systematic review interventions in physiotherapy practice...

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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=idre20 Download by: [Cornell University Library] Date: 17 September 2016, At: 07:41 Disability and Rehabilitation ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20 Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review Christina Driver, Bridie Kean, Florin Oprescu & Geoff P. Lovell To cite this article: Christina Driver, Bridie Kean, Florin Oprescu & Geoff P. Lovell (2016): Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review, Disability and Rehabilitation, DOI: 10.1080/09638288.2016.1223176 To link to this article: http://dx.doi.org/10.1080/09638288.2016.1223176 Published online: 16 Sep 2016. Submit your article to this journal View related articles View Crossmark data

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Page 1: systematic review interventions in physiotherapy practice ...physiomeetsscience.com/wp-content/uploads/2016/10/Knowledge-behaviors... · evolution of the scope of physiotherapy practice

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=idre20

Download by: [Cornell University Library] Date: 17 September 2016, At: 07:41

Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Knowledge, behaviors, attitudes and beliefs ofphysiotherapists towards the use of psychologicalinterventions in physiotherapy practice: asystematic review

Christina Driver, Bridie Kean, Florin Oprescu & Geoff P. Lovell

To cite this article: Christina Driver, Bridie Kean, Florin Oprescu & Geoff P. Lovell (2016):Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use ofpsychological interventions in physiotherapy practice: a systematic review, Disability andRehabilitation, DOI: 10.1080/09638288.2016.1223176

To link to this article: http://dx.doi.org/10.1080/09638288.2016.1223176

Published online: 16 Sep 2016.

Submit your article to this journal

View related articles

View Crossmark data

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REVIEW ARTICLE

Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the useof psychological interventions in physiotherapy practice: a systematic review

Christina Drivera, Bridie Keana,b, Florin Oprescua and Geoff P. Lovellc

aCluster for Health Improvement, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore,Australia; bCentre of Excellence for Applied Sport Science Research, Queensland Academy of Sport, Sunnybank, Australia; cSchool of SocialSciences, University of the Sunshine Coast, Maroochydore, Australia

ABSTRACTPurpose: To systematically review and analyze the literature exploring the knowledge, behaviors, atti-tudes, and beliefs of physiotherapists towards the use of psychological interventions in their practice.Methods: A systematic search was conducted, of articles published between January 1996 and February2016, using selected electronic databases followed by crosschecking of reference and citation lists. Articleswere selected on the basis of the research reported relating to knowledge, behaviors, attitudes or beliefsof physiotherapists towards using a number of different psychological interventions. Quality assessmentwas conducted by three reviewers independently, and thematic analysis of the included studies wasperformed.Results: Fifteen studies were included in the analysis. Results indicate that physiotherapists are aware ofpsychological interventions, are using a variety within practice, and have positive attitudes and beliefstowards their use. However, there are barriers to the incorporation of psychological interventions intotheir practice, including lack of knowledge, time constraints, and role clarity. The desire for further trainingwas also evident.Conclusion: Notwithstanding the reported awareness and use of psychological interventions in physio-therapy practice, barriers to implementation exist indicating that further research is necessary to addresshow to effectively equip physiotherapists, to employ such techniques within their scope of practice.

� IMPLICATIONS FOR REHABILITATION� Physiotherapists use and have positive attitudes and beliefs towards a variety of psychological inter-

ventions including goal setting, positive, and motivational talk, cognitive behavioral therapy strategiesand offering social support.

� Barriers preventing the incorporation of psychological interventions in practice include, lack of know-ledge, time constraints, and role clarity.

� Despite the use of such interventions, physiotherapists identify the need for further training, to bebetter equipped to confidently utilize these in practice.

� These results justify the incorporation of training in psychological interventions in physiotherapistqualifying studies, but also as continued professional development opportunities for physiotherapistscurrently working in the field.

ARTICLE HISTORYReceived 3 March 2016Revised 28 July 2016Accepted 8 August 2016Published online 7 Septem-ber 2016

KEYWORDSPsychological interventions;physiotherapy; biopsychoso-cial; injury; goal setting

Introduction

Disability as a result of disease or injury and consequentialrehabilitation can impact physical, emotional, social, cognitive,and behavioral aspects related to ones’ health.[1] Health professio-nals involved in rehabilitation can have a substantial influence onthe physical, social, and psychological recovery of patients.[2,3]This established connection endorses the importance of adoptinga biopsychosocial perspective for rehabilitation with thoseaffected by disability.

Over the last two decades, research has increasingly attendedto the psychological component of a biopsychosocial model,investigating the psychological issues associated with the rehabili-tation process. Much of the early research focused on sport-related injuries and rehabilitation,[4] outlining the extent to whichmultiple factors such as cognitions, emotions, social, contextual,

and biological factors can affect rehabilitation outcomes.[5] Morerecently published research has documented the multifacetedexperiences acknowledged by patients living with chronic pain,suggesting that pain was only one component of the suffering,as patients were more affected by the resulting psychologicaldistress, such as worry, isolation, and anguish.[6]

Psychological aspects of rehabilitation have also been investi-gated with regards to conditions, such as chronic pain manage-ment in the elderly, hip fractures, and work disability. Patientssuffering from chronic pain have been found to have increasedrisk of developing depression, anxiety, poor self-esteem, and socialisolation;[7] and the opinion that a biomedical model alone failsto explain the complexity of pain is becoming more accepted.[8]Indeed, it has been suggested that patients recovering from hipfracture are susceptible to reduced self-efficacy and unsupportivecoping strategies, with long-term physical limitations resulting in

CONTACT Christina Driver [email protected] Cluster for Health Improvement, Faculty of Science, Health, Education and Engineering,University of the Sunshine Coast, Maroochydore, Australia� 2016 Informa UK Limited, trading as Taylor & Francis Group

DISABILITY AND REHABILITATION, 2016http://dx.doi.org/10.1080/09638288.2016.1223176

