Physiotherapists’ assessment of psychosocial factors in individuals with musculoskeletal pain: A scoping review

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Physiotherapists’ assessment of psychosocial factors in individuals with musculoskeletal pain: A scoping review

https://doi.org/10.21203/rs.3.rs-3409736/v1

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This study aims to review physiotherapists’ practice in assessing psychosocial factors in individuals with musculoskeletal pain. A comprehensive electronic search was conducted on May 2022 in four databases: PubMed, Web of Science, Science Direct, and Scopus. Two reviewers independently screened retrieved studies for potential inclusion in the review. Data were extracted by two independent reviewers using a standardized extraction form. A total of 15 studies were included. Physiotherapists assessed musculoskeletal pain using the biomedical model, with little consideration of the assessment of psychosocial factors. Although physiotherapists were aware of the importance of assessment of the psychosocial factors, those factors were not routinely assessed in clinical practice. In general, some physiotherapists have informally assessed the psychosocial factors during patients’ interviews\dialogues, while others rely on gut feelings during patients’ interviews to identify psychosocial factors. Formal screening of psychosocial factors using validated questionnaires was not part of the routine clinical practice of physiotherapists. Multiple factors were described to be the barriers to such assessment including lacked education in assessing psychosocial factors, the need for skills and training on such assessment, and insufficient treatment session duration.

assessment

psychosocial

physiotherapists

musculoskeletal pain

Musculoskeletal (MSK) pain affects joints, tendons, muscles, ligaments, and supporting structures, such as intervertebral discs. ¹ According to the Global Burden of Disease, MSK disorders were amongst the top ten causes of increasing the number of disability adjusted life years (DALY) between 1990 and 2019.² Low back pain ranked fourth in teenage years into old age, while neck pain ranked 19th ranking in ages between 25 and 49 years.² In addition, osteoarthritis ranked 18th at the age of 50 to 74 years.²

Multifactorial factors that contribute to MSK pain include both physical and psychosocial factors.³ A large body of evidence has shown a relationship between psychosocial factors and MSK pain. This evidence suggested that psychosocial factors are one of the leading causes of aggravating pain severity, reducing physical health and functional performance at work, and increasing the level of impairment in individuals suffering from MSK pain.^4,5 Furthermore, psychosocial distress is frequently associated with the transition of MSK pain from acute to chronic pain.⁶

Psychosocial distress is a broad concept given to several factors, such as poor quality of life, depression, anxiety, fear avoidance, catastrophizing pain, and kinesiophobia.^7,8 These factors contribute to poor prognosis and persistence of pain following the first pain experience.⁹ Moreover, negative believe and fear may cause an overreaction to pain related movement, leading to avoidance of any movement or physical activity that may provoke the pain.⁵ This pain experience may explain why some patients are unable to make a full recovery. Therefore, using the biopsychosocial model, which has been validated over 30 years of research during the assessment of pain is important for planning better treatment strategies.^10,11

In general, physiotherapists assess MSK pain from the biomedical view of pain, which focuses on tissue damage or the pathological aspect of pain.^12,13 However, evidence showed that the relationship between tissue damage and the pain experience is not always correlated.¹⁴ To date, little is known regarding physiotherapists' assessment of the psychosocial aspect of pain. Therefore, this scoping review aims to investigate the clinical practice of physiotherapists related to the assessment of psychosocial factors in individuals with MSK pain.

Design

A scoping review protocol was drafted a priori according to the Joanna Briggs Institute Reviewers’ Manual 2015 for JBI scoping reviews.¹⁵

Data Sources and Searches

A comprehensive electronic search was conducted on May 2022 in the following databases: PubMed, Web of Science, Science Direct, and Scopus from January 1990 to May 2022. Keywords and relevant MESH headings were used to identify relevant studies to the aim of the scoping review, such as “evaluation “or “screening” or “assessment “paired with “physiotherapy” or “physical therapy” or “physiotherapists” paired with “musculoskeletal” or “musculoskeletal pain” or “spinal Pain” or “joint pain” or “peripheral pain” or “neck pain” or “shoulder pain” or “back pain” or “knee pain” adding “psychosocial" or “psychological” or “biopsychosocial”.

Study selection

After duplication was removed, two independent reviewers screened titles and abstracts of retrieved articles. Full-text articles were screened by the same reviewers for possible inclusion in this scoping review based on eligibility criteria. Disagreements between reviewers were resolved by consulting a third reviewer. Studies were included in the scoping review if:

• Studies were involved musculoskeletal pain (neck pain, back pain, lower extremity, and upper extremity pain).

