Confidence key to implementing PIPT for low back pain

Photo: Photo by Jesper Aggergaard A recent study investigating the attitudes of physiotherapists in relation to psychologically informed physical therapy (PIPT) to treat low back pain (LBP) reveals that confidence may be key in delivering better patient outcomes.

In Australia, low back pain (LBP) is the most common musculoskeletal complaint observed in general practice, impacting the lives of up to one in seven and one in four Australians at any given time.

A 2019 study published in the Journal of Musculoskeletal Care examined the relationship between physiotherapists’ attitudes and beliefs about PIPT for low back pain and their treatment of clients with this complaint.

In the study, 32 musculoskeletal physiotherapists, including 17 women and 15 men, employed at NHS Trust in the United Kingdom, were interviewed to gauge their level of understanding, ability to implement and confidence in using PIPT in treatment.

The questionnaire was delivered via an anonymous electronic survey, whereby participants were asked to reflect on clients who experienced LBP that lasted more than 12 weeks, with or without sciatica, and without red flags or signs of serious pathology.

The study recorded and evaluated the following:

> General information about each physiotherapist

A Likert scale to assess each physiotherapist’s thoughts and opinions about psychologically informed physical therapy approaches and other treatment methods

A 19‐item modified Pain Attitudes and Belief Scale, (PABS) to categorise physiotherapists as having a biomedical or biopsychosocial treatment orientation

The results of the survey revealed that while most physiotherapists value the use of psychological techniques, there are barriers to implementing these methods to treat clients in their practice.

The study found that all physiotherapists recognised that psychological approaches were important in the management of LBP, with 18 regarding them as extremely important, and 11 as very important.

Moreover, most of the physiotherapists surveyed believed they understood PIPT, with four rating their understanding as very good, 16 as good, seven as fair, and only four rated their understanding as poor.

However, despite a high level of understanding of PIPT, more than two-thirds (23 out of 32) of the physiotherapists said they were somewhat, slightly, or not at all confident to use psychological techniques as part of physical therapy.

Australian Physiotherapy Association (APA) Pain Physiotherapist Tyne Timmers said low back pain and other musculoskeletal injuries are traditionally treated within a biomedical model, which is underpinned by a belief that pain and injury are caused by a pathoanatomical disorder.

“This is an overly simplistic view, and reductionistic in nature.

“Only 15 per cent of people with low back pain have an identified pathoanatomical diagnosis, with the others grouped into non-specific low back pain,” said Mr Timmers.

The majority of these cases are likely associated with cognitive and behavioural aspects of pain, rather than sensory of biomedical ones and may be better treated with PIPT.

As a result, "treatment options are more closely correlated to changes in fear-avoidance beliefs, pain self-efficiency, psychological distress and coping strategies, as opposed to biomedical ones such as increased core strength and flexibility," said Mr Timmers.

Sports Physiotherapist Clare Singleton uses PIPT to address the psychological, social and environmental factors that contribute to pain in her patients.

However, the ability to implement psychological techniques requires identifying the psychological contributors to a patient’s pain presentation.

“One way of identifying these contributors is to use an Orebro Musculoskeletal Pain Screening Questionnaire to uncover potential psychological and social factors.

“Then integrate the evidence gathered from the patient interview and physical assessment with the information from the psychological screening.

“Both client and clinician work together in a collaborative approach and agree on goals of treatment and responsibilities of each party.

“When catastrophising or fear avoidance is recognised, explore the patient’s beliefs and identify how they fit within the presentation of the patient’s pain.

“Lastly, utilise graded exercise or activity as a treatment technique, which involves finding a patient’s baseline of activity by having them perform the activity within pain limits.

“Activity is then gradually increased from this baseline, utilising a strategy known as pacing.

“In this approach, pain is not used as a determining factor of the activity,” said Ms Singleton.

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