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a lack of social engagement, and inability to perform daily tasksand activities.[9] Increase in psychological risk factors, such asthese have resulted in patients encountering emotional conse-quences including frustration, fear avoidance, and decreased cop-ing strategies.[9,10] Sullivan et al. [11] discussed the importanceof addressing psychological risk factors, which can affect rehabili-tation for work disability, as the occurrence of such risk factorsincrease the likelihood that pain-related disability will continue forlonger periods of time. The severity of the injury or disease canalso have substantial acute and long-term psychological effectsdue to varying outcomes and recovery periods associated withrehabilitation,[10] and depression is increasingly being identifiedas a common condition among those living with a long-termdisability.[1]

Physiotherapists (PTs) are traditionally those responsible for theassessing, diagnosing, and treating those who are affected by dis-ability from disease or injury, aiming to restore, maintain andimprove function and ability in patients of all ages with varying lev-els of injury, pain, and health conditions.[12–14] PTs, appear to bewell positioned to adapt their roles and expand their scope of prac-tice, to offer more relevant services and opportunities, aiding in themanagement of the increasing health burdens of the population,and the complex nature of disability.[15] Reports suggest that anevolution of the scope of physiotherapy practice has alreadystarted resulting in patients being increasingly addressed from abiopsychosocial perspective.[16] The previously defined roles andboundaries in the healthcare system including physiotherapy havedeveloped over time to incorporate psychological strategies as anadjunct to physical therapy.[17] Consequently, PTs involved in thetherapy and rehabilitation process for individuals affected by dis-ability, could arguably have an important role to play in addressingpsychological aspects, which may contribute substantially to betterclient care, wellbeing, and rehabilitation outcomes.

Evidence supports the use of psychological interventions dur-ing rehabilitation, to increase adherence to physiotherapy pro-grams, and improve recovery outcomes.[2,11,17,18] Interventionsincluding goal setting, cognitive behavioral therapy (CBT), mentalimagery, relaxation, motivational interviewing, self-talk, andencouraging social support have all been found to be useful toolsto enhance the rehabilitation process.[4,19–26] Historically, theuse of psychological interventions and their significance duringrehabilitation have been driven predominantly by sport psych-ology literature, and more recently the challenges faced by PTs inthe implementation of such interventions in the clinical manage-ment of pain [22,27] have been explored. However, acknowledg-ing the current diverse specialties of practicing PTs and theirexpanding role in healthcare, some literature has also exploredthe effectiveness and feasibility of psychologically orientated inter-ventions in other areas of PT practice.

The expansion of PTs roles has led to the inclusion of PTs in themultidisciplinary care of those with complex mental health condi-tions, particularly aimed at the promotion of physical activity andmanagement of associated co-morbidities, such as cardiorespira-tory disease and diabetes.[28,29] It has been acknowledged thatPTs working with clients with Schizophrenia recognized the import-ance of using holistic interventions to encourage mind-body aware-ness,[30] and that engagement in physical activity can promotepsychological wellbeing.[29,31] Furthermore, research investigatingPT’s involvement in neurological rehabilitation reported that men-tal practice, relaxation, and activity coaching alongside routinephysiotherapy had beneficial effects for their clients.[32,33]

Additional research identified the valuable contribution PTshave in the rehabilitation of those with cancer, HIV/AIDS and clientsin palliative care settings,[34–37] as such conditions often result in

co-morbidities such as chronic pain, emotional distress, and lack ofmobility and functionality.[36,37] PTs play an important role inimproving quality of life and wellbeing in clients, and cancerpatients themselves have expressed the value in PTs being able tooffer a holistic perspective addressing their psychological and phys-ical needs.[35] Despite the body of research addressing the broaderareas of physiotherapy practice and the benefits of psychologicalorientated interventions for clients, the knowledge, behaviors, atti-tudes and beliefs of the PTs themselves towards such interventionsare yet to be systematically researched and documented.

With the current shift towards adopting a biopsychosocial per-spective in physiotherapy practice incorporating psychologicalinterventions, it is important to gain insight into how this chang-ing role is perceived by PTs themselves, and to identify the chal-lenges in accepting this role. Previous reviews have synthesizedinformation with regards to limited areas of physiotherapy prac-tice; the integration of psychosocial principles within back painmanagement,[27,38] and psychological interventions utilized bymusculoskeletal PTs predominantly in the UK.[39] However, basedon the aforementioned limitations of previous reviews that appearto lack generalisability to the broader context of physiotherapy, itis important to ascertain an international perspective concerningmultiple facets of physiotherapy practice.

In the light of current healthcare trends encouraging thesepurported changes in PT roles, but the limited and somewhat dis-perse research in this area, this review aims to identify the know-ledge, behaviors, attitudes, and beliefs of PTs towards the use ofpsychological interventions in physiotherapy practice. Specifically,it will be report commonly utilized psychological interventionswithin physiotherapy practice; what are the attitudes towardssuch interventions, including any potential differences across prac-tice areas; what are PTs most commonly identified barriers; andwhat if any PTs perceive are their key training needs with regardsto psychological interventions. The result of such a review couldhave important implications for the design of training and supportfor PTs, including the associated benefits for their patients’ recov-ery and wellbeing.

Methods

Literature search

A systematic literature search [40] was conducted using onlinedatabase search engines including Scopus, Web of Science,PubMed, and PsychInfo, followed by crosschecking reference andcitation lists. The search was performed by the first author betweenJanuary 2016 and February 2016. Search strategies focused on theinitial inclusion of titles and/or abstracts containing the key words“physiotherapy” OR “physiotherapists” OR “physical therapy,” thenfurther narrowed down, including key words; “cognitive behavioraltherapy” OR “goal setting” OR “imagery” OR “visualization” OR “self-talk” OR “relaxation” OR “positive reinforcement” OR “motivationalinterviewing” OR “social support” OR “coping strategies” OR“biopsychosocial” OR “psychosocial” OR “psychological”. Key wordsincluded specific psychological interventions and broad terms toaccount for the potential differences in interpretations and labelsof psychological strategies. A final key word search included“knowledge” OR “attitudes” OR “beliefs” OR “behaviors” OR “views”OR “perceptions” (Table 1). Duplicates were removed and theremainder titles and abstracts were assessed for relevance, referringto full text if further information was necessary. Relevant articleswere checked for peer review status, discussed based on the inclu-sion and exclusion criteria (CD, FO, GL), quality assessed (CD, GL,BK) and assessed for risk of bias (CD, GL).

