It is clear now for most primary health care practitioner, including physiotherapists, that addressing psychosocial (PS) factors is important in the management of musculoskeletal symptoms. Patients presenting with PS factors are associated with a higher risk of reporting pain (particularly chronic pain) (Hoogenndoorn et al, 2000) and these factors have an important role in the development and subsequent recovery of low back pain episodes (Andresson, 1999; Wand and O’Connell, 2008 What are the current beliefs and knowledge of physiotherapists in the evaluation of the PS factors in patients with chronic low back pain (CLBP)? Starting from this question, we looked at physiotherapists’ personal views about the BPS model and the different ways they assess and manage PS factors with patients presenting with CLBP. We focused our research on Italian physiotherapists as there was limited research into Italian physiotherapists’ views and assessment of PS factors in patients with CLB (Zangoni & Thomson 2017).

Whilst the word psychosocial is widely used in the context of physiotherapy, the meaning of this word can remain unclear. What it means is the interaction between the person and his/her social environment and the barriers that can derive from this interaction (Singla et al, 2015) and it is characterized by the combination of the individual’s cognitive, emotional and social status influencing their condition. PS factors often include negative behaviours, fear avoidance beliefs, social withdrawal, problems at work, low mood, coping strategies and faith/religious beliefs (Kendall, 1999; Overmeer et al, 2004; Innes, 2005). Current literature and guidelines for low back pain (LBP) in UK, Australia, New Zealand and Italy recommend that PS factors should be addressed in addition to traditional biomedical factors when managing patients with LBP (Negrini et al, 2004; NICE, 2016; Synnott et al,2015; Darlow et al, 2014). Although the literature and guidelines recommend the incorporation of the BPS model into clinical practice (NICE, 2016) when managing patients with CLBP, it does not seem to be translated in practice yet: activities of reasoning and practice in physiotherapy are still centered on a traditional biomedical model of care (Darlow et al, 2014; Cruz et al, 2012; Singla et al, 2015; Piccoliori et al, 2013). In Italy, we observed little evidence about the knowledge and understanding of the role of PS factors in the management of people with CLBP (Negrini et al, 2004) and the reported data underlined:

  • Lack of standardisation in the teaching of PS factors assessment
  • Resistance of general medical practitioners and physiotherapists in adopting a BPS model in their clinical practice (Negrini et al, 2004).
  • Limited research describing and explaining Italian physiotherapists’ attitudes and beliefs towards PS factors in patients suffering from CLBP.

This led us to investigate Italian physiotherapists’ personal beliefs about PS factors, the different ways they assess and manage PS factors in clinical practice and the possible deriving barriers, with particular interest in patients presenting CLBP (Zangoni & Thomson, 2017).

For those interested in research methods, this section is for you, for the others feel free to jump to the next paragraph! A qualitative research design using semi-structured interviews to collect the data was adopted with Italy-based physiotherapists, as we intended to approach experiences, interactions and beliefs, that can’t be measured in numbers. We then used a grounded theory approach to analyse and compare the data resulting from different perceptions and experiences participants had in relation to PS factors in CLBP. A grounded theory approach was selected for the study as it allows active process of collection and interpretation of data that are constructed by the researcher as a result of his/her interaction with the interviewee (Charmaz, 2016; Thomson et al, 2014). You can find more details of the study and its design here.

We found that that all of our participants demonstrated awareness about the multifactoriality of CLBP and identified PS factors as important factors to consider when evaluating and treating these patients. General recognition of social factors (family, work, social relations), stress and negative attitudes were reported by all the participants but expectations and psychological factors, including depression or anxiety, were less mentioned (Pincus et al, 2006a, b; Nicholas et al, 2011).

Although participants demonstrated some understanding of the BPS model, they did not appear to have acquired the knowledge and skills necessary to implement it in practice: they did not appear to have acquired the knowledge and skills necessary. When exploring the barriers practitioners faced in the daily practice, the struggling to apply a multidimensional approach became even more apparent. Physiotherapists discussed patients’ expectations of receiving manual treatment and feared that taking time to discuss about PS factors would be considered as a waste of time by the patients. This perceived attitude of patients lead the physiotherapists to avoid or limit the exploration of these PS factors in order to avoid the disruption of the therapeutic relationship previously established. The fear to disrupt the relationship with patients was considered by the participants an important barrier, as reflected in quotes such as:

“First of all there is a cultural barrier, I mean in their opinion if you are a physiotherapist you have to do a massage and fix their back… Sometimes patients look at the discussion as a lack of time”

“If a person is reserved, trying to talk about those aspects or analyse them in depth could contribute to his suffering, and to outdistance him from you”

Our participants demonstrated clear interest in the PS factors but they also felt they did not have the appropriate knowledge/understanding of the BPS model and of the clinical guidelines; this was another important barrier in conducting PS assessment and treatment. To assess PS factors they mainly used general questions in the form of a dialogue during the case history led by the patient. The issue is that identification or awareness of PS factors is not enough for changing patient management and outcome as active engagement in identifying the potentially modifiable factors is fundamental (Main et al, 2010; Synnott et al, 2015).

