR impairment OR disease). The final search was conducted on May 14, 2018.

Inclusion of relevant articles

To capture all relevant research articles and to identify possible trends in the literature, we did not place any limits on date of publication or age of participants. We used RefWorks (ProQuest LLC, Ann Arbor, MI), a bibliographic software package, to manage the articles from the different databases and to select articles for review. Inclusion criteria were articles written in English that included a physiotherapy intervention and a mental health intervention administered alongside each other to treat people with chronic conditions. We defined physiotherapy intervention as any treatment administered by a physiotherapist in any clinical setting. A mental health intervention consisted of behavioural, cognitive–behavioural, or any psychological intervention used alongside physiotherapy. A chronic condition was any musculoskeletal, neurological, cardiovascular, metabolic, endocrinal, psychological, or multi-system condition that had persisted for 3 or more months. We included journal articles of any study design. Finally, we screened the reference lists of the included articles to find additional potential articles.

Exclusion criteria were as follows: articles not in English; articles not peer reviewed; articles that used only a physiotherapy intervention or only a mental health intervention but not both; articles that addressed an acute or subacute condition (< 3 mo); and articles whose full content was not accessible through the database, through the McMaster University library, or through an online search.

We randomly selected 30 articles and reviewed titles and abstracts to standardize what articles to include or exclude. We discussed any discrepancies until we reached consensus. To address the research question more specifically, we conducted a second title and abstract screen to include only articles in which a physiotherapist had been involved in providing the mental health intervention or the mental health intervention had occurred concurrently during a physiotherapy session.¹⁶

Data extraction

We used a process of charting and sorting material according to key issues and themes, as proposed by Arksey and O’Malley.¹³ We developed a data charting form using Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA) for data extraction. We all reviewed five randomly selected articles for data charting to establish uniform data charting methods. We also discussed discrepancies and reached decisions on data chart themes through consensus. The final data chart gathered together information about each study: author, journal, year, country, type of study, type of chronic condition, population, setting, and purpose. The chart then provided information about the research question, including a description of the interventions used (type of mental health intervention, type of physiotherapy intervention, description of intervention, frequency of intervention, duration of intervention, duration of follow-up), other treatment providers involved (co-treatment providers), how the physiotherapists interacted with these co-treatment providers (communication among team members), and whether the studies had noted any limitations in the treatments provided (potential harms). Finally, any other relevant information about the study was included under Notes.

Data analysis

We coded and analyzed the data descriptively.

Results

After performing the initial search, we identified 9,490 articles. After we removed duplicates and performed the title and abstract screen, 139 articles remained. Full-text screening removed 40 articles, and 4 were added from the reference lists of the included articles. A total of 103 articles were included in this scoping review. (Figure 1 provides a PRISMA chart of this process, and the online Appendix provides all the data we collected about the articles.)

Figure 1 .

PRISMA chart of the scoping review.

PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

General characteristics of included studies

The 103 publications showed a trend toward using mental health strategies in physiotherapy. Only 6 articles published before 2000 were identified, but 33 articles were published from 2015 to 2018. The greatest number of publications occurred in the United Kingdom (25; 24.3%), followed by Sweden (14; 13.6%), the Netherlands (11; 10.7%), Australia and Norway (each 9; 8.7%), and the United States (8; 7.8%). Studies included randomized controlled trials (48; 46.6%), followed by qualitative studies (23; 22.3%), non-randomized intervention studies (21; 20.4%), systematic reviews (6; 5.8%), observational studies (4; 3.9%), and a clinical commentary (1; 1.0%). Outpatient facilities were the primary locations used for the intervention studies (68 of 93; 73.1%). In 19 studies, the setting was not specified. (See Table 1.)

Table 1 .

Characteristics of Included Studies (N = 103)

Characteristic	No. of studies (%)
Year of publication
2015–2018	33 (32.0)
2010–2014	34 (33.0)
2005–2009	20 (19.4)
2000–2004	10 (9.7)
1995–1999	5 (4.9)
1990–1994	1 (1.0)
Country of publication
United Kingdom	25 (24.3)
Sweden	14 (13.6)
The Netherlands	11 (10.7)
Australia	9 (8.7)
Norway	9 (8.7)
United States	8 (7.8)
Canada	3 (2.9)
China	2 (1.9)
Denmark	2 (1.9)
Germany	2 (1.9)
Italy	2 (1.9)
Spain	2 (1.9)
Austria	1 (1.0)
Bahrain	1 (1.0)
Belgium	1 (1.0)
Brazil	1 (1.0)
Other	7 (6.8)
Unknown	3 (2.9)
Type of publication
Randomized controlled trial	48 (46.6)
Qualitative study	23 (22.3)
Non-randomized intervention study	21 (20.4)
Systematic review	6 (5.8)
Observational study	4 (3.9)
Clinical commentary	1 (1.0)
Setting of intervention studies (n = 93)
Outpatient (physiotherapy clinic, community centre, rehabilitation centre, primary care facility, doctor’s office, psychiatric clinic, chronic pain clinic, university facility, not specified)	49 (52.7)
Outpatient hospital	19 (20.4)
Not specified	19 (20.4)
Online	2 (2.2)
Inpatient	2 (2.2)
Other	2 (2.2)

