Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

Figures & data

Table 1. Inclusion and exclusion criteria.

Element	Inclusion criteria	Exclusion criteria
Population	The approach recommended is specifically recommended for physiotherapists to use with clients experiencing psychological distress. If published in a physiotherapy journal it is assumed that it is recommended for physiotherapists unless otherwise stated.	May mention health professionals in general but the approach does not specifically mention relevance for physiotherapists.
Concept	Discusses an approach that is consistent with the VandenBos (2015) definition of an approach.	Discusses an approach that does not provide guidance for assessing and managing clients experiencing psychological distress.
	Discusses an approach that provides guidance on assessing and managing clients experiencing psychological distress or mental disorders
Context	Discusses an approach relevant to an area of clinical physiotherapy practice.	Discusses an approach relevant to non-clinical areas of physiotherapy practice (e.g. clinical educators identifying distress among physiotherapy students)
	Published between 1/1/1990 and 30/05/2023 inclusive.
Type of literature	Secondary or tertiary literature (e.g. reviews, clinical practice guidelines, masterclasses, and commentaries) Literature which has been published in an academic journal.	Original research articles (e.g. trials, observational studies, and case reports). Literature which has not been published in an academic journal, such as magazine articles, news articles, books and book chapters,
Practical Considerations	Full text available online. Published in English.

Table 2. Search terms.

Concept	Search terms
Physiotherapist	Physical therapist, Physiotherapy, Physical therapy
Psychological Distress	Emotional distress, mental distress, distress, depression, anxiety, suicide, nonsuicidal self-injury, mental health, mental disorder, mental illness
Approach	Guideline, guide, protocol, pathway, screen, assessment, management, tool, instrument, questionnaire, referral, decision making

Table 3. Search strategy for Medline ALL on the Ovid platform.

Query
1	(Physiotherap* or “Physical therapy” or “Physical therapist” or “Physical therapists”).tw. or (exp Physical Therapists/)
2	(distress* or depress* or anxi* or suicid*, “self-injury,” “self-harm” or “mental health” or “mental illness” or “mental illnesses” or “mental disorder” or “mental disorders” or “psychosocial factor” or “psychosocial factors” or “psychological factor” or “psychological factors”).tw. or (exp Psychological Distress/or exp Depression/or exp Anxiety/or exp Self-Injurious Behavior/or exp Mental Health/)
3	(guide* or protocol* or pathway* or screen* or assess* or manag* or tool* or instrument* or questionnaire* or refer* or “decision making”).tw. or (exp disease management/or exp Practice Guidelines as Topic/or exp risk assessment/or exp Decision Making/or exp Mass Screening/or exp Surveys and Questionnaires/or exp Referral and Consultation/)
tw = Text Word (title and abstract); exp = Exploded Subject Heading. The Boolean operator “and” combined queries 1 and 2 and 3. Limiters of publication date (1/1/1990 to 30/05/2023 inclusive) will be used. Terms sourced from the Ovid MEDLINE controlled vocabulary thesaurus are preceded by “exp.”

Figure 1. Literature search, screening and selection flowchart (Haddaway, Page, Pritchard, and McGuinness, 2022).

Table 4. Recommended approaches identified in the review.