We had the feeling that the difficulties in the management of patients and the persistency of PS factors seemed to have created preconceptions about the outcome in patients with CLBP. Some of the participants believed that often only a partial recovery form the chronic state is possible:

“I expect a partial resolution… With chronic low back pain I do not consider myself so good to resolve a problem that is present from minimum 3 months in 10 sessions… My aim is to educate, train and get the patient conscious of his possibilities…

Conversely one participant stated that in some cases too much attention is given to the PS factors, diverting the attention from a possible leading biomedical cause perpetuating the symptomatology:

“In my opinion one part of chronic lumbar problems is underdiagnosed, the cause is musculoskeletal and not biopsychosocial… I think that nowadays there is an underestimation, everyone is moving towards the psychosocial aspects”

The findings of our research reflect the results of similar studies conducted in Australia and UK by Singla et al, (2015) and Darlow (2016) which found physiotherapists recognise the importance of PS factors but still tend to focus on clinical biomedical and biomechanical findings. The lack of active engagement in identifying which are the potential modifiable factors due to superficiality and missing standardization within the physiotherapy profession have to be addressed through a shift from biomedically-oriented to biopsychosocially-oriented practice. Moreover, limited education about the PS aspects in the university training and the need of additional specific training to improve the knowledge of physiotherapists in this area is needed in order to improve physiotherapists’ uncertainty about the management of the these factors.

What can we do on our own without going on another course?

Activities of mentoring in the clinical settings, improving our capacity to listen to patients to contextualise their symptoms in their social environment and gradual engagement with assessment scales of the BPS status are probably a good starting point. In regards to the assessment scales, the STarT Back Screening Tool is a simple questionnaire helping clinicians to screen primary care patients with LBP and stratify them into low, medium and high risk to develop persistent disabling symptoms.

Training practitioners to implement a BPS approach is difficult. Until recently, interventions to increase practitioners’ provision of psychosocial interventions have had little effect on patient outcomes but more recent attempts have been a bit more successful in physiotherapy. An interesting study compared the impact of BPS training and biomechanical training on physical therapy students: those who took the BPS training showed a reduction in fear-avoidance and pain impairment beliefs of patients, and an improvement of the recommendations given by students for activity and work but the biomechanical group showed opposite trends (Domenech et al, 2011). Probably good evidence that curricula need changing!

Another problem of previous training programmes was teaching content delegates already knew! It can be difficult to know which content to include: sometimes the content is not novel enough and therefore delegates learn little which has little or no impact on their practice. Finally, no studies have so far explicitly stated if their learning packages were informed by any behavioural change frameworks. Changing one’s behaviour is hard in all fields (e.g. smoking or obesity prevention) and the same challenges are faced for training programmes aiming to modify clinician’s behaviour when managing patients. We developed an 8-hour e-learning programme to train 45 osteopaths with more than 15 years to the BPS model for the management of patients with non-specific low back pain (Draper-Rodi et al, 2016). We saw that this quite short course had a positive impact on the participants’ attitudes to back pain. Participants’ perceptions of the BPS model after taking the e-learning programme were represented in three categories: not structural enough, part of existing practice and transformative. Participants found e-learning a very effective way of taking CPD: it was very easy to do whether during clinic gaps or at home and its flexibility allowed many of them to retake lessons when content was challenging. E-learning was found suitable to disseminate new knowledge to manual therapists including those in remote areas. We are currently looking at continuing research on this topic, maybe using blended learning (e-learning and face-to-face) to offer a full BPS training to manual therapists

In conclusion, the lack of active engagement in identifying which are the potential modifiable factors due to superficiality and missing standardization within the physiotherapy profession have to be addressed through a shift from biomedically oriented to biopsychosocially oriented practice. Moreover, additional specific training about PS aspects and the BPS model is needed, starting from the improvement of the university programmes on this topic and the development of an effective BPS training programme for practitioners.

Link to the full article:

Giacomo Zangoni, MSc, BSc, MHCPC, MCSP, Physiotherapist and Osteopath

Dr Oliver P. Thomson PhD, MSc, PG Cert, BSc (Hons), DO, Associate Professor

Dr Jerry Draper-Rodi D.Prof. (Ost), PG Dip, PG Cert, DO, Senior Research Fellow at University College of Osteopathy




Andersson, G.B., 1999. Epidemiological features of chronic low-back pain. Lancet 354 (9178), 581e585.

Charmaz, K., 2016. Constructing Grounded Theory. SAGE Publications.

Darlow, B., (2016). Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine. 20, pp.53-61

Darlow, B., Perry, M., Stanley, J., (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. British Medical Journal, 4(5): e004725.

Domenech, J., Sànchez-Zuriaga, D., Segura-Ortì, E., Espejo-Tort, B. & Lisòn, J. F. 2011. Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: A randomised clinical trial. Pain, 152, 2557-2563.