Note: Percentages may not total 100 because of rounding.

Characteristics of participants

Almost two-thirds of the studies involved adults aged 18 years or older (67; 65.0%), and almost a third specifically involved adults aged 65 years or older (31; 30.1%). In seven (6.8%) articles, physiotherapists were the population of interest. Chronic conditions represented included low back pain (43; 41.7%); chronic pain with an unspecified location (16; 15.5%); chronic neck pain, chronic musculoskeletal pain, and chronic fatigue (each 7; 6.8%); osteoarthritis (4; 3.9%); chronic pelvic pain and chronic whiplash-associated disorder (each 3; 2.9%); chronic spinal pain and multiple sclerosis (each 2; 1.9%); and chronic shoulder pain, chronic facial pain, degenerative disc disease, fibromyalgia, obesity, cancer, and cerebral palsy (each 1; 1.0%). (See Table 2.)

Table 2 .

Characteristics of Participants in Included Studies (N = 103)

Characteristic	No. of studies (%)
Chronic condition
Chronic low back pain	43 (41.7)
Chronic pain (unspecified)	16 (15.5)
Chronic neck pain	7 (6.8)
Chronic musculoskeletal pain	7 (6.8)
Chronic fatigue	7 (6.8)
Osteoarthritis	4 (3.9)
Chronic pelvic pain	3 (2.9)
Chronic whiplash associated disorder	3 (2.9)
Chronic spinal pain	2 (1.9)
Multiple sclerosis	2 (1.9)
Chronic shoulder pain	1 (1.0)
Chronic facial pain	1 (1.0)
Degenerative disc disease	1 (1.0)
Fibromyalgia	1 (1.0)
Obesity	1 (1.0)
Cancer	1 (1.0)
Cerebral palsy	1 (1.0)
Various	2 (1.9)
Population*
Adults, aged ≥ 18 y	67 (65.0)
Older adults, aged ≥ 65 y	31 (30.1)
Age not specified	17 (16.5)
Physiotherapists	7 (6.8)
Adolescents, aged 12–18 y†	5 (4.9)
Women	2 (1.9)
Allied health professionals	1 (1.0)
Canadian Armed Forces personnel	1 (1.0)
Children aged < 12 y	1 (1.0)

^*Some articles described more than one population.

^†Two studies considered adulthood to begin at age 16 y.

Characteristics of interventions

The most common mental health intervention used by the physiotherapists was CBT (73; 70.9%) followed by graded exercise or activity (41; 40.0%). Additional strategies used in interventions described as CBT by the study authors were cognitive restructuring, countering negative thoughts, providing graded exposure to previously feared activities, promoting positive coping strategies, giving positive reinforcement, and prescribing time-contingent rather than pain-contingent exercise.^17–20 Various combinations of mental health interventions were also used; the most common examples were CBT plus graded exercise (23; 22.3%) and CBT plus graded exposure (8; 7.8%). (See Table 3.)

Table 3 .

Characteristics of Interventions in Included Studies (N = 103)

Characteristic	No. of studies (%)
Type of mental health intervention*
CBT	73 (70.9)
Graded exercise or activity	41 (40.0)
Graded exposure	14 (13.6)
Acceptance and commitment therapy	4 (3.9)
Motivational interviewing	3 (2.9)
Other (ego-strengthening psychotherapy, Feldenkrais Method, Mensendieck somatocognitive therapy, Norwegian psychomotor physiotherapy, psychologically informed practice, psychomotor approach, psychosomatic approach, social cognitive theory)	8 (7.8)
Combined mental health interventions†
CBT + graded exercise	23 (22.3)
CBT + graded exposure	8 (7.8)
Graded exercise + graded exposure	3 (2.9)
CBT + graded exercise + graded exposure	2 (1.9)
Other + graded exercise	1 (1.0)
Type of physiotherapy intervention‡
Exercise	94 (91.3)
Other (exercise + manual therapy, hydrotherapy, relaxation, electrotherapy, acupuncture, or education)	12 (11.7)
None	5 (4.9)
Various other	3 (2.9)
Co-treatment provider (N = 9)
Psychologist	7 (77.8)
Occupational therapist	1 (11.1)
Gynecologist	1 (11.1)

^*Some articles included more than one mental health intervention.