• Studies have involved assessment of psychosocial factors either subjectively or using bedside assessment tools, such as self-report questionnaires.

• Studies’ participants were physiotherapists and manual therapists.

• Studies were published in English.

Studies were excluded as follows:

• Studies were investigated the assessment of psychosocial factors in patients with non-musculoskeletal conditions.

• Studies were included children or adolescents.

• Studies were investigated the management of psychosocial factors.

• Editorials, case reports, experimental studies, or reviews.

Data Charting

Data were extracted by two independent reviewers using a standardized extraction form that was developed by the research team. This extraction form includes; the author name, year of publication, study design, country setting, number of participants, methods investigated physiotherapists’ assessment of psychosocial factors, assessed psychosocial factors, and outcome data/ results of included studies.

Data synthesis and analysis

The findings from included studies were combined to reach a conclusion based on the similarities of findings. This review presented a narrative analysis of the results.

Study selection

The electronic search yielded 21189 studies. After duplication was removed, 20260 studies were selected for title screening. After title screening, 76 studies were considered for abstract screening. Of those, only 15 studies were selected after the full-text screening (Fig. 1).

Study characteristics

Participants were physiotherapists, undergraduate physiotherapy students, and interns from different country settings. The total number of participants in included studies was 1799, ranging from 8 to 900 participants. Participants were 432 physiotherapists from Australia,^16–19 39 physiotherapists were from the Netherlands,^20,21 924 were from the United Kingdom.^22–24 While 404 participants were from other countries, such as Ireland, Sweden, Switzerland, Italy, Brazil, Belgium.^25–27 Of the total number of participants in the included studies, 335 were female physiotherapists (Table 1).

Table 1

Study characteristics
Author/Year	Study design	Country	Number of Participants	Methods investigated physiotherapists’ assessment of psychosocial factors	Investigated Psychosocial factors	Outcome data/ results
Teo et al. (2020)¹⁹	qualitative study	Australia	22 Australian physiotherapists	Semi-structured telephone interviews	Psychosocial factors	Physiotherapists focus on the biomedical aspect of OA pain. Some physiotherapists were aware of psychosocial factors. However, they have infrequently assessed these factors.
Lennon et al. (2020)²⁹	cross-section study online survey	Ireland	320 physiotherapists	Online survey contains closed- and open-ended questions	Psychosocial distress	About half of the physiotherapists who completed the survey routinely assessed the psychological distress. A quarter of those used validated questionnaires, such as the Hospital Anxiety and Depression Scale, the EQ-5D, and the Keele STarT Back Screening Tool, to assess symptoms of fear, anxiety, and catastrophizing.
Emilson et al. (2016)²⁶	descriptive and explorative research design	Sweden	12 primary health care physiotherapists	Video recording of physiotherapists’ assessment of their patients	Yellow and red flags	The majority of experienced physiotherapists evaluated the red and yellow flags. However, the integration of the findings in analyses and treatment was incomplete.
Singla et al. (2015)¹⁶	qualitative descriptive research	Australia	9 Physiotherapists	Semi-structured interview of physiotherapists	Psychosocial factors	Physiotherapists rely on gut feelings during patients’ interviews to identify psychosocial factors. Physiotherapists reported lacked understanding of psychosocial factors, and limited knowledge and expertise made them hesitant to assess these factors.
Brunner et al. (2018)²⁷	pragmatic, observational study	Switzerland	20 physiotherapists	Open-ended questionnaire	Test physiotherapists ability to allocate patients in a risk prognostic groups, including functional limitation in one year, Distress, depression, anxiety, and Kinesiophobia	Physiotherapists were poor at assigning patients to risk stratification groups, or recognizing psychological factors, such as depression, anxiety, and kinesiophobia without any formal screening questionnaires.
Oostendorp et al. (2015)²¹	observational prospective cross-sectional design	Netherlands	20 manual physical therapists	Audio recording of manual therapists’ assessment of their patients	Somatic, Psychological (Cognition, Emotion, and Behavior), and Social dimensions of chronic pain	Manual physical therapists inadequately covered the psychological and social domains of chronic pain.
Cowell et al. (2018)²⁴	qualitative study	England	10 physiotherapists	semi-structured interviews	Cognitive and emotional factors	Physiotherapists are aware of the importance of considering the multifaceted of non-specific chronic low back pain management, but felt lacking of knowledge and time to effectively address cognitive and emotional factors for managing patients with non-specific low back pain.
van Wilgen et al. (2014)²⁰	qualitative analysis	Netherlands	19 physiotherapists	Audiotape physiotherapists’ assessment of their patients	Illness perceptions	Physiotherapists were biomedically oriented. Physiotherapists rarely ask for emotional representation during the assessment of their patients.
Man et al. (2019)¹⁷	Cross- sectional online survey	Australia	181 physiotherapists	Triple P Questionnaire	Psychosocial factors	Physiotherapists routinely encountered patients with psychosocial issues during patients’ interviews. However, physiotherapists were less confident in assessing psychosocial factors by questionnaires.
Roussel et al. (2015)²⁵	Mixed methods	Belgium	34 Physiotherapists and 34 patients	Videotaped interviews	Illness perception	Physiotherapists were not sufficiently addressed the psychosocial aspect of illness perception. Physiotherapists’ questions were mainly focused on the biomedical aspect of illness perception, including illness identity, provoking factors, and treatment control.
Zangoni & Thomson (2017)²⁸	Qualitative research design	Italy	8 physiotherapists	Semi-structured interviews of physiotherapists	Psychosocial factors	Physiotherapists identified psychosocial factors during their discussions with patients. Physiotherapists have a basic understanding of psychosocial factors and their impact on patients with chronic low back pain, but they lack skills and knowledge in evaluating and managing psychosocial factors.
França et al. (2019)³⁰	qualitative design	Brazil	10 physiotherapists	Five face to face interviews and five video interviews.	Biopsychosocial factors	Physiotherapists have little theoretical knowledge about the biopsychosocial model. However, they do not articulate their knowledge in practice. Among physiotherapists who asses biopsychosocial factors, the majority were not using questionnaires.
Sanders et al. (2013)²³	qualitative research	UK	12 physiotherapists	semi-structured qualitative Interviews	Psychosocial problems	Physiotherapists navigate patients’ psychosocial problems and address the lay health beliefs of patients through patients’ reassurance and lifestyle advice.
Bishop et al. (2005)²²	Cross sectional descriptive vignette survey	United Kingdom	900 Physiotherapist	Patient Vignettes (Case Scenarios) of patients with acute low back pain	Patient’s risk of chronicity	Physiotherapists recognized patients at high risk of chronicity. However, advice not to work recommended by the majority of physiotherapists’ assessment was not based on the presence or absence of psychosocial risk factors.
Driver et al. (2019)¹⁸	Mixed methods on-line cross sectional survey	Australian	201 physiotherapists	Two open-ended questions to describe use of psychological strategies with their patients	Patient attitudes, cognitions, emotions, coping, behaviours, life style, and social support.	Findings showed that physiotherapists tend to have the biopsychosocial viewpoint when considering the use of psychosocial strategies in practice. Patients’ attitude was the most factor physiotherapists assessed.