Author	Country*	Type	Topic	Clients	Identification/Assessment	Management
Alappattu and Bishop (2011)	USA	Perspective	Treating pain-related fear	People with chronic pelvic pain	Routinely screen psychological variables, particularly pain-related psychological factors, using measures such as the STAI, FPQ, PCS. Continue to monitor psychological variables over the course of treatment. Pain-related fear assessment should be informed by the score on the screening tools, and interpreted through the Fear Avoidance Model.	Physiotherapists can address pain-related fear using cognitive coping strategies, pain and psychological education, and appropriate trained physiotherapists could use cognitive-behavioral interventions. Refer to a mental health professional, such as a psychologist and/or sex therapist, if the results of screening tools warrant further evaluation.
Billek-Sawhney, Wagner, and Braun (2014)	USA	Perspective	Screening for, and managing depression	People in acute care settings	Be observant to the signs and symptoms of depression. In inpatient settings, screen for depression using the 2-item PRIME-MD with Arroll’s “Help” question. Also mentions a three-question tool (Jamison, 2006). In outpatient settings, also consider screening through the interview and with intake forms, using the longer tools such as the GDS-15, BDI-II, or SDS. If risk of suicide is perceived, ask directly about suicidal ideation, and if confirmed, ask about plans, means, and intent.	Use exercise as an intervention for depression, and adapt management to promote self-efficacy and empowerment, through strategies such as graded activity and offering clients “some choice.” Allow clients to vent therapeutically and involve others to reinforce social support. Clients with depression should be referred to mental health professionals, and those at risk of suicide should be immediately evaluated by a medical or mental health professional.
Bunzli et al. (2017)	Australia	Commentary	Understanding pain-related fear	People with low back pain	Assess pain-related fear using the CSM framework, which involves asking questions such as “do you worry that [your low back pain] will impact all the other things you need to get done?” and “how hopeful are you for the future?” during the interview.	Management of pain-related fear involves helping the person make sense of their pain along the five dimensions of the CSM, reflecting on the basis of these beliefs, discussing how these beliefs influence behavior, presentation of new information, and adopting new behaviors.
Cancelliere and Mohammed (2019)	Canada	Commentary	Assessing and psychosocial factors	People with mild traumatic brain injury	Screen for common mental disorders (depressive disorders, anxiety disorders including PTSD), emotional regulation issues, apathy, aggression, irritability using the ACE symptom checklist, PHQ-9, GAD-7, PC-PTSD-5, and PCL-5. Screening for anxiety and depression should occur whenever the physiotherapist observes symptoms.	Offer management strategies such as education and reassurance in relation to mild traumatic brain injury symptoms and prognosis, sleep hygiene, stress management, CBT, and collaborate with other health professionals when needed.
Caneiro et al. (2022)	Australia	Perspective	Treating pain-related fear	People with musculoskeletal pain	Prior to the interview, screen all clients using a multidimensional screening tool such as the short form ÖMPSQ-SF, SBST, or STarT Musculoskeletal Tool. Use scores of individual items to guide interview. During the interview, explore client’s story, fears, worries, and concerns. Explore pain-related emotions with the CSM framework. Use behavioral experiments to explore emotional response to pain.	To address pain-related fear, using CFT (e.g. exposure with control, and making sense of pain) as an approach to promote safety learning. Refer to (and facilitate) co-care as needed.
Caneiro, Bunzli, and O’Sullivan (2021)	Australia	Masterclass	Role of beliefs	People with musculoskeletal pain	Prior to the interview use a multidimensional screening questionnaire (ÖMPSQ-SF). Use relevant items to guide the interview and to facilitate disclosure. During the interview, assess pain-related distress using the CSM, asking questions such as “does this pain get you down” and “do you worry about your pain?” In addition, explore general mental health including anxiety, mood, and stress. Use guided behavioral experiments to assess emotional response.	Use behavioral learning, and education to empower self-management and disconfirm unhelpful beliefs. Refer to a psychologist when comorbid mental health conditions (e.g. emotional distress and depression) are identified, ideally as part of integrated multidisciplinary team.
Chimenti, Frey-Law, and Sluka (2018)	USA	Perspective	Mechanism-based approach to physiotherapy	People with acute or chronic pain	If psychological factors are identified, or suspected, during the interview, follow-up with a screening tool or tools. Examples include the 2-item PRIME-MD, PROMIS Depression Item Bank, PROMIS Anxiety Item Bank, PROMIS Anger Item Bank, GAD-7, DRAM, SBST, PCS, FABQ, and TSK.	If screening is positive, particularly score for the DRAM and SBST, engage or refer for PIP, and/or a MDT approach with a psychologist. When psychosocial factors are identified, consider cognitive-behavioral therapy – informed techniques, education, and manual therapy.
Daley et al. (2021)	USA	Clinical practice guideline	Assessment and management	People returning to work post injury/illness	During history taking, screen for yellow flags, including catastrophizing, fear avoidance beliefs, kinesiophobia, low self-efficacy, and enquire about comorbidities such as anxiety and depression. When screening for yellow flags, use reliable and valid tools, such as the ÖMPSQ, WHQ, PACE Tool, BDRQ, TSK, PRODI, CPFI and FABQ, as part of the evaluation and throughout treatment.	If psychosocial barriers are present, then coordinate care and referral to a psychologist with the employer, worker, and other key stakeholders. Additionally incorporate PIP strategies, such as individual goal setting, motivational interviewing, education regarding activity pacing, problem solving, relaxation, and coping techniques into the plan of care.
De Baets et al. (2023)	Belgium	Commentary	Management of fear of movement	People with chronic musculoskeletal pain	Use a combination of an in-depth interview, screening tools (TSK, FABQ) and behavioral assessment to identify pain-related fear and avoidance. When screening using self-reported measures, item-based analysis is recommended over total score analysis.	To address pain-related fear, the authors recommend in vivo exposure therapy and discourage safety behavior.