2 C. DRIVER ET AL.

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Inclusion and exclusion criteria

Inclusion and exclusion criteria were developed by the researchteam to identify key areas of interest. These criteria were informedby previously published literature, addressing the strengths andlimitations of such research. Table 2 outlines the inclusion andexclusion criteria.

Quality assessment

Guidelines for Critical Review Forms (GCRF) developed by theMcMaster University Occupational Therapy Evidence BasedPractice Research Group [41,42] were used to assess the qualityand risk of bias of the included articles. GCRFs have been used inprevious systematic reviews [43,44] and a PT narrative review.[45]The GCRF were chosen as they can easily be applied to PT-basedresearch and two separate checklists for qualitative and quantita-tive study designs are utilized. Studies that were predominantlyquantitative with a very small component of qualitative (surveyswith short answer responses) were assessed as quantitative.

Articles were scored based on meeting certain criteria andrecorded to give each article an overall quality score. The criteriafor the quantitative assessment were adapted slightly, due to allthe quantitative studies reviewed being survey based. The GCRFassessment items referring to outcomes and interventions wereconsequently omitted as this was not the focus of the currentreview. The GCRF results section was also amended to reflect thedescriptive nature of survey results, hence removing the statisticalsignificance item. Additionally, the item referring to drop outs wasmodified to response rate to better reflect the design of thereviewed studies. The assessment criteria for quantitative researchtherefore included study purpose, literature, design, sample,results, conclusions, and clinical implications. The assessment crite-ria for qualitative research included study purpose, literature,study design, sample, data collection, data analysis, trustworthi-ness, conclusions, and implications. One mark was given if the

criteria were evidently met and no marks were given if the criteriawere not obvious. Qualitative articles were given a score out of 24and quantitative articles were given a score out of 9 and con-verted to percentages. The articles were subjected to blind assess-ment by three of the authors (CD, GL, BK) resulting in agreementscores of 90% or better. The subsequent results were discussed,and any discrepancies in items were deliberated until a consensuswas reached.

Data analysis and synthesis

Thematic analysis of the included articles results was conductedfollowing the six steps outlined by Braun and Clarke,[46] catego-rizing the results into themes addressing the aims of the review.Consistent with previous reviews involving multiple researchdesigns,[45] a meta-analysis method of synthesis was not adopteddue to the heterogeneity of the included studies.

Study identification

Initial search strategies as described resulted in 947 studies beingidentified through database searches and nine additional studiesthrough citation and reference checking, one of which wasretrieved by contacting the author.[47] Screening by way of dupli-cate removal resulted in 802 studies, and further screening pro-duced 100 studies to be assessed for eligibility. Evaluationthrough title and abstract assessment followed resulting in a totalof 41 studies being identified as relevant. Peer review status waschecked and subsequent assessment and discussion by three ofthe authors based on the inclusion and exclusion criteria resultedin the final inclusion of 17 studies. Twenty-four studies wereexcluded from the final review, as they did not meet eligibility cri-teria (Figure 1).

Quality assessment of the remainder studies identified that 16articles achieved 75% or over (one scored 67%), and had low risk

Table 1. Search strategy.

Database Type of search Keywords and strategyNo. of articles

retrieved

PubMed Title and abstract Physiotherapists OR physiotherapy OR physical therapyAND Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral ther-

apy OR goal setting OR imagery OR visualization OR self-talk OR relaxation ORpositive reinforcement OR motivational interviewing OR social support OR copingstrategies

AND knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views

248

PsychInfo Abstract Physiotherapists OR physiotherapy OR physical therapyAND Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral ther-

apy OR goal setting OR imagery OR visualization OR self-talk OR relaxation ORpositive reinforcement OR motivational interviewing OR social support OR copingstrategies

AND knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views

190

Web of science Title, then within search results Physiotherapists OR physiotherapy OR physical therapyWithin search results:Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral therapy

OR goal setting OR imagery OR visualization OR self-talk OR relaxation OR positivereinforcement OR motivational interviewing OR social support OR coping strategies

Within search results:Knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views

172

Scopus Title, then within search results Physiotherapists OR physiotherapy OR physical therapyWithin search results:Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral therapy

OR goal setting OR imagery OR visualization OR self-talk OR relaxation OR positivereinforcement OR motivational interviewing OR social support OR coping strategies

Within search results:Knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views

337

Crosschecking reference and citation lists 9

PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 3

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of bias. However, after quality assessment it was decided that afurther two studies were to be excluded from the review.[3,48]Through in depth analysis of the results, it was established thatboth studies did not separate the results of health professionals,athletic trainers and PTs, therefore could not be used to general-ize to the PT population specifically, consequently falling outside

the inclusion criteria. Table 3, summarizes the 15 included studiesand quality assessment results.

The studies included PTs from the US,[49,50] the UK,[51–57]Australia,[47,58–61] New Zealand,[47] and Canada.[47] One inter-national study did not report on the nationality ofrespondents.[62]

Table 2. Inclusion/exclusion criteria.

Inclusion criteria Exclusion criteria

� Research centered on qualified physiotherapists (or physical therapists)� Involved at least one psychological intervention from the list below:

� Goal setting� Imagery/visualization� Self-talk� Relaxation� Positive reinforcement� Motivational interviewing� Cognitive behavioral therapy� Coping strategies� Social support

� Involved the discussion of knowledge, beliefs, attitudes, behaviors, views, per-ceptions, or similar concepts

� Peer reviewed and in any language� Published between January 1996 and February 2016� All study designs included

� Review articles� Involved only the testing of outcomes when using psychological interventionswith patients, rather than the perception of the physiotherapists using them

� Discussion of nonspecific psychological aspects as opposed to specific psycho-logical interventions

� Studies involving physiotherapy students and therefore not practicing� Studies not involving physiotherapists� For the purpose of this review, studies involving only athletic trainers wereomitted due to the difference in role characteristics, compared tophysiotherapists

Figure 1. Prisma flow chart.