Assessment of psychosocial factors

The included studies used different methods to investigate the way physiotherapists assess psychosocial factors in individuals with MSK pain in their clinical practice. These methods include semi-structured interviews,^{16,19,23,24,28} online surveys contain closed and open-ended questions,²⁹ triple P questionnaire,¹⁷ two open-ended questions,^18,27 patient vignettes,²² videotaped interviews,^25,26 mixed face to face interviews and video interviews,³⁰ and audiotaped (Table 1).^20,21

Seven of the included studies investigated general psychosocial factors.^{16,17,19,23,28–30} While others investigated specific factors, such as illness perception,^20,25 cognitive and emotional factors,^18,24 social dimensions of chronic pain,²¹ distress, anxiety, depression, and kinesiophobia.²⁷ In addition, one study assessed patients’ risk of chronicity,²² while one study investigated red and yellow flags²⁶ (Table 1). Physiotherapists in seven of the included studies assessed the psychosocial factors informally based on gut feelings, or interviews/discussions with their patients.^{16,17,22,26–28,30} However, five of the included studies showed that physiotherapists did not mainly focus on psychosocial factors during the assessment of their patients.^19–22,25

Some studies indicated that physiotherapists were less confidant or hesitant to use any formal screening questionnaires.^16,17,30 Only one study revealed that some physiotherapists used validated questionnaires in assessing psychosocial factors, such as the Hospital Anxiety and Depression Scale, the EQ-5D, and the Keele STarT Back Screening Tool to assess fear, anxiety, and catastrophizing.²⁹ Two studies reported that physiotherapists used the biopsychosocial model for the assessment of their patients, however, the extent of using such as model was based on physiotherapists’ clinical experience, perceived knowledge, and skills^18,24 (Table 1).