^†Some articles include more than one combined intervention.

^‡Some articles included more than one physiotherapy intervention.

CBT = cognitive–behavioural therapy.

Other mental health interventions used by the physiotherapists were acceptance and commitment therapy (4; 3.9%); motivational interviewing (3; 2.9%); and ego-strengthening psychotherapy, the Feldenkrais Method, Mensendieck somatocognitive therapy, Norwegian psychomotor physiotherapy, psychologically informed practice, psychomotor approach, psychosomatic approach, and social cognitive theory (each 1; 1.0%). The majority of physiotherapy interventions delivered consisted of exercise (94; 91.3%) or exercise in combination with another type of intervention, such as manual therapy, hydrotherapy, relaxation, electrotherapy, acupuncture, or education (12; 11.7%).

Of the articles that focused on the physiotherapist’s training in and implementation of mental health interventions, the techniques investigated were CBT (5 of 7) and acceptance and commitment therapy (2 of 7).

Some interventions had participants partaking in one to three sessions per week for 2–30 weeks (35 of 93 intervention studies; 37.6%). In 10 studies, the participants were involved in 20–30 hours of intervention time for a shorter duration, approximately 2–5 weeks. The intervention frequency, duration, or both were not specified or varied in most studies. Finally, collaboration with other health care providers during the physiotherapy session was reported in 9 studies, with a psychologist being the most common professional working alongside the physiotherapist (7; 77.8%).

Discussion

Main findings

This scoping review included 103 articles. Physiotherapists most often used graded approaches to provide exercise and activity training for individuals with chronic conditions, and graded exercise and activity were included in interventions that were broadly described as CBT. Along with other strategies, this reveals the diversity of CBT-based approaches that physiotherapists can use to support individuals with chronic conditions. Also, as this article emphasizes, many other mental health strategies are used along with physiotherapy. However, detail was lacking as to how these techniques were specifically implemented during a treatment session.

The literature revealed that most of the research inquired into the physiotherapists’ use of mental health strategies combined with exercise programmes; however, in a few cases, mental health techniques were combined with adjunct treatment methods such as manual therapy and electrotherapy, hydrotherapy, or acupuncture. The findings perhaps represent how the physiotherapy profession has evolved in recent years to provide more holistic care rather than focusing solely on the physical rehabilitation of injuries.

The chronic conditions that most physiotherapist-led mental health interventions were associated with are chronic low back pain and other types of chronic pain. Because of the psychological nature of pain, the need for a cognitive–behavioural approach to pain management in physiotherapy practice is warranted.²¹ Starting a new routine often requires a change in behaviour and the dissociation of fear from movement when there is pain present. However, this study adds other conditions that may be worth considering for a more holistic approach to care, such as obesity and chronic fatigue.

The literature also revealed that physiotherapists often implemented the mental health strategies independently, even when working as part of a larger multidisciplinary team. In the instances in which a physiotherapist collaborated with another health care professional, that professional was often a psychologist, and in two studies the physiotherapist was supervised by a psychologist.^22,23

The methodological strengths of this scoping review are its broad literature search and our consensus-building strategies. In addition, we had both content and method experts on the team, which was beneficial when interpreting the literature.

Fit in the literature

From our literature search, we identified multiple systematic reviews that investigated the effectiveness of physiotherapist-led cognitive or behavioural interventions for individuals with chronic pain.^24–29 A recent systematic review explored the effectiveness of physiotherapist-led CBT interventions for low back pain, concluding that compared with education or exercise alone, cognitive–behavioural interventions had a greater effect on reducing disability and pain and improving quality of life.²⁶ However, as with our scoping review, those authors found that there was inadequate detail about how the interventions were implemented, leading to an inability to replicate them in clinical practice.²⁶

A strategy used by physical therapists in Scandinavian mental health settings includes basic body awareness therapy, which incorporates the mind and body in slow movements and awareness of postural stability and breathing within the flow of movements. This approach, or similar ones, have been used in a number of mental health and chronic pain conditions.^30–33 However, no research using these techniques was found from Canada.