Delitto et al. (2012)	USA	Clinical practice guideline	Assessment and management	People with low back pain	Effective screening for depression involves more than just generating a clinical impression. Use screening tools, such as the 2-item PRIME-MD, to screen for depression. When the screen is positive, the client should then complete a full-length depressive symptom questionnaire such as the PHQ or BDI. Similarly, screen for other severe psychiatric disturbances (e.g. anxiety), and pain-related distress (using FABQ and PCS). If affective symptoms are noted, consider diagnosis of (I) acute or subacute low back pain with-related cognitive or affective tendencies, or (II) chronic low back pain with related generalized pain.	Use education, counseling, graded exercise to address cognitive factors, affective tendencies and pain behaviors (e.g. depression, fear avoidance, and pain catastrophizing). Refer to a medical professional or mental health professional if the results of the interview and questionnaire suggest the presence of depressive symptoms. An immediate assessment by a medical professional and/or mental health professional is indicated for safety reasons if the client had a plan to harm himself/herself or others. A similar process could be used for clinicians who screen for other psychopathology (e.g. anxiety).
Donnelly, Brockwell, Rankin, and Moore (2022)	UK	Commentary	Whole-systems assessment	People returning to running postpartum	Screen psychological well-being using a validated tool, such as the EPDS or the CAPS-5. Consider assessment of fear of movement using the TSK, and if running being used as a coping strategy.	Refer to specialist clinicians when signs of excessive and obsessive beliefs and behaviors are observed, or when the results of the screening tests are suggestive of poor psychological wellbeing.
Edgerton et al. (2019)	USA	Literature review	Role in the BPS approach	People with chronic pain	Use the clinical interview to subjectively explore a person’s pain experience and psychosocial symptoms such as anxiety, trauma, and depression. Consider using tools such as the ÖMPSQ, SBST, FABQ, and PCS to assess for mental impairment.	Employ an interdisciplinary approach involving a psychotherapist. Education and exposure learning to target fear avoidance, and maladaptive thoughts, and CBT for pain-related distress.
Faulkner and Snell (2023)	New Zealand	Perspective	Framework for understanding psychosocial factors	People with persistent post-concussion symptoms	Screen for (i) acute psychological distress following concussion using the DASS-21 or HADS, (ii) preinjury mental health status using the STAI, or ASI, (iii) processes that drive psychological distress using tools such as the FAB-TBI, IPQ-R, C-scale, and SF-36).	Normalize emotional symptoms of concussion and acute stress reaction through education. Offer strategies, such as diaphragmatic breathing, to manage emotional symptoms of concussion. Referral for specialized mental health treatment, when indicated, such as in the presence of preexisting mental health problems.
George and Zeppieri (2009)	USA	Commentary	Fear-avoidance model	People with chronic low back pain	During the first session, assess fear-related to specific activities using the FDAQ. Reassess during management using the FDAQ. Also mentions the FABQ for assessment of general pain-related fear. The assessment is informed by the fear-avoidance model.	Manage pain-related fear and fear of activities using a behavioral approach. Items ranked 40/100 on the FDAQ or higher are targeted as part of graded exposure. Education is used to support adaptive coping strategies, and exercise prescription is a part of graded exposure.
Harland and Lavallee (2003)	UK	Literature review	Psychological assessment and management	People with chronic low back pain	Routinely screen for depression and anxiety using the HADS, and SDS, or DRAM. Also mentions the YFQ, and CSQ. However, results from the HADS and SDS should only be used in audit measurement and as referral criteria for psychological input, unless trained and authorized to act on these assessments.	Referral is recommended when scores suggest the presence of anxiety or depression, which requires an evaluation from a mental health professional. Management when psychological factors are present involves taking an active, rather than passive treatment approach to avoid reinforcing maladaptive behaviors.
Harrison, Thorp, and Ritzline (2014)	USA	Commentary	Diagnostic classification	People with temporomandibular disorders	Screening for psychological issues occurs during the clinical interview, or in the waiting room prior through the use of questionnaires such as the PHQ-ADS. During the clinical interview, listen for signs and disclosures of depression, anxiety, and psychological stress. When diagnosing temporomandibular disorder, the examination involves psychosocial aspects (such as depression anxiety, fear and anger) that either foundationally or indirectly contribute to the primary symptoms.	Provide education and use pain-modulation strategies such as stress reduction, sleep hygiene, physical activity and diaphragmatic breathing. When major psychological disorders such as moderate to severe depression, anxiety, and/or pain-related disability are identified, refer to a behavioral health specialist.
Hodges (2019)	Australia	Commentary	Hybrid approach to a model of care	People with low back pain	Stratification to High, Medium, and Low risk profiles using the SBST. After stratification, those classified as medium risk have their pain mechanism classified using the combination of interview, questionnaires, and clinical examination of pain system function. As part of this process, psychological features are assessed using the DASS-21, CES-D, FABQ, and PCS.	For those classified as high-risk, consider/use psychological treatments including behavioral therapies, pain coping skills, cognitive-behavioral, and acceptance-based therapies, education, and movement training. For those classified as medium-risk, treatments vary depending on pain mechanism and may include pain education, reassurance, psychologically informed interventions, fear conditioning, acceptance, graded activity and social intervention. Referral to a psychologist for specialist psychological treatments is indicated for those classified as high risk, and those classified as medium risk with neuropathic pain and central pain mechanisms.