4 C. DRIVER ET AL.

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Table3.

Summaryof

includ

edarticlesandresults

ofqu

ality

assessment.

Authors

Stud

yaim

Metho

dology

and

participants

Keyfin

ding

sLimitatio

nsQAScore

Quant/9

Qual/2

4

Holdenet

al.[61]

Gaininsigh

tinto

Australian

PT’sknow

ledg

e,percep-

tions,u

sage

andtrain-

ingof

motivational

strategies

forLower

back

pain

(LBP)and

return

toactivity.

Quantitativedesign

.Online

crosssectionaln

ation-

wideclosed

questio

nsurvey.P

Tsweremem

-bersof

the

Musculoskeletal

Group

oftheAu

stralian

Physiotherapy

Associationworking

with

patientswith

LBP

n¼170

MostPTsfeltitwas

extrem

elyimpo

rtantto

usemotivationalstrategiesforLBP

tohelp

return

tousuala

ctivity.C

ommon

barriers

repo

rted

weretim

econ-

straints

andlack

oftraining

.Active

goal

settingmostrecogn

ized

strategy

butno

tmostcommon

lyused,d

ueto

time.Transtheoretical

Mod

elbased

coun

selingwas

theleastused.P

Tsrepo

rted

active

goal

settingas

most

common

training

received

atun

dergradu

atelevela

ndtraining

increasedcon-

fidence

andperceivedeffectiveness.How

ever,go

alsettingon

lyperceivedas

mod

eratelyeffective.Manyfamiliar

with

CBT,andperceivedas

mod

erately

effective,bu

tbarriers

includ

edlack

oftraining

.Trainingin

CBTresultedin

increasedconfidence

butno

tperceivedeffectiveness.Halfof

PTsfamiliar

with

MI,repo

rted

usingitsometimes

andperceivedas

mod

eratelyeffective.

Mostused

praise

andencouragem

entwith

everypatient.

Treatm

entfid

elity

dueto

lack

ofun

derstand

ingof

motivationalstrategies

listed.

Self-selectionbias

andsampleheavily

weigh

tedtowards

one

statein

Australia.O

nly

targeted

PTsworking

with

LBPpatients.

8/9

Lloydet

al.[57]

ExplorePTsexperiences

andperceptio

nsof

usingcollabo

rativego

alsettingwith

stroke

patientsin

theUK.

Qualitativedesign

.Semi-structuredface

toface

interviews.UKPTs

basedin

stroke

units

at3NationalH

ealth

Serviceho

spitals.n

¼9

PTsacknow

ledg

edthat

patients’health,p

ersonala

ndenvironm

entalfactors

affected

psycho

logicaladjustm

entto

post

stroke

cond

ition

andeffectiveness

ofgo

alsetting.

Goalsettin

gskillsevolvedover

timethroug

hinform

allearn-

ingandwereinstinctive.PTswereno

table

toidentifystructureor

atheoret-

icalfoun

datio

nof

theirknow

ledg

e.Develop

ingatherapeutic

relatio

nship

was

impo

rtantto

PTsto

enable

effectivecollabo

rativego

alsettingandPTs

believedthat

thisem

powered

patientsto

take

anactiverole.G

enerallyPTs

feltthat

collabo

rativego

alsettingiscomplex

andfurthertraining

andexperi-

ence

increasedconfidence.

Did

notreachdata

satur-

ationdu

eto

timecon-

straints

therefore

theoriesestablishedare

provisional.Sample

selected

dueto

locatio

nto

theresearcher.

21/24

Nielsen

etal.[58]

Investigatetheop

inions

andexperiences

ofPTs

whilstimplem

entin

gCB

Tinto

theirpractice

inAu

stralia.

Qualitativedesign

.Semi-structuredph

one

interviews.Au

stralian

PTstrainedin

pain

cop-

ingskillstraining

and

working

with

knee

osteoarthritispatients.

n¼8

PT’shadoverallp

ositive

experiencewith

CBTwhich

enabledthem

toencourage

patientsto

take

anactiverole

intheirrehabilitation/pain

managem

ent.Most

used

relaxatio

nandself-talkstrategies

forcoping

.PTs

feel

CBTisrelevant

andapprop

riate

fortheirpracticebu

texpressedthat

somePTslack

adequate

know

ledg

eto

deal

with

thedepthof

issues.B

arriersto

useof

CBTinclud

e;lack

ofknow

ledg

e,skills,tim

e,cost

andscop

eof

practice.Training

inCB

Tat

postgraduate

levelsug

gested.

Smallsam

plesize

involving

onlypain

managem

ent

techniqu

eswith

knee

osteoarthritispatients.

Samplelim

itedto

two

states

inAu

stralia.

18/24

Scott-Dem

pster

etal.[56]

Discovertheexperiences

andperceptio

nsof

PTs

usingactivity

pacing

with

patientswith

chronicpain

intheUK.

Qualitativedesign

.Semi-structuredface

toface

interviews.UKPTs

experienced

inusing

activity

pacing

with

chronicpain

patients.

n¼6

Activity

pacing

was

identifiedby

PTsas

impo

rtantto

help

patientsadaptto

pain,and

encouraged

patientsto

bemoreproactivein

theirrehabilitation

throug

hassessingtheirow

ncapabilities.PTshigh

lighted

theimpo

rtance

ofa

therapeutic

relatio

nshipbu

tbarriers

includ

edadjustingtheirrole

toa“sit

with

”rather

than

“fixit”

perspective.Activity

pacing

was

notused

inisola-

tionandshou

ldbe

partof

amultifaceted

approach

topain

managem

ent.