Implications for practice

Physiotherapists can provide many mental health interventions autonomously; however, practitioners have identified potential barriers that may prevent them from doing so: having insufficient knowledge about how to use mental health strategies with their clients, a lack of time, and problems with being reimbursed.⁷ These barriers can all be dealt with to improve access to these services. A potential challenge in implementing these strategies is that they often involve exposing individuals’ emotions and targeting feared situations, which may result in patients disengaging from these types of treatments.^7,34 Therefore, physiotherapists may need to consider seeking additional training to conduct mental health interventions.

This review included recent qualitative research on the training that physiotherapists had received in the use of specific mental health interventions.^35–37 This research demonstrated a potential need for physiotherapists to obtain further training so that they could use these treatment strategies effectively. Alternatively, physiotherapy educators could consider whether training in applying mental health strategies is included in their educational programmes and, if not, whether it should be and how to incorporate it. We did not collect data about whether the physiotherapists had received formal training in the mental health strategies they were implementing, but some articles reported that physiotherapists had in fact received extensive training.^{20,23,38–45}

From a practical perspective, physiotherapy works best when patients are able to carry out the recommended activities or exercises. There are many barriers to changing behaviours and therefore to optimally implementing physiotherapy recommendations. Using mental health or integrated strategies alongside traditional physiotherapy can help address patients’ fear and other possible barriers. This study shows that physiotherapists can use a variety of strategies to support their patients with chronic conditions. The positive effects of these approaches on patient and provider satisfaction, along with positive changes in outcomes, are important for a physiotherapy practice to consider when deciding whether to invest time and resources in training and to provide these mental health strategies.

Implications for research

One of the primary reasons why articles were excluded in the title and abstract screen was that they did not make it clear which health care provider was implementing the mental health intervention when a physiotherapist was part of a multidisciplinary team. Future research should ensure that the specific strategies used by each health care provider are documented; however, word counts and other publishing constraints can limit this important knowledge translation piece. Future research could also examine the difference between the effectiveness of interventions delivered by physiotherapists who have received formal training in mental health strategies compared with those who have not.

Techniques that incorporate mind and body using a structured approach, such as basic body awareness therapy, are not represented in Canadian research. Attitudes toward and acceptance of these techniques by Canadian physiotherapists and the public are unknown. Thus, whether these or any other mental health strategies are included in Canadian physiotherapy training, and to what extent, could be an interesting avenue of study.

Our review focused on the use of mental health interventions in chronic conditions. As a result, it identified one study in which physiotherapists had implemented mental health strategies for individuals with obesity, the purpose being to prevent the development of secondary chronic conditions.⁴⁶ Future research could investigate physiotherapists’ use of mental health interventions for the primary and secondary prevention of chronic disease.

This scoping review had several limitations. First, it focused on conditions that were chronic; thus, it excluded subacute and acute conditions. Although this approach may have missed a portion of the literature on how physiotherapists are currently implementing mental health interventions, we believe that there is a greater argument for using these interventions for individuals with chronic conditions because of their association with psychological factors such as fear-avoidance beliefs and pain catastrophizing.⁴⁷ Second, because of the large body of research that was returned by our literature search, grey literature was not accessed.

In addition, “motivational interviewing” was not used in our search string; however, a few studies that used this technique as a mental health intervention were returned in the results and included in this scoping review.^48–51 Finally, when completing the title and abstract screen, we noticed that many articles appeared to be relevant to our research question, but they were written in languages foreign to us, most notably in German.

Conclusion

The most common forms of mental health interventions used by physiotherapists in the literature are CBT techniques, usually in the form of graded activity, graded exercise, or graded exposure. These techniques are most often combined with physiotherapy exercise programmes to treat people with chronic low back pain or chronic pain. Many studies lacked the depth of information that would be required to replicate them. Future research should focus on providing more comprehensive descriptions of training protocols and interventions so that other clinicians can integrate them into their clinical practice. Studies on the use of mental health strategies in physiotherapy for other chronic conditions and for primary and secondary prevention could be fruitful.

Key Messages

What is already known on this topic

Physiotherapists are on the front line of treating people with chronic conditions. Fear avoidance, catastrophizing, depression, and anxiety, as well as confidence and self-efficacy, have proved to correlate with the pain and disability outcomes of individuals treated by physiotherapists for low back pain.⁵ Using mental health strategies such as CBT can help treat chronic pain.^6–8 Therefore, incorporating both physical and psychological treatment components can contribute to effectively managing chronic conditions using physiotherapy.⁵

What this study adds

Our scoping review adds to the current literature because we took a broad approach: including all chronic conditions and a variety of study designs to gain a better understanding of how physiotherapists are implementing mental health interventions in various practice settings.