This scoping review investigated the clinical practice of physiotherapists related to the assessment of psychosocial factors in individuals with MSK pain. A total of 15 studies met the eligibility criteria. Overall, physiotherapists focused on biomedical assessment with little consideration for the assessment of psychosocial factors in their clinical practice. Evidence from four included studies indicated that physiotherapists informally assessed psychosocial factors during conversations with their patients or depending on their patients’ interview/discussion or based on physiotherapists’ gut feelings.^16,17,28,29 There was one study where physiotherapists used validated questionnaires, such as the Hospital Anxiety and Depression Scale, the EQ-5D, and the Keele STarT Back Screening Tool to assess symptoms of fear, anxiety, and catastrophizing.²⁹

The biopsychosocial model has been recommended as an alternative to the biomedical model for the assessment of patients with chronic MSK pain.²⁰ Despite the awareness of some physiotherapists about the relationship between physical and psychological well-being,^{19,20,22,28,29} physiotherapists have strong beliefs in the role of the biomedical model in individuals with MSK pain.^{19–22,25–27} In addition, some physiotherapists a lacked clear understanding of the extent to which psychosocial assessment is appropriate for their clinical practice.^{18,23,24,26,27,30} Therefore, there is a need for enhancing the implementation of the biopsychosocial model in clinical practice for better management strategies in individuals with MSK pain.

Physiotherapists reported some barriers to the assessment of psychosocial factors in their clinical practice. Those barriers include insufficient session duration and inadequate time to build a trusting patient-therapist relationship.^17,18,24 Furthermore, some physiotherapists afraid of interrupt the patient-therapist relationship by discussing patients’ psychological distress.²⁸ Additionally, other physiotherapists indicated that patients’ refusal or lack of awareness and beliefs about the role of psychosocial factors and their implications in the development and maintenance of MSK pain might make physiotherapists hesitate to assess the psychosocial factors.²⁸

The aforementioned barriers to the assessment of psychosocial factors indicated the need for providing physiotherapists with skills and training to effectively incorporate psychosocial assessment in their clinical practice. Physiotherapists felt lacking in knowledge for the understanding of psychosocial factors, and limited knowledge and expertise made them hesitant to effectively address psychosocial factors for managing patients with MSK pain.^17,24,26 Therefore, it is suggested that enhancing physiotherapy undergraduate and postgraduate curricula with lectures/training courses related to the assessment of psychosocial factors. This would assist physiotherapists to implement better treatment strategies for the persistence of MSK pain.

Strengths

This is the first scoping review that identified the current practice of physiotherapists related to the assessment of psychosocial factors in individuals with MSK pain. The included studies had a great range of male and female physiotherapists of different ages, and various work settings across several countries, which could reflect the global physiotherapy clinical practice. This review highlighted the need for increasing awareness of the importance and implementation of the assessment of the psychosocial factors in the daily practice of physiotherapists when assessing and managing individuals with MSK pain.

Limitations

The potential limitation of this scoping review includes only four databases for studies’ identification. However, a substantial number of studies were found for this review. Only studies were written in English included in this review. Therefore, it is likely that additional studies were written in other languages may be relevant to this scoping review. Despite these limitations, this scoping review can provide valuable data related to the current physiotherapy clinical practice for the assessment of psychosocial factors.

Clinical implication

Physiotherapists should enhance their knowledge to implement the biopsychosocial model for the assessment of individuals with MSK pain. The assessment of the psychosocial aspect of MSK pain will assist physiotherapists in tailoring better treatment strategies to achieve treatment objectives. Physiotherapists can identify the contribution of psychosocial factors in individuals with MSK pain during history taking/interview and further assess identified factors using different validated patient self-reported questionnaires.

The biomedical model was the dominant approach for the assessment and management of individuals with MSK pain. Despite adequate awareness of physiotherapists about the importance of the assessment of psychosocial factors in individuals with MSK pain, it was not a key part of their clinical practice. This was attributed to insufficient education, lack of training and skills, limited session time, and fear of interruption of the patient-therapist relationship. Therefore, there is a need for building the capacity of physiotherapists in assessing psychosocial factors in individuals with MSK pain. Future research should overcome the barriers to the assessment of the psychosocial factors in physiotherapy clinical practice to improve individuals’ treatment objectives.

Acknowledgements:

All gratitude and appreciation to Dr. Rani Othman and Dr. Umar Alabasi for their contribution to study selection.

Author contributions:

The author (Abdullah Alqarni) wrote the main manuscript.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Availability:

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests: The author declare no competing interests.

Ethics approval and consent to participate: Not applicable.

Consent for publication: Not applicable.

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No competing interests reported.

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Physiotherapists’ assessment of psychosocial factors in individuals with musculoskeletal pain: A scoping review

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Abstract

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Introduction

Methodology

Results

Study selection

Study characteristics

Assessment of psychosocial factors

Discussion

Strengths

Limitations

Clinical implication

Conclusion

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References

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