Smallsam

pleselected

due

togeog

raph

ical

locatio

nto

theinterviewer.

Limitedto

femalePTs

working

with

chronic

pain

andexperienced

inactivity

pacing

.

21/24

Soun

dyet

al.[62]

Investigatingtheperceived

valueof

socialsupp

ort

toencourageph

ysical

activity

inschizoph

renic

patients.

Qualitativedesign

.Crosssectionalo

pen-ended

survey.P

Tsweremem

-bersof

theInternational

Organizationof

Physiotherapists

inMentalH

ealth

with

atleast1year

experience

ofworking

with

schizo-

phrenicpatients.n¼40

PTsdescrib

edfour

dimension

sof

socialsupp

ort;inform

ational,tang

ible,esteem

andem

otional,andtheimpo

rtance

ofsocial

integration.

PTsidentifiedthe

impo

rtance

ofinform

ationalsup

portthroug

heducationabou

tthebiop

sycho-

social

benefitsof

physical

activity.U

nderstanding

patients’needs,engaging

with

them

,offe

ringencouragem

ent,po

sitivereinforcem

ent,motivational

interviewing,

andotherpsycho

logicalstrategiesweredescrib

edby

PTsas

form

sof

socialsupp

ortto

increase

confidence

andsupp

ortbehavior

change.

PTsperceivedsocial

integration/peer

supp

ortto

beeffectivewith

regardsto

adherenceto

physical

activity.

Low

respon

serate,and

natio

nalitiesof

respon

d-ents

notrepo

rted

sodifficultto

generalize.

Limitedto

specialists

PTsandincomplete

respon

sesto

some

them

es.

16/24

Arvinen-Barrow

etal.[51]

Exam

inePTsperson

alper-

ceptions

abou

ttheuse

ofpsycho

logicalinter-

ventions

insportinjury

rehabilitationin

theUK.

Qualitativedesign

.Sem

i-structured

interviews

with

UKbasedchar-

teredPTsworking

insports

medicine,

recruitedfrom

aprevi-

ousstud

y.n¼7

Psycho

logicalinterventions

areno

ttaug

htto

PTsbu

tmostaw

areof

theirlack

ofform

altraining

.PTs

wereaw

areof

psycho

logicalaspects

ofinjury

and

thinkit’snecessaryto

useinterventio

ns.M

ostPTswereknow

ledg

eablein

encouragingsocialsupp

ortandusinggo

alsetting,

butmainlyPT

directed,

anddescrib

edusingpo

sitivereinforcem

ent.Imageryandrelaxatio

nwere

repo

rted

aslargelyun

derutilized.B

arriers

identifiedwerelim

itedform

altrain-

ing,

timeandrole

clarity.

Self-selectionbias

ofpar-

ticipants,and

small

sampleof

PTson

lyworking

with

sports

injury.

20/24

(continued)

PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 5

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Table3.

Continued

Authors

Stud

yaim

Metho

dology

and

participants

Keyfin

ding

sLimitatio

nsQAScore

Quant/9

Qual/2

4

Beissner

etal.[49]

Stud

iedPTsexperiences

with

usingCB

Twith

olderadults

suffe

ring

from

chronicpain

inthe

US.

Quantitativedesign

.Cross

sectionaln

ation-wide

phon

esurvey

inUS.PTs

weremem

bers

ofthe

Geriatricsand

Ortho

pedics

sectionof

theAm

erican

Physical

TherapyAssociation

(APTA).n

¼152

PTshadpo

sitiveattitud

estowards

CBT.Mostused

activity

pacing

butrarely

used

cogn

itive

restructuring,

relaxatio

ntechniqu

esandvisual

imageryor

dis-

tractio

n.Themajority

indicatedinterest

inusingCB

Ttechniqu

esin

practice

andexpressedhigh

interest

inlearning

more.Barriers

includ

edlack

ofknow

-ledg

e,tim

e,reimbu

rsem

entconcerns

andpatient

expectation.

Shortph

onesurvey

not

allowingforindividu

alinterpretatio

n.PTson

lyinvolved

inchronicpain

managem

entwith

older

patients.

9/9

Ham

son-Utleyet

al.[50]

Exploretheattitud

esof

PTs(and

ATs)towards

usinggo

alsetting,

imageryandpo

sitive

self-talkwith

injured

athletes

intheUS.

Quantitativedesign

.Cross

sectionalA

ttitu

des

Abou

tImagerysurvey.

PTsfrom

theAP

TAdatabase

listedas

work-

ingin

outpatient

ortho-

pedicrehabilitationin

US.n¼356(PTs)

PTshave

overallp

ositive

attitud

etowards

imagery,po

sitiveself-talkandgo

alsettingin

rehabilitation.

Thosewith

form

altraining

inpsycho

logicalskills

had

morepo

sitiveattitud

esanddesiredfurthertraining

.OverallPTsbelievedthe

aboveskillsto

beeffectivein

rehabilitationwith

regardsto

adherenceand

outcom

es.

Leadingstatem

ents

used

forsurvey.O

nlystud

ied

PTsworking

with

injuredathletes

inou

t-patient

setting.

8/9

Laffe

rtyet

al.[52]

Investigatetheview

sof

PTs(clubandno

n-club

)towards

thepsycho

-logicalaspects

oftheir

practicewith

sports

injuriesin

theUK.

Quantitativedesign

.Mod

ified

versionof

the

AthleticTraining

and

SportPsycho

logy

Questionn

aire

(ATSPQ

)in

theUK.

Certified

PTs

working

with

sports

injuries.n¼87

PTsrepo

rted

usinggo

alsetting,

variety

inexercises,enhancingself-confidence,

encouragingpo

sitiveself-thou

ghts

andeffectivecommun

icationmost.Least

used

techniqu

eswererelaxatio

n,redu

cing

depression

andteaching

emo-

tionalcon

trol

strategies.P

Tsthou

ghtitimpo

rtantto

incorporatesportpsy-

cholog

icaltechniqu

esinto

PTpractice.