Linton and Shaw (2011)	Sweden	Perspective	Incorporating psychological factors into practice	People with chronic pain	Routinely screen for mood symptoms during intake and initial consultation. After 2 weeks, if no immediate resolution screen for yellow flags and take a thorough clinical history looking for pain-related distress (e.g. fear avoidance and pain catastrophizing) and other forms of preexisting distress.	Physiotherapists can address pain-related fear through graded exposure, self-management, problem-solving strategies, and return-to-work planning. Appropriately trained clinicians can address pain-related distress (fear, anxiety, depression) with acceptance and commitment, cognitive-behavioral therapy, activation, relaxation, and positive psychology techniques.
Linton, Flink, and Vlaeyen (2018)	Sweden	Perspective	A psycho-etiological approach	People with chronic pain	Through the combination of a clinical interview and psychological screening with tools such as the ÖMPSQ, transdiagnostic factors can be identified. These transdiagnostic processes include forms of distress such as worry, general anxiety, avoidance, and catastrophizing.	Treatments target transdiagnostic factors to deal with problem as a whole, such as those factors that underpin depression and pain-related dysfunction. Examples of interventions include education/communication, exposure training, and coping planning.
Main and Watson (1999)	UK	Review	Psychological aspects of pain	People with pain	Pain-related fear should be assessed subjectively and with behavioral indicators of fear such as guarded movement. Tools used to screen and identify pain-related distress may include pain drawing (not as a standalone), behavioral observation rating test, behavioral (nonorganic) signs, with questionnaires such as FABQ and TSK mentioned.	If pain-related distress is observed, psychologically oriented treatment such as a pain management program may be needed. Physiotherapists should offer education and reassurance to the client about their pain. Pain-related depression may be treated with a cognitive behavioral approach. Unless psychiatrically ill, a referral may be harmful and magnify distress.
Main et al. (2023) and Main et al. (2023)	USA	Perspective	Communication in psychologically informed practice	People with chronic pain	Prior to the interview, have the client complete a tool such as the SBST, ÖMPSQ-SF, or OSPRO-YF. Facilitate self-disclosure by being open about the context of the consultation and the focus of the assessment. Use the aforementioned tools to inform the interview. Ask about pain interference to explore its impact and how they are coping with it using questions such as “You noted that pain here was an 8/10, so your pain is clearly significantly troublesome.” Consider using the aforementioned tools as a treatment monitoring tool.	The role of the physiotherapists in management is like that of a coach, with the focus on re-engagement in usual activities. Management has a specific focus on addressing obstacles, which may include psychological factors. Addressing psychological factors may involve facilitating behavior change to help the client cope with their pain through education, CBT, ACT, motivational interviewing, guarded optimism, stress reduction and mindfulness. The management approach should be the product of shared decision-making. It is also important to revisit any psychological obstacles during management.
Nijs et al. (2019)	Belgium	Masterclass	Pain neuroscience education	People with cancer-related pain	Consider assessing pain-related distress through the interview and with questionnaires such as the Brief IPQ, PCS, TSK, PIPS, and FPQ. Use the STAI, BDI, and HADS to screen for depression and anxiety.	Manage pain-related distress with biopsychosocially-driven pain management strategies, including acceptance-based interventions, stress-management, graded exposure and education (including pain neuroscience education).
O’Sullivan et al. (2018)	Australia	Perspective	Description of CFT	People with low back pain	Prior to interview, use a multidimensional screening questionnaire (e.g. the ÖMPSQ). Explore the client’s story and listen for any signs of fear and pain-related distress. During the interview, directly ask clients about their emotional response to pain, such as depressed mood (e.g. does it get you down? In what way?) and anxiety (e.g. Do you worry about the pain?). Use guided behavioral experiments to assess pain response such as pain-related distress.	Help clients make sense of their pain, target pain-related distress (such as fear of movement) via exposure with control, and support positive lifestyle changes, such as using relaxation strategies and physical activity to address sleep disturbances related with pain, worry, or stress. Interdisciplinary care is indicated in the presence of psychiatric and/or psychological comorbidities such as major depressive disorder and post-traumatic stress disorder.
O’Sullivan, Smith, Beales, and Straker (2017)	Australia	Commentary	Multidimensional Perspective	Adolescents with low back pain	During the clinical interview, explore the adolescent’s story and concerns noting signs of psychological distress (anxiety and depressed mood) and other psychosocial factors. To facilitate this, use a multidimensional screening questionnaire, such as the ÖMPSQ, and SBST.	As part of a CFT management approach, provide education regarding the association between pain and distress, provide reassurance, and reinforce learning through experiential learning. Consider support from others including guardians and a psychologist (and other health professionals) when pain is disabling, and related with high levels of depressed mood, anxiety, and social stress.
Rabey and Moloney (2022)	UK	Perspective	Integrating allostatic load into practice	People with musculoskeletal pain	Through the clinical interview and use of screening tools, screen for psychological stressors (e.g. anxiety). Use screening tool (e.g. ÖMPSQ) prior to consultation or at the start of the consultation. If indicated, explore further during the interview and consider a more specific questionnaire (e.g. DASS and FABQ). During the interview, explore potential psychological stressors (e.g. adverse childhood experiences, sustained emotional stress, and severe trauma), their relevance to the presentation, and management of such stressors. Be observant for signs of hyper-related or hypo-arousal states. Examine pain/movement-related distress responses through movement-based physical examination. Use a clinical reasoning framework (Mitchell, Beales, Slater, and O’Sullivan, 2018) or a bubble diagram to clinically reason the relative contributions of the examination results.	If psychological assessment and management is beyond the individual scope of the clinician, refer onwards to a health professional skilled in that area. Management is likely to be highly individualized and emerges from a client-centered shared-decision process. Examples of management approaches may include mindfulness, stress inoculation, meditation and breathing practices, sleep interventions; however, consider timescales/resources available such as access to psychotherapy if necessary. Management may be multidimensional, however, a predominantly unidimensional approach with limitations discussed may also be appropriate.
