title: Does Teaching Physical Therapists to Deliver a Biopsychosocial Treatment Program Result in Better Patient Outcomes? A Randomized Controlled Trial Do psychological factors predict outcome in both low-back pain and shoulder pain? How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain It's time for change with the management of non-specific chronic low back pain Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study What is "the good back-consultation"? A combined qualitative and quantitative study of chronic low back pain patients' interaction with and perceptions of consultations with specialists. Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain Do Physical Therapists in the United Kingdom Recognize Psychosocial Factors in Patients With Acute Low Back Pain? Do physical therapists change their beliefs, attitudes, knowledge, skills and behaviour after a biopsychosocially orientated university course? Does physiotherapy management of low back pain change as a result of an evidence-based educational programme?
abstract: Background Psychosocial prognostic factors are important in the development of chronic pain , but treatment providers often lack knowledge and skills to assess and address these risk factors . Objective The aim of this study was to examine the effects on outcomes ( pain and disability ) in patients of a course about psychosocial prognostic factors for physical therapists . Design This study was a r and omized , controlled trial . Setting The setting was primary care practice . Participants Forty-two primary care physical therapists attended an 8-day university course ( over 8 weeks ) aim ed at identifying and addressing psychosocial risk factors . Intervention The physical therapists were r and omly assigned to either the course or a waiting list . They treated consecutive patients with acute and subacute musculoskeletal pain both before and after the course . Measurements We measured physical therapists ' attitudes and beliefs about psychosocial factors , knowledge , and skills before and after the course . We measured patients ' pain , disability , catastrophizing , and mood at the start of treatment and at a 6-month follow-up . Methods The physical therapists were r and omly assigned to either the course or a waiting list . They treated consecutive patients with acute and subacute musculoskeletal pain both before and after the course . Results Pain and disability outcomes in all patients of physical therapists who had participated in the course or in patients at risk of developing long-term disability who had higher levels of catastrophizing or depression were not significantly different from those outcomes in patients of physical therapists who had not participated in the course . Pain and disability outcomes in patients with a low risk of developing long-term disability— and pain outcomes in patients with a high risk of developing long-term disability — were not dependent upon whether the attitudes and beliefs of their physical therapists changed during the course . However , disability outcomes in patients with a high risk of developing long-term disability may have been influenced by whether the attitudes and beliefs of their physical therapists changed . Limitations A limitation of this study was that actual practice behavior was not measured . Conclusions An 8-day university course for physical therapists did not improve outcomes in a group of patients as a whole or in patients with a risk of developing long-term disability . However , patients who had a risk of developing long-term disability and had higher levels of catastrophizing or depression may have shown greater reductions in disability if the attitudes and beliefs of their physical therapists changed during the course Background and Objective : Psychological factors are assumed to predict persistent or recurrent musculoskeletal pain . The influence of psychological factors in patients with low-back pain ( LBP ) or shoulder pain was explored to study whether there is similarity regarding the factors that predict persisting pain and disability . Methods : Patients presenting in primary care with a new episode of shoulder pain or non-specific (sub)acute low back pain ( LBP ) were enrolled in a prospect i ve study . In both patient groups ,  pain catastrophising , distress , somatisation and fear-avoidance beliefs  were measured at baseline . Primary outcome measures at 3 months were ( 1 ) persistent symptoms , and ( 2 ) < 30 % reduction in functional disability .  Multivariate logistic regression analysis was used to study the associations between psychological factors and outcome . Results : A total of 587 patients with shoulder pain and 171 patients with LBP were enrolled in the study . In patients with shoulder pain , most associations of psychological factors with outcome were weak and not significant . Only in patients with longer symptom duration at baseline ( ⩾3 months ) were higher scores on catastrophising significantly associated with persistent symptoms ( p = 0.04 ) . In patients with LBP , psychological factors were more strongly associated with poor outcome , although most associations were not significant . Conclusion : Psychological factors , with the exception of fear-avoidance beliefs , are more strongly associated with persistent pain and disability in patients with LBP than in those with shoulder pain . This seems to indicate that in a primary care population the influence of psychological factors on outcome may vary across patients with different types of pain & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes Background The impact of the relationship ( therapeutic alliance ) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain ( LBP ) has not been previously investigated . Objective The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes . Design This was a retrospective observational study nested within a r and omized controlled trial . Methods One hundred eighty-two patients with chronic LBP who volunteered for a r and omized controlled trial that compared the efficacy of exercises and spinal manipulative therapy  rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session . The primary outcomes of function , global perceived effect of treatment , pain , and disability were assessed before and after 8 weeks of treatment . Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment . Results The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome . The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts ( general exercise versus motor control exercise , spinal manipulative therapy versus motor control exercise ) . There was no treatment effect modification when outcome was measured with function , pain , and disability measures . Limitations Therapeutic alliance was measured at the second treatment session , which might have biased the interaction during initial stages of treatment . Data analysis was restricted to primary outcomes at 8 weeks . Conclusions Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP . Future research should investigate the factors explaining this relationship and the impact of training interventions aim ed at optimizing the alliance Low back pain ( LBP ) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health re sources spent on LBP disorders , the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies , opiod medications , spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach , and evidence that only 8–15 % of patients with LBP have an identified patho-anatomical diagnosis , result ing in the majority being diagnosed as having non-specific LBP.3 Of this population , a small but significant group becomes chronic and disabled , labelled non-specific chronic low back pain ( NSCLBP ) , consuming a disproportionate amount of healthcare re sources .4 1 . Over the past decade , the traditional biomedical view of LBP has been greatly challenged . This is a result of : the failure of simplistic single-dimensional therapies to show large effects in patients with NSCLBP5–8 ; 2 . the results of clinical trials testing commonly prescribed interventions demonstrating that no management approaches are clearly superior5–7 9 ; 3 . the stories of NSCLBP patients relating their own ongoing pain experiences of multiple failed treatments , conflicting diagnoses , lost hope and ongoing suffering10 ; 4 . the indisputable evidence supporting the multidimensional nature of NSCLBP as a disorder , where disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones11 12 ; 5 . positive outcomes in r and omised controlled trials ( RCTs ) are best predicted by changes in psychological distress , fear avoidance beliefs , self-efficacy in Background Musculoskeletal complaints have a significant impact on work in terms of reduced productivity , sickness absence and long term incapacity for work . This study sought to explore GPs ’ and physiotherapists ’ perceptions of  sickness certification in patients with musculoskeletal problems . Methods Eleven ( 11 ) GPs were sample d from an existing general practice survey , and six ( 6 ) physiotherapists were selected r and omly using ‘ snowball ’ sampling techniques , through established contacts in local physiotherapy departments .  Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes . The interviews were audio recorded and transcribed verbatim , following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology , where themes were identified and contrasted between and within both groups of respondents . Results Three themes were identified from the analysis : 1 ) Approaches to evaluating patients ’ work problems 2 ) Perceived ability to manage ‘ work and pain ’ , and 3 ) Policies and penalties in the work-place . First , physiotherapists routinely asked patients about their job and work difficulties using a structured ( protocol -driven ) approach , whilst GPs rarely used such structured measures and were less likely to enquire about patients ’ work situation . Second , return to work assessment s revealed a tension between GPs ’ gatekeeper and patient advocacy roles , often resolved in favour of patients ’ concerns and needs . Some physiotherapists perceived that GPs ’ decisions could be influenced by patients ’ dem and for a sick certificate and their close relationship with patients made them vulnerable to manipulation . Third , the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption , and over which GPs and physiotherapists could exercise only limited control . Conclusion We conclude that healthcare professionals need to take account of patients ’ work difficulties , their own perceived ability to offer effective guidance , and consider the ‘ receptivity ’ of employment context s to patients ’ work problems , in order to ensure a smooth transition back to work OBJECTIVE To identify core elements of what patients with chronic low back pain perceive as good clinical communication and interaction with a specialist ( " The Good Back-Consultation " ) . DESIGN Qualitative study including observation of consultations and a subsequent patient interview . Quantitative data were also recorded . SUBJECTS Thirty-five patients with chronic low back pain referred to a specialist . METHODS Thirty-five consultations were observed with respect to history-taking , clinical examination and interaction between patient and doctor . Patients were subsequently interviewed about how they perceived the consultation . Fourteen specialists with various specialty branches and 35 patients ( 18 males ) participated . For 3 of the specialists a positive effect ( return to work ) on patients with chronic low back pain had been documented in previous r and omized controlled trials . Qualitative data analysis was performed using a template method . RESULTS Most patients thought that the history-taking and clinical examination had been thorough and satisfactory . Patients emphasized the importance of being given an explanation during the examination of what was being done and found , of receiving underst and able information on the causes of the pain , of receiving reassurance , discussing psychosocial issues and discussing what can be done . The most important characteristic of " The Good Back-Consultation " was that the specialist took the patient seriously . CONCLUSION The findings may represent an important potential for enhancing clinical communication with patients Study Design . We conducted an observational study using mailed question naires to 3 r and om sample s of general practitioners from Victoria and New South Wales , Australia in 1997 , 2000 , and 2004 . Objective . To determine whether general practitioners ’ beliefs about low back pain ( LBP ) differ according to whether they have a special interest in back pain , musculoskeletal , or occupational medicine ; and whether these beliefs are modified by having had continuing medical education ( CME ) about back pain in the previous 2 years . Summary of Background Data . Physician surveys continue to demonstrate that general practitioners only partially manage LBP in an evidence -based way . Identified barriers to changing physician behavior , in regard to management of back pain , have included patient factors such as their past back pain experiences and preferences for care as well as physician beliefs about the association of pain and activity ; although the influence of physician special interests has not been studied . Methods . Back pain beliefs of different subsets ( special interests vs. no special interests and CME vs. no CME ) were compared using relative risks ( RRs ) adjusted for state and survey . The analysis was then repeated including all special interests and recent back pain CME in the model . Results . Responses were received from 3831 general practitioners ( overall response rate [ RR ] : 38.2 % ) . Physicians with a special interest in LBP were more likely to believe that complete bed rest and avoidance of work is appropriate for acute low back pain ( RR : 1.89 [ 95 % CI : 1.53–2.33 ] and 1.55 [ 95 % CI : 1.31–1.83 ] , respectively ) and lumbar spine radiographs are useful ( RR : 1.36 [ 95 % CI : 1.21–1.51 ] ) . The disparity between those with and without a special interest in LBP was still evident after adjusting for the presence of other special interests and recent CME . After adjusting for the presence of other special interests and recent CME , therewere no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine , while those with a special interest in occupational medicine and those who had received recent CME had better beliefs . Conclusion . A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence . This has serious implication s for management of back pain in the community Study Design . A cross-sectional , descriptive vignette survey of practicing , musculoskeletal physical therapists . Objectives . The aim of this study was to determine if musculoskeletal physical therapists , in the United Kingdom , recognize when patients with low back pain ( LBP ) are at risk of chronicity due to psychosocial factors . A secondary aim was to explore the advice they give to patients about  work and activities .  Summary of Background Data . Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability . Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention . Methods . Three vignettes were written based on acute LBP patients attending for physical therapy  and incorporated into a self-completed postal question naire sent to a simple r and om sample of musculoskeletal physical therapists in the United Kingdom ( n = 900 ) . After one reminder , 20 % of nonresponders were sent a further question naire ( n = 80 ) . Data were analyzed using the Statistical Package for the Social Sciences ( SPSS version 11 ) . Results . The response rate was 57.7 % ( n = 518 ) with 453 meeting all inclusion criteria . The sample consisted of physical therapists working in the musculoskeletal field across all practice setting s. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes . Advice to restrict work and activity was common . Conclusions . Most physical therapists recognize when patients are at high risk of developing chronicity , yet many recommend the patient limit their activity levels and not work . Advice to “ not work ” is associated with more severe perceived spinal pathology , suggesting persistence of the biomedical model for LBP AIM The aim of this study is to examine the effects of an 8-day university-based training course , aim ed at identifying and addressing psychosocial prognostic factors during physiotherapy treatment , in shifting therapists towards a more biopsychosocial orientation as measured by changes in beliefs/attitudes , knowledge , skills and behaviour . METHOD We combined a r and omized controlled trail with a pre-post design . Forty-two physiotherapists applied for a university-accredited training course design ed to enhance knowledge and management of psychosocial factors in their practice with patients suffering from musculoskeletal pain . The course participants were r and omized either to receiving the course or to a waiting list for training . Attitudes and beliefs towards , and knowledge of psychosocial factors , patient vignettes and a video of an imaginary patient were tested before and after training . The patients of the course participants were asked to fill out a question naire with background questions at treatment start . The patients also received a question naire about the physical therapists ' behaviour and patient satisfaction 6 weeks after treatment start . RESULTS The results show that physical therapists ' attitudes and believes became more biopsychosocially and less biomedically orientated , they were less convinced that pain justifies disability and limitation of activities , and their knowledge and skills on psychosocial risk factors increased after a university-accredited training course . Yet despite these changes their patients perceived their practice behaviour before and after the course as similar and were equally satisfied with their treatment and treatment result . CONCLUSION A course , which enhanced biopsychosocial attitudes and beliefs , as well as increased such knowledge and skills did not change the way patients perceived their physical therapists . A future question is whether it improves patient outcome RATIONALE The concept of evidence -based medicine is important in providing efficient health care . The process uses research findings as the basis for clinical decision making . Evidence -based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide . Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence . The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed . AIMS The aim of this study was to investigate if physiotherapists ' clinical management of patients with low back pain would change following an evidence -based education package , which utilized local opinion leaders and delivered the best evidence . METHOD Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster r and omized by location of work , to two groups . The intervention group received an evidence -based programme on the management of low back pain , including advice regarding increasing activity levels and return to normal activity and challenging patients ' fears and beliefs about their pain . The control group received a st and ard in-service training package on the management of common knee pathologies . The physiotherapists ' clinical management of patients with low back pain was measured prior to training and 6 months post training . Outcome measures were based on physiotherapists completing ' discharge summary ' question naires , which included information relating to the use and importance of therapies for treating their low back pain patients . RESULTS There were few significant differences in treatment options between the intervention and control groups post training . Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain , there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention . CONCLUSIONS Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain . This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice . Whilst there were some limitations in the overall size of the study , the results help to give an insight into the challenges faced by the health care system and research ers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care
target: Physiotherapists partially recognised cognitive , psychological and social factors in people with LBP .
  Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP , and some stigmatised the behaviours suggestive of cognitive , psychological and social contributions to LBP .
  Physiotherapists perceived that neither their initial training , nor currently available professional development training , instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP .
background: QUESTION What are physiotherapists ' perceptions about identifying and managing the cognitive , psychological and social factors that may act as barriers to recovery for people with low back pain ( LBP ) ?