Smallsam

pleforqu

antita-

tivestud

y,andon

lylookingat

sports

injuries.

8/9

Arvinen-Barrow

etal.[53]

Exam

inetheview

sof

PTs

with

regardsto

thepsy-

cholog

icalaspectsof

theirpractice,with

insports

injury

clinicsin

theUK.

Quantitativedesign

.Mod

ified

versionof

ATSPQcalledthe

Physiotherapistand

SportPsycho

logy

Questionn

aire

(PSPQ)in

theUK.

CharteredPTs

working

insports

injury

clinics.n¼361

Nearly

allP

Tsacknow

ledg

edthepsycho

logicale

ffectsof

injury,ratingstress

andanxietyas

themostcommon

respon

se,and

consider

itimpo

rtantto

addresstheseaspects.Mostused

interventio

nswerego

alsetting,

variety

inexercisesandencouragingpo

sitiveself-thou

ghts

with

imageryandrelaxatio

nleastused.P

Tsrepo

rted

training

desiresin

goal

setting,

variety

orexercises,

positiveself-thou

ghts,u

nderstanding

motivation,

listening

skillsandincreas-

ingathletes’confidence.M

ostrepo

rted

wantin

gspecifictraining

atpo

st-

graduate

level.

Samplingmetho

dno

twell

repo

rted

andon

lyaddressedPTsworking

with

sports

injuries.

8/9

JevonandJohn

ston

[54]

Exploretheknow

ledg

eandattitud

esof

PTs

towards

psycho

logical

aspectsof

rehabilitation,

working

with

UK

Olympians.

Qualitativedesign

.Sem

i-structured

interviews

with

charteredPTsin

theUK,

who

were

mem

bers

oftheBritish

OlympicAssociation

Steerin

gGroup

.n¼19

PTsrepo

rted

awarenessof

psycho

logicalinterventions

andimpo

rtance

ofaddressing

psycho

logicalaspects.K

nowledg

eandskillswerepredom

inantly

gained

throug

hclinical

practiceandvicario

usexperiences.A

therapeutic

rela-

tionshipwas

describ

edas

impo

rtantandthey

held

positiveattitud

estowards

interventio

nsin

practice.Barriers

includ

edlack

ofform

altraining

andknow

-ledg

e,tim

e,role

clarity

andscop

eof

practice.Allu

sedsomeform

ofgo

alsettinganddescrib

edaspectsof

social

supp

ort,on

lysomedescrib

edrelax-

ationandvisualization.

Onlystud

iedPTsworking

with

Olympicathletes.

19/24

Hem

mings

andPovey,[55]

Surveyed

theperceptio

nsof

PTsin

theUKwith

regardsto

thepsycho

-logicalcon

tent

ofPT

practicewith

sports

injury.

Quantitativedesign

.Mod

ified

versionof

ATSPQ,calledthePSPQ

.PTsfrom

theEngland

EasternRegion

Sports

MedicineDirectory.

n¼90

PTsrepo

rted

theimpo

rtance

ofpsycho

logicalfactorsrelatedto

sportinjury

and

recogn

ized

stress

andanxietyas

common

respon

sesto

injury.P

sycholog

ical

skillsmostused

werevariety

ofexercises,go

alsettingandpo

sitiveself-talk.

Leastused

weresocial

supp

ort,redu

cing

depression

andteaching

emotional

controlstrategies.PTstraining

desireswereaimed

atgo

alsetting,

under-

standing

motivationandvariety

inexercises.They

feltitleastimpo

rtantto

learnabou

tsocial

supp

ort,increasing

self-confidence

ofathleteandteaching

emotionalcon

trol

strategies.

Smallsam

pleof

PTson

lyworking

insports

medi-

cine

intheEast

ofEngland.

8/9

(continued)

6 C. DRIVER ET AL.

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Results

Table 3 summarizes the included articles and results of qualityassessment. Fifteen studies that addressed various aspects associ-ated with the use of psychological interventions in physiotherapypractice were included in this systematic review. Nine studiesfocused on sports injuries, four on chronic pain, one on mentalhealth, and one on neurological rehabilitation. The results dis-played common identifiable themes across all practice settingsproviding valuable insight into the knowledge, behaviors, atti-tudes, and beliefs of PTs towards the use of psychological inter-ventions in practice. Table 4, presents the results of thematicanalysis identifying first, second, and third order themes. The fourfirst order themes included: knowledge and behaviors, attitudesand beliefs, perceived barriers, and training needs.

Knowledge and behaviors

Goal setting was described as regularly used in six studies[47,51–55] and was the primary focus for one study.[57]Motivational strategies such as positive reinforcement, motiv-ational talk/interviewing, and effective communication wereapproaches highlighted by PTs in seven studies,[47,51,52,59–62]with positive reinforcement and praise being the most used strat-egy in one study.[61] Social support was identified as an import-ant component in three studies,[51,52,54] and was the main focusof one study.[62] CBT was formally described in three stud-ies,[49,58,61] however, many other studies described techniquesthat fall under CBT-based strategies including activity pacing, self-talk, and cognitive restructuring.

The response for least used interventions was difficult to quan-tify due to heterogeneity of the studies. Teaching emotional con-trol strategies and reducing depression were reported as leastused in three studies,[52,55,60] whilst cognitive restructuring anddistraction methods were mentioned twice, as being rarelyused.[47,49] Although attitudes towards mental imagery was thefocus of one study,[50] reporting that generally PTs attitudes werepositive, it was conveyed as one of the least used (and leastimportant to know about) interventions by PTs in seven of thestudies reviewed.[47,49–51,53,59,60] Relaxation was highlighted asleast used in six studies,[49,51–53,59,60] yet reported as frequentlyused in two studies.[54,58] Furthermore, encouraging social sup-port whilst regarded as important in some studies,[51,52,54,62]was subsequently identified at least used in one study.[55]

Attitudes and beliefs

The majority of studies indicated that PTs acknowledged the psy-chological effects of disability from injury or associated pain andwere aware of the various responses elicited by cli-ents,[47,50–55,60] with some studies identifying that PTs believedstress and anxiety were the most commonly encounteredresponses.[47,53,55] The importance of PTs being able to addresspsychological aspects and offer support during physiotherapypractice was evident in all studies.