Rebbeck (2017)	Australia	Commentary	Review of exercise, education, and behavioral interventions	People with whiplash	For WAD grades I to III, assess psychological distress (including post-traumatic stress), pain catastrophizing, and fear avoidance during initial consult for chronic whiplash, or 3 weeks after for acute whiplash. In some instances, assessment of psychological factors before 3 weeks may be indicated for acute whiplash. For chronic whiplash, reassess psychological distress again before 6 month.	Consider exercise plus behavioral therapy approach when person is experiencing high pain levels, high disability, and psychological distress. Consider referral to a psychologist if high levels of psychological distress are noted.
Simon and Hicks (2018)	USA	Perspective	Comprehensive management approach	Older adults with low back pain	Screen for depression using the GDS or CES-D. With the exception of depressive symptoms, which the authors state is beyond the scope of physiotherapists to assess, they recommend assessment of pain-related fear using the PCS or FABQ, and assessment of pain catastrophizing using the PCS.	Use cognitive-behavioral physical therapy to manage psychological distress when it is a symptom of client’s low back pain. Cognitive-behavioral physical therapy include mindfulness, mindfulness-based exercise (e.g. tai chi and graded tasking). The mindfulness interventions may help with general distress. Refer/communicate with the primary care physician when depressive symptoms are identified.
Simonds, Abraham, and Spitznagle (2022)	USA	Clinical practice guideline	Assessment and management	People with pelvic girdle pain during the postpartum period	Screen for mood disorders and suicidal ideation using the EPDS. Consider screening for aspects of low mood and anxiety not captured by the EPDS using additional scales. Also consider use of questionnaires for fear and kinesiophobia, particularly for those with persistent pelvic girdle pain or those not responding well to management.	Refer to a physician and/or a mental health professional if the EPDS score is 10 or above. For suicidal ideation, if any positive response to item 10 on the EPDS, should be considered a red flag and immediately referred to the emergency department. Physiotherapists should establish connections with mental health professionals in anticipation of referrals.
Smith et al. (2020)	USA	Perspective	Assessment and management	People with post – intensive care syndrome	Screen all clients with a history of hospitalization, particularly those who required intensive care unit (ICU) care, for depression and anxiety using the HADS. The authors also mentioned the 2-item PRIME-MD but caution against its use in this context. Use the IES-R to screen for PTSD symptoms.	Coordinate care with an interprofessional team, when symptoms of depression, anxiety, and PTSD in clients are identified. This may involve a referral to a mental health professional or other specialists. Consider encouraging clients to access peer-support groups where survivors of critical illness can connect and support each other’s recovery.
Spearing and Bailey (2012)	UK	Analytical literature review	Screening for, and managing depression	People with chronic physical illness	Screen all clients with the 2-item PRIME-MD. If positive, follow up with a validate measure of depression, such as the PHQ-9, BDI-II, BDI-PC, CES-D, and SDS. Engage in further questioning regarding depressive symptoms if competent to do so.	For clients with chronic physical ill health, general advice to promote wellbeing would be staple practice for many therapists, for example: promoting healthy eating, avoiding excess alcohol and smoking, and taking regular exercise. All clients suspected to be experiencing depression to be referred for a full evaluation and diagnosis.
Stearns et al. (2021)	USA	Commentary	Screening and managing psychosocial factors	People with musculoskeletal pain	Screen all clients using a multidimensional screening tool such as OSPRO-YF, SBST, and ÖMPSQ. Also cites the PROMIS Depression Item Bank and PROMIS Anxiety Item Bank. Alternatively, screen clients who don’t respond to routine care after 4–6 weeks. Assess psychosocial factors identified during initial screening with multidimensional measures and relevant unidimensional screening tools, such as the PCS, TSK, FABQ, PASS-20. Scores on screening tools can guide the clinical interview. Psychological factors should be reassessed every 2 weeks to monitor progress.	Management of psychosocial factors is largely within the scope of physiotherapy, and physiotherapists should establish a referral network. Management options include standard physiotherapy, psychologically informed physiotherapy, psychologically informed physiotherapy with referral, and immediate referral. Psychologically informed physiotherapy involves motivational interview, self-management, cognitive behavioral strategies, and coping skills. If the physiotherapist feels ill equipped to manage pain-related distress, perceives that additional specialized care may be beneficial, or there are symptoms of mental illness then a referral should occur. Cotreating after referral to a psychological service is appropriate. In the event of signs of serious mental illness such as clinical depression and suicidality, an immediate referral is indicated.
Sterling (2014)	Australia	Review	Physical and psychological assessment	People with whiplash injuries	Based on client history and interview, select a questionnaire based on the symptoms noted. For example, the IES for post-traumatic stress symptoms, PHQ-9 for depression, or the PCS for pain catastrophizing.	If moderate levels of psychological distress are measured with the relevant questionnaire, physiotherapists can address this as part of psychologically informed physiotherapy if they are confident to do so. If high levels of distress are identified, or the distress is persisting after a period of psychologically informed physiotherapy, a referral to the client’s general practitioner or a clinical psychologist is recommended.
Sterling and Kenardy (2008), and Sterling (2009)	Australia	Masterclass	Physical and psychological assessment	People with whiplash injuries	Use the IES (or IES-R) to screen for post-traumatic stress symptoms, and the GHQ-28 and SF-36 for general psychological distress. Fear-avoidance and catastrophizing could also be assessed.	Advice and reassurance may help alleviate some distress during the initial period post injury. Referral for a psychological evaluation should occur after 3 to 4 weeks if recovery is not apparent, because early psychological referral could interfere with normal recovery. If referral for a psychological evaluation is indicated, co-care should occur.
