Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?

Figures & data

Table 1 Key Components Comprising Psychologically Informed Practice (PIPT)

Over-Arching Components of PIPT
	Rationale/Goals/Objectives	Concrete Example
Patient Centered Communication	Realization - shared understanding Understanding the pain experience by actively eliciting patient perspective, including but not limited to psychosocial and cultural contexts	Motivational Interviewing Shared Decision Making
Treatment Specific Components
	Rationale/Goals/Objectives	Concrete Example
Pain Modulation	Relief - pain intensity and severity Short-term primarily aimed at decreasing intensity/severity, can be delivered by provider but should also include self-management components	TENS Manual Therapy Physical Modalities Directional Preference Exercise
Reinforcement = providing encouragement when patient reports using hot packs at home to help relieve pain.
Pain Coping Skills	Regulation - physical and emotional Pain relief is not a direct target but may be a “side effect” of altering the individual’s sensory environment to allow for different processing of nociception.	Deep Breathing Progressive Muscle Relaxation Activity pacing Education Mindfulness
Reinforcement = answering questions and practicing deep breathing exercises in clinic
Activity and Exercise Recommendations	Re-activation - physical activity About preventing disability through avoidance, encourage resumption of activities despite the pain, and behavioral/psychological dosing principles	Graded Exposure Graded Activity
Reinforcement = praising patient for reaching activity goal in clinic, despite pain levels not improving yet

Table 2 PIPT Training Examples for Licensed Physical Therapists

Research Physical Therapists in TARGET Trial^Citation59	Research Physical Therapists in Knee OA RCT^Citation26	Outpatient MSK Physical Therapists^Citation27	Primary Care Clinicians and Outpatient Physical Therapists in MATCH Trial^Citation21	Outpatient Physical Therapists in STarT Back Trial^Citation15
One day course, primarily didactic	Ten, 45-min modules delivered over 4 days with ongoing mentoring/feedback	Two-day course, mixture of didactic and experiential, training manual, monthly supervision/feedback	Six didactic sessions for primary care, five days of intensive training for PTs with ongoing mentoring and supervision	One-to-six-day training depending on intervention group
•Pain Attitudes and Beliefs Scale for Physical Therapists •Confidence in PIPT skill application	•Treatment fidelity checklist to measure therapist adherence to protocol/manual and session performance	•Treatment fidelity checklist to measure therapist adherence to protocol/manual and session performance	•Electronic healthcare record monitoring	•Health record auditing
1. Summarize relationships between pain neuroscience, pain models, and the development and maintenance of chronic low back pain 2. Identify patients at high risk for transitioning from acute to chronic low back pain 3. Apply targeted treatment for patients at high risk for transitioning from acute to chronic low back pain 4. Understand primary assumptions of CBT and specific skills associated with CBT based interventions 5. Recognize effective communication skills and be able to implement as a key component to PIPT	1. Establishes/maintains rapport 2. Applies program protocol to participants’ situation/challenges 3. Encourages participant involvement in the sessions 4. Asks open-ended questions, encourages change, rolls with resistance, supports self-efficacy	Not reported	Not reported	Not reported.

Figure 1 Dissemination and implementation framework.

Notes: Reprinted from Brown CH, Curran G, Palinkas LA et al. An Overview of Research and Evaluation Designs for Dissemination and Implementation. Annu Rev Public Health. 2017;38:1–22. Copyright © 2017 Annual Reviews. This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 (CC-BY-SA).³⁴

Table 3 Hybrid Effectiveness-Implementation Study Designs with Corresponding PIPT Research Questions, Clinical Outcomes, and Implementation Outcomes⁴³

Type 1	Type 2	Type 3
Focus: Effectiveness of intervention with “exploration” of intervention implementation	Focus: Dual focus on effectiveness and implementation outcomes	Focus: Implementation outcomes
Primary aim: Determine effectiveness of PiP approach for patients with low back pain. Secondary aim: Better understand context for using PiP approaches in outpatient physical therapy settings. Primary question: Does a one-day PiP training program for outpatient physical therapists result in improved functional outcomes for patients with low back pain? Secondary question: What are the barriers and facilitators for using PiP approaches for patients with low back pain?	Co-primary aim: Determine effectiveness of PiP approach while also determining feasibility and utility of a particular implementation intervention or strategy. Co-primary questions: Does a PiP approach work for patients with low back pain in an outpatient physical therapy clinic? Does the implementation method (one-day, in-person PiP training program) show promise in facilitating use of PiP approaches in this context?	Primary aim: Determine utility of a specific implementation intervention or strategy (eg one-day, in-person PiP training program vs online PiP training module). Secondary aim: Assess functional outcomes for patients with low back pain. Primary question: Which implementation method (in-person training vs online module) works better at facilitating use of PiP approaches in clinic? Secondary questions: Are functional outcomes acceptable? Are the changes in pain scores clinically meaningful? What are the utilization rates of PiP approaches for in-person training vs online training?

Figure 2 PIPT implementation roadmap.

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