All studies confirmed that PTs were aware of psychologicalinterventions either through formal training, clinical practice orvicarious understanding, and overall, PTs held positive attitudestowards psychological interventions in practice. Furthermore,those who had some level of formal training in psychologicalinterventions held more positive attitudes than those without for-mal training,[49,50] and predominantly those with underpinningknowledge valued the importance of psychological skillshigher.[54] In contrast, Holden et al. [61] found that PTs believedTa

ble3.

Continued

Authors

Stud

yaim

Metho

dology

and

participants

Keyfin

ding

sLimitatio

nsQAScore

Quant/9

Qual/2

4

Franciset

al.[60]

Investigatetheview

sof

AustralianPTstowards

theuseof

psycho

logical

skillsin

sports

injury

rehabilitation.

Quantitativedesign

.Survey

adaptedfrom

Sports

Physiotherapists’V

iews

onPsycho

logical

Strategies

Questionn

aire

(PVP

SQ)PTsworking

insports

medicinein

Melbo

urne,A

ustralia.

n¼57

Psycho

logicalcom

ponentswererecogn

ized

byPTsas

beingimpo

rtantin

rehabilitationof

injury.Lackof

know

ledg

ewas

suspectedto

beabarrieras

manyneutralrespo

nses

wererepo

rted

towards

psycho

logicalinterventions.

PTsfeltthemostimpo

rtantfactor

was

goal

setting,

commun

icationand

motivationandtheleastimpo

rtantwererelaxatio

n,teaching

emotionalcon

-trol

strategies

andimagery.PTsexpressedadesire

tolearnmoreabou

tgo

alsetting,

positivereinforcem

ent,un

derstand

ingintrinsicmotivation,

encourag-

ingself-talkandenhancingself-confidence.

Smallsam

pleof

PTson

lyworking

insports

medi-

cine

inMelbo

urne.

8/9

Ninedek

andKo

lt[59]

Exam

ined

theop

inions

ofAu

stralianPTsregarding

therole

ofpsycho

-logicalstrategiesin

rehabilitationwith

sports

injuries.

Quantitativedesign

.Survey

adaptedfrom

PVPSQ.

PTswho

hadcompleted

orwerecompletinga

postgraduate

course

insports

physiotherapyin

Australia.n

¼150

Mosteffectivestrategies

wererepo

rted

tobe

commun

icationskills,andpo

sitive

reinforcem

ent.PTsvalued

goal

setting,

positiveandsincerecommun

ication

andun

derstand

ingmotivationas

mostimpo

rtantto

learnabou

t.Relaxatio

nandimagerywererepo

rted

asleastimpo

rtantforhelpingathletes.

Sampleconsistedon

lyof

PTswho

hador

were

completingsports

physiotherapycourses

atapo

stgraduate

level.

8/9

Ford

andGordo

n[47]

Stud

iedtheview

sof

Australian,

Canadian

andNew

Zealandsports

PTsregardingthe

impo

rtance

ofpsycho

-logicalaspects

ofrehabilitation.

Quantitativedesign

.Survey

mailedto

sports

PTsin

New

Zealand(n¼65),

Australia

(n¼147)

and

Canada

(n¼45).

n¼257

PTsdescrib

edtheimpo

rtance

ofaddressing

psycho

logicala

spects

ofinjury

and

repo

rted

stress

andanxietyas

common

lyseein

injuredathletes.P

Tswere

positivetowards

theuseof

goalsettingandincreasing

confidence

inathletes

andutilizedthesestrategies.Theyalso

ratedtheseas

mostimpo

rtantto

learnabou

t.Co

gnitive

restructuringandimagerywereratedas

least

impo

rtant.

Smallsam

ples

from

Canada

andNew

Zealandandlim

itedto

sports

PTs.

8/9

PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 7

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CBT, motivational interviewing and goal setting were moderatelyeffective, yet formal training in these strategies did not increaseperceived effectiveness.

Positive attitudes were identified towards the use of goal set-ting,[47,50] effective communication to increase confidence,[47]positive self-talk, pain tolerance support (coping strategies), men-tal imagery,[50] and activity pacing [56] particularly with regardsto encouraging proactive rehabilitation, adherence to rehabilita-tion, and recovery speed. Social support was also perceived to beeffective for adherence to physical activity programs for schizo-phrenic patients.[62]

Perceived barriers

Barriers affecting the use of psychological interventions in physio-therapy practice were only documented in a few of the includedstudies. Lack of knowledge and understanding from limited formaltraining [49,51,54,58] and lack of practical skills [54,58] werebelieved to be common barriers. Practice and consultation con-straints in the form of time restrictions,[49,51,54,58] cost/reim-bursement issues [49,58] and the perceived need to prioritizephysical care,[51,58] were also frequently described barriers. Otherbarriers included, managing the publics’ expectations of the PTrole,[57,58] role clarity and individual scope of practice,[51,54] andunsure feelings of when or when not to refer a client to apsychologist.[51,58]

Training needs

The discussion of desires for further training in psychological inter-ventions was raised in only some of the included studies. Themost commonly addressed further education needs were effectivegoal setting and communication skills, along with techniques toincrease motivation and client confidence, for example

encouraging positive self-talk and creating variety.[47,53,55,59,60]In the two studies that addressed CBT,[49,58] both raised the issueof wanting CBT training at a postgraduate level.