Van Wyngaarden, Noehren, and Archer (2019)	USA	Restricted literature review	Assessing psychosocial profile	People with musculoskeletal pain	Screen all clients with the PHQ-2 and OSPRO-YF. With clients with LBP, use SBST and then the OSPRO-YF at follow-up to reduce client burden. If PHQ-2 is positive, complete PHQ-9. Based on scores of OSPRO-YF, classify as noncontributory psychosocial profile, moderate psychosocial profile, moderate‐to‐high psychosocial profile, or high psychosocial profile. Consider further assessment using unidimensional assessment tools such as the PCS and TSK. Continue to monitor psychosocial profile using screening tools..	Clients classified as having a moderate, or moderate-to-high, or high psychosocial profile should continue to be monitored and provided with psychosocial interventions such as cognitive‐behavioral therapy, pain education, graded exposure, and motivational interviewing. If the client is classified as having a high psychosocial profile and their profile remains elevated after a month of management, they should be referred to a psychosocially informed physiotherapist and/or a psychologist.
Vandyken and Hilton (2017)	Canada	Literature review	Treatment of Central Pain Mechanisms	Women with sexual pain	During history taking, look for personal challenges or threats that occurred when the pain began. Use screening tools to assess pain-related negative appraisals and cognitions, such as the PCS and TSK. Assess for mental distress using the DASS-21.	Engage in the following management if within the individual physiotherapist’s scope of practice or refer on if not. To manage stress, anxiety, catastrophizing, and fear avoidance, suggested interventions include pain education, mindfulness meditation, and CBT. In addition, breathing exercises, yoga, and sleep hygiene for stress, a self-soothing routine and gratitude training for anxiety, social support is recommended for catastrophizing, and CFT, graded exposure, and graded motor imagery for fear avoidance.
Varela and Melvin (2023)	USA	Narrative Review	Role of physiotherapy	People with depressive disorders	Screen for depressed mood and diminished interest as part of the standard health status intake questionnaire. To assess severity of depression, use the PHQ-9. Screening for suicide occurs as part of the assessment of depression, with item nine on the PHQ-9 being used to screen for suicide. Assessment of depressive symptoms continues after the initial screening process	When depression is suspected, collaborate with mental health professionals. Immediately refer any client at imminent risk of suicide or self-harm to the client’s health care team. Suicidality without immediate risk should still be communicated with a mental health professional and referrer. While direct treatment of depression is beyond scope, interventions of the mind and body awareness (e.g. physical activity), mindfulness training, and sleep hygiene education can have an impact on depression.
Vieira, Brown, and Raue (2014)	USA	Selective literature review	Screening for, and managing depression	Older adults	Screen clients with the PHQ-2, and if positive, complete PHQ-9. Also consider using the GDS-15. Suggests that physiotherapists go beyond the use of screening tools in their assessment; however, does not provide further details, instead referring the reader to other training material.	PHQ-2 scores of 2 or 3+ should be referred to for a mental health evaluation. Physiotherapists play a role in facilitating referrals, which may involve education, mirroring the client’s language, encouragement, and discussing referral in the context of other mental health conditions (e.g. poststroke depression). Clients experiencing persistent depressive symptoms should also be referred.
Watson (1999)	UK	Editorial	Psychological assessment	People with musculoskeletal pain	Use the clinical interview to explore client’s psychological wellbeing, and if the client does not respond to treatment, formally screen for depression, anxiety, poor coping, injury/pain-related fear, avoidance beliefs, somatic anxiety stress, high self-report of stress or anxiety, using psychosocial questionnaires such as DRAM, and the ÖMPSQ.	Physiotherapists play a key role in managing pain-related distress, such as targeting treatment at reducing fears and increasing activity. Non-pain-related distress, such as distress related with marriage or financial issues should prompt a referral to a mental health professional. Management may also involve joint multidisciplinary or interdisciplinary management.
Wijma, van Wilgen CP, Meeus, and Nijs (2016)	Belgium	Perspective	Biopsychosocial assessment	People with chronic pain	Ask specifically about emotional factors-related to pain, such as psychological issues arising from work, family, financial, or social stressors, psychological traumatic onset of the pain, and fear of movement. Screen for perceived injustice (a form of anger) using the IEQ. To assess pain-related distress, use the PCS, Brief IPQ, and if necessary, the TSK. To screen for anxiety and depression use clinical questioning. If necessary, consider using a tool such as the STAI, CED-S. PHQ-2, and PHQ-9. Screen for PTSD and stress through the clinical interview.	During pain neuroscience education, if pain-catastrophizing, anxiety, depression, perceived injustice, PTSD, and stress are identified, then education between the interplay of mental health and the pain neuromatrix is provided. In addition, basic psychological support should be included such as acknowledgment, and comfort. To inform referral, physiotherapist asks themselves “is this patient (with chronic pain) in the right place here with me, or should he/she be treated in a multidisciplinary setting or referred to another provider?
Willy et al. (2019)	USA	Clinical practice guideline	Assessment and management	People with patellofemoral pain	Screen for psychological factors that require a referral to a mental health professional. Screen for anxiety, depression, fear avoidance, kinesiophobia, and catastrophizing using the OSPRO-YF, FABQ, and the PCS.	Based on screening and examination, determine whether the client is (i) appropriate for physiotherapy alone, (ii) appropriate for physiotherapy as a part of co-care with another health professional, or (iii) not appropriate for physiotherapy. If psychosocial factors are identified, consider cognitive behavioral treatments, reassurance, and graded exposure to activity.