Draper-Rodi J, Vogel S, Bishop A. 2016. Impact of an e-learning programme on the biopsychosocial model for non-specific low-back pain on experienced osteopaths’ attitudes to back pain: A mixed-methods study. Manual Therapy 25, e167-e168

Innes, S.I., 2005. Psychosocial factors and their role in chronic pain: a brief review of development and current status. Chiropr. Osteopat. 13 (1), 1.

Kendall, N.A., 1999. Psychosocial approaches to the prevention of chronic pain: the low back paradigm. Best Pract. Res. Clin. Rheumatol. 13 (3), 545e554.

Main, C. J., Foster, N., Buchbinder, R., (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice & Research Clinical Rheumatology, 24 pp. 205–217.

Negrini, S., Monticone, M., Chirchiglia, S., Fabiani, L., Gattinoni, F., Giorgianni, R., Giovannoni, S., Minozzi, S., Politano, E., 2004. Experience in Italy in the development and application of clinical guidelines for low back pain. Eur. Medicophysica 40 (1), 45e53.

NICE, 2016. Low Back Pain and Sciatica in over 16s: Assessment and Management.

Nicholas, M.K., Linton, S.J., Watson, P.J., Main, C.J., 2011. The “Decade of the Flags” Working Group. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys. Ther. 91, 737e753.

O’Sullivan, K., O’Sullivan, P., O’Sullivan, L. & Dankaerts, W. 2013. Back pain beliefs among physiotherapists are more positive after biopsychosocially orientated workshops. Physiother Pract Res, 34, 37-45.

Overmeer, T., Linton, S.J., Boersma, K., 2004. Do physical therapists recognise established risk factors? Swedish physical therapists’ evaluation in comparison to guidelines. Physiotherapy 90 (1), 35e41.

Piccoliori, Giuliano, Adolf Engl, Doris Gatterer, Emiliano Sessa, Jürgen Der Schmitten, and Heinz-harald Abholz, ‘Management of Low Back Pain in General Practice – Is It of Acceptable Quality : An Observational Study among 25 General Practices in South Tyrol ( Italy )’, 2013

Pincus, T., Vogel, S., Breen, A., Foster, N., Underwood, M., 2006a. Persistent back pain and why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. Eur. J. Pain 10 (1), 67, 67.

Pincus, T., Vogel, S., Burton, A.K., Santos, R., Field, A.P., 2006b. Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence. Arthritis Rheum. 54 (12), 3999e4010.

Singla, M., Jones, M., Edwards, I., Kumar, S., 2015. Physiotherapists’ assessment of patients’ psychosocial status: are we standing on thin ice? A qualitative descriptive study. Man. Ther. 20 (2), 328e334.

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., O’Sullivan, K., 2015. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J. Physiother. 61 (2), 68e76.

Thomson, O., Petty, N., J., Scholes, J., (2014). Grounding osteopathic research – Introducing grounded theory. International Journal of Osteopathic Medicine, 17, pp. 167-186.

Wand, B.M., O’Connell, N.E., 2008. Chronic non-specific low back painesub-groups or a single mechanism? BMC Musculoskelet. Disord. 9 (1), 1.

Zangoni, G., & Thomson, O. P. (2017). “I need to do another course”- Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back painMusculoskeletal Science and Practice, 27, 71–77.

About Giacomo Zangoni


Giacomo is a registered Osteopath and Physiotherapist, obtaining the Master’s degree in Osteopathy at University College of Osteopathy (London) and previously the Bachelor’s degree in Physiotherapy at the University of Padua (Italy). Since 2012 he has been collaborating in Italy and now in London with sport societies and working in private clinics and rehabilitation centers. Giacomo is currently collaborating with the Research team of the British School of osteopathy on the evaluation of psychosocial factors in chronic low back pain.

About Dr Oliver Thomson

olly thomson

Dr Oliver Thomson is a practicing osteopath and Associate Professor at the University College of Osteopathy where he leads the research teaching for the undergraduate and postgraduate osteopathy programs. Oliver completed his PhD in osteopathy at the University of Brighton, Clinical Research Centre for Health Professions, where he explored osteopaths’ clinical decision-making. His research interests include clinical decision making and reasoning, professional identity and beliefs, and qualitative research and has published extensively in these areas. He is an Associate Editor of the International Journal of Osteopathic Medicine and is on the international advisory board for Musculoskeletal Science and Practice.

About Dr Jerry Draper-Rodi



Dr Jerry Draper-Rodi is an academic clinician: he is CPD Manager and Research Lecturer at the University College of Osteopathy, chairs Oxfordshire Osteopathic Network and practises in Oxfordshire. He was awarded a Professional Doctorate in Osteopathy in 2016. His research was on the acceptability, feasibility and likely impact of a biopsychosocially-informed e-learning programme for non-specific LBP on experienced osteopathic practitioners’ attitudes to back pain. He has presented his research in numerous conferences and has published articles in peer-reviewed journals. Jerry is a reviewer for the International Journal of Osteopathic Medicine.