36-Item Short Form Survey (SF-36), Acute Concussion Evaluation symptom checklist (ACE), Back Disability Risk Questionnaire (BDRQ), Beck Depression Inventory (BDI), Beck Depression Inventory 2ND Edition (BDI-II), Beck Depression Inventory for Primary Care (BDI-PC), Brief Illness Perception Questionnaire (Brief IPQ), Center for Epidemiological Studies Depression (CES-D), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Cognitive Behavioral Therapy (CBT), Cognitive Functional Therapy (CFT), Cogniphobia Scale (C-scale), Cumulative Prognostic Factor Index (CPFI), Depression Anxiety and Stress Scales (DASS), Depression Anxiety and Stress Scales − 21 item (DASS-21), Distress and Risk Assessment Method (DRAM), Edinburgh Postnatal Depression Scale (EPDS), Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI), Fear Of Daily Activities Questionnaire (FADQ), Fear of Pain Questionnaire (FPQ), Fear-Avoidance Beliefs Questionnaire (FABQ), General Anxiety Disorder-7 (GAD-7), General Health Questionnaire (GHQ-28), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), Injustice Experience Questionnaire (IEQ), Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF), Örebro Musculoskeletal Pain Question – short form (ÖMPSQ-SF), Örebro Musculoskeletal Pain Question (ÖMPQ), Pain Anxiety Symptom Scale (PASS-20), Pain Catastrophizing Scale (PCS), Patient Health Questionnaire (PHQ-2), Patient Health Questionnaire (PHQ-9), Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS), Patient-Reported Outcome Measurement Information System Anger (PROMIS Anger), Patient-Reported Outcome Measurement Information System Depression (PROMIS Depression), Plan of Action for a Case (PACE Tool), Posttraumatic Stress Disorder (PTSD), Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), Psychological Inflexibility in Pain Scale (PIPS), Psychosocial Risk for Occupational Disability Instrument (PRODI), Revised Illness Perception Questionnaire (IPR-R), Revised Impact of Event Scale (IES-R), STarT Back Screening Tool (SBST), State-Trait Anxiety Inventory (STAI), Tampa Scale for Kinesiophobia (TSK), Work and Health Questionnaire (WHQ), Zung Self-Rating Depression Scale (ZSDS).

Figure 2. Distribution of included articles by year of publication.

Table 5. Screening and assessment instruments.

Instrument		Brief Description	Further information (e.g. interpretation/psychometrics)	# of Articles
Psychiatric Conditions
	General Health Questionnaire (GHQ-28)	Screening tool for common psychiatric conditions in medical settings.	Sterling (2011)	1
Depression and Anxiety
	Depression Anxiety and Stress Scales (DASS-21 and DASS-42)	Measure of anxiety, depression, and stress	Parkitny and McAuley (2010)	4
	Hospital Anxiety and Depression Scale (HADS)	Measure of anxiety and depression.	Beekman and Verhagen (2018)	4
	Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS)	Screening tool for anxiety and depression that combines the PHQ-9 and GAD-7 scores.	Kroenke et al. (2016)	1
Depression
	Patient Health Questionnaire (PHQ-2)	Screening tool for depression.	Kroenke, Spitzer, and Williams (2003)	8
	Patient Health Questionnaire (PHQ-9)	Screening tool for depression	Kroenke, Spitzer, and Williams (1999)	7
	Beck Depression Inventory (BDI, BDI-II, BDI-PC)	Measure of depression	Beck et al. (1961; BDI), Beck, Steer, and Brown (1996; BDI-II), and Beck, Guth, Steer, and Ball (1997; BDI-PC)	4
	Center for Epidemiological Studies Depression (CES-D)	Measure of depression	Radloff (1977)	3
	Zung Self-Rating Depression Scale (ZSDS)	Measure of depression	Hunter and Murphy (2011)	3
	Geriatric Depression Scale (GDS)	Measure of depression among older adults	Yesavage et al. (1983)	3
	Edinburgh Postnatal Depression Scale (EPDS)	Screening tool for perinatal depression.	Shrestha et al. (2016)	2
	Patient-Reported Outcome Measurement Information System Depression (PROMIS Depression)	Measure of depression	Pilkonis et al. (2011)	2
Anxiety
	State-Trait Anxiety Inventory (STAI)	Measure of state and trait anxiety	Julian (2011)	5
	General Anxiety Disorder-7 (GAD-7)	Measure of generalized anxiety	Spitzer, Kroenke, Williams, and Löwe (2006)	2
Post-Traumatic Stress
	Impact of Event Scale (IES or IES-R)	Measure of post-traumatic stress symptoms	Horowitz, Wilner, and Alvarez (1979; IES) and Motlagh (2010)	3
	Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)	Measure of post-traumatic stress disorder symptoms	Weathers et al. (2017)	1
	Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5)	Measure of post-traumatic stress disorder symptoms	Blevins et al. (2015)	1
Anger and Perceived Injustice
	Patient-Reported Outcome Measurement Information System Anger (PROMIS Anger)	Measure of anger	Pilkonis et al. (2011)	1
	Injustice Experience Questionnaire (IEQ)	Measure of perceive injustice associated with injury.	Sullivan et al. (2008)	1
Health-Related Distress
	Pain Catastrophizing Scale (PCS)	Measure of pain-related worrying (i.e. pain catastrophizing)	Sullivan, Bishop, and Pivik (1995) and Crombez et al. (2020)	13
	Fear-Avoidance Beliefs Questionnaire (FABQ)	Measure of fear and avoidance beliefs about physical activity and work in people with low back pain	Waddell et al. (1993)	12
	Örebro Musculoskeletal Pain Question (ÖMPSQ or ÖMPSQ-SF)	Screening tool for early identification of yellow flags in with pain	Linton and Boersma (2003) and Linton, Nicholas, and MacDonald (2011)	11
	Tampa Scale for Kinesiophobia (TSK)	Measure of fear of movement-related pain in patients with musculoskeletal pain	Weermeijer, Meulders, and Meulders (2018)	10
	STarT Back Screening Tool (SBST)	Screening to for physical and psychosocial factors (e.g. depression fear, anxiety, and catastrophizing) in people with low back pain	Traeger and McAuley (2013)	8
	Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF)	Screening and assessment tool for pain-associated psychological distress	Lentz et al. (2016) and Butera, George, and Lentz (2020)	4
	Distress and Risk Assessment Method (DRAM)	Screening tool for psychological distress in people with pain	Main et al. (1992)	3
	Illness Perception Questionnaire (Brief IPQ and IPR-R)	Measure of cognitive and emotional representations of illness	Ng (2012) and Hill (2010)	3
	Fear of Pain Questionnaire (FPQ)	Measure of pain-related fear	McNeil and Rainwater (1998)	2
	Cumulative Prognostic Factor Index (CPFI)	Measure of fear of movement, depression, and pain catastrophizing based on the BDI-II, TSK, and PCS	Wideman and Sullivan (2012)	1
	Fear Of Daily Activities Questionnaire (FADQ)	Measure for fear of activities in people with low back pain	George, Valencia, Zeppieri, and Robinson (2009)	1
	Pain Anxiety Symptom Scale (PASS-20)	Measure of pain-related anxiety	Coons, Hadjistavropoulos, and Asmundson (2004)	1
	STarT MSK tool	Screening tool for physical and psychosocial factors (e.g. depression fear, anxiety, and catastrophizing) back, neck, knee, shoulder, or multisite pain	Dunn et al. (2021)	1
	Psychological Inflexibility in Pain Scale (PIPS)	Measure of pain avoidance and cognitive fusion with pain	Wicksell et al. (2008)	1
	Cogniphobia Scale (C-scale)	Measure of fear and avoidance of cognitive exertion in headache sufferers	Seng and Klepper (2017)	1
	Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI)	Measure of fear avoidance behavior in adults after mild traumatic brain injury	Snell et al. (2020)	1
	Work and Health Questionnaire (WHQ)	Screening tool for work-related factors and psychosocial variables in injured workers	Wideman and Sullivan (2012)	1
	Back Disability Risk Questionnaire (BDRQ)	Screening tool for disability risk factors in people experiencing occupational low back pain.	Shaw, Pransky, Patterson, and Winters (2005)	1
	Psychosocial Risk for Occupational Disability Instrument (PRODI)	Screening for psychosocial risk for disability in injured workers with low back pain	Schultz et al. (2005)	1
	Plan of Action for a Case (PACE Tool)	Tool intended to connect risk identification with interventions in injured workers.	Iles, Sheehan, Munk, and Gosling (2020)	1
	Acute Concussion Evaluation symptom checklist (ACE)	Symptom checklist (physical, cognitive, emotional, and sleep) in people with mild traumatic brain injury	Gioia, Collins, and Isquith (2008)	1
General Health and Wellbeing
	36-Item Short Form Survey (SF-36)	Measure of physical functioning, role limitations (physical), bodily pain, general health, vitality, social functioning, role limitations (emotional), mental health, and reported health transition	Ware, Snow, Kosinski, and Gandek (1993) and Ware (2000)	2

The PHQ-2 category includes the 2-item screening test for depression taken from the Primary Care Evaluation of Mental Disorders Procedure (2-item PRIME-MD), although the instruments vary slightly (Haggman, Maher, and Refshauge, 2004). The EPDS has also been used to screen for perinatal anxiety (Shrestha et al., 2016).

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