Discussion

Knowledge and behaviors

A variety of techniques were reported and described by PTs,although sometimes not formally labeled as psychological inter-ventions. Additionally, some studies were focused towards oneintervention in particular whilst others addressed many, and someinvestigated perceptions rather than actual use. For this reason, itwas difficult to quantify and conclude which interventions wereutilized most or least used across the studies. It was apparent thatmany PTs described techniques they employed in practice, butdid not formally label these techniques as psychological interven-tions suggesting there is still much confusion about what PTsbelieve to be actual psychological interventions.

The observed research focus given to examining goal settingin the physiotherapy context is consistent with previous researchin rehabilitation, recognizing it as one of the most widelyaccepted and fundamental interventions for successful physiother-apy practice.[63] Scobbie et al. [63] proposed the development ofa practice framework to implement effective goal setting. Theyoutlined the importance of tailoring the framework to the individ-ual client based on their rehabilitation status, emphasizing the sig-nificance of a systematic method to goal setting in rehabilitationpractice. Two studies in this review [57,61] reported that PTsbelieved goal setting effectiveness may be reduced when clientsare not ready to be actively involved in the process; a further twostudies identified the use of goal setting as a prescription by PTswithout shared ownership with the client,[51,54] which may limiteffectiveness.[63] One study [57] highlighted that PTs believed a

Table 4. Results of thematic analysis of included studies.

1st Order 2nd Order 3rd Order

Knowledge and behaviors Interventions used Goal settingPositive reinforcement, effective communication and motivational talk/interviewingEncouraging positive self-talk and increasing self-confidence (in patient)Creating variety in exercisesEncouraging social supportActivity pacing (CBT)

Interventions identified as least used Mental imageryRelaxation techniquesCognitive restructuring (CBT), distraction methodsTeaching emotional control strategies and reducing depressionEncouraging social support

Attitudes and beliefs Awareness and importance Awareness of the negative impacts of psychological responses to disabilityAware of the benefits of interventions on adherence and rehabilitation outcomesImportance of addressing physical and psychological aspectsIntuitive support rather than structured interventions

Positive attitudes and experiences Positive attitudes towards using in practiceHelps encourage patients to be proactive in rehabilitationAttitudes developed mostly through clinical experience and some trainingTherapeutic relationship integral part of physiotherapy

Perceived Barriers Lack of knowledge and skills Limited formal training (especially at undergraduate level)Lack of understanding of types and appropriateness of interventionsLack of practical skills to confidently implement in practice

Time and money Practice/clinic environment constraints (reimbursement)Consultation limitations (time constraints and client attendance)Perceived need to prioritize physical care due to consultation times

Scope of practice Personal role clarity within individual scope of knowledgePublic perceptions of physiotherapists traditional roleUnsure when to address issues and when to refer

Training needs Training desires and level CBT at postgraduate levelEffective goal setting, communication and motivational techniques for optimal practicePostgraduate training important as clinical experience necessary first

8 C. DRIVER ET AL.

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balance between PT lead and patient lead goal setting was essen-tial, but varied dependant on the rehabilitation stage. Accordingly,further education in the most effective methods of goal settingfor PTs through a framework similar to that described by Scobbieet al. [63] may be advantageous.

Motivational interviewing is increasingly being adopted inhealthcare and rehabilitation settings to encourage and motivatebehavior change;[64,65] a concept confirmed by PTs in the morerecent studies in the current review.[61,62] Positive self-talk,[52,53,55] encouraging self-confidence in clients,[51,52,59] andcreating a variety of exercises [52,53,55] were other strategies uti-lized by PTs in the studies reviewed, to encourage participationand engagement in rehabilitation. Such techniques can act toenhance the therapeutic relationship between the health profes-sional and client, adopting a patient-centered approach, promotingengagement, and adherence in physiotherapy programs.[25,66]

Social support and perceived support from peers and PTsthemselves during rehabilitation can have a positive impact onrecovery outcomes and adherence to physiotherapy pro-grams;[26,67,68] a principle perceived important according to PTsworking with patients with schizophrenia in the currentreview.[62] The awareness and willingness of most PTs to offersupport through adopting a therapeutic relationship is evidentthroughout the studies, suggesting that social support is also pre-sented in methods that PTs themselves have not formally identi-fied. This emphasizes the importance of PTs maintaining apositive relationship with their clients, offering support from manyangles and dimensions.

In this review, it was identified by Nielsen et al. [58] andBeissner et al. [49] that PTs felt CBT is relevant and appropriatefor physiotherapy practice and enabled them to encourage clientsto be proactive in their rehabilitation; whilst Holden et al. [61]reported that most PTs surveyed were familiar with CBT and per-ceived it as moderately effective. CBT has been acknowledged asan intervention pivotal to the treatment of lower back pain [22]and CBT-based rehabilitation programs such as the ProgressiveGoal Attainment Program have proven effective in rehabilitatingpatients by identifying psychological risk factors and supportingreturn to work.[17,69] Brunner et al. [22] determined that CBT-based strategies within PT practice for the prevention of lowerback pain, could enable the advancement of active coping strat-egies with patients, and Bryant et al. [70] established that PTstrained in a CBT-based pain coping skills program were able toexhibit a high level of ability during PT sessions. In this review,Scott-Dempster et al. [56] ascertained that PTs using activity pac-ing in chronic pain management needed to adjust their thinkingout of a biomedical model, developing techniques such as reflect-ive listening and experiential learning, and should be utilized aspart of a process rather than a stand-alone treatment.

Cognitive and behavioral change techniques, such as thosementioned (amongst others) can be seen as crucial elementswithin a biopsychosocial model of care and important factors toadopt in order to address the complex nature of disability.Nonetheless, these methods were also described as least used bya few studies, and were not listed as regularly applied in practiceby any study reviewed. This is concerning given the increasingincidence of depression, anxiety, reduced self-efficacy, unsupport-ive coping strategies frustration, and fear avoidance amongstthose living with injury and disability.[1,9,10]

There still remains a limited body of research addressing theappropriateness of CBT within general physiotherapy practice andNielsen et al. [58] outlined that even after training in CBT, PTs felttheir knowledge was still limited. In contrast Holden et al. [61]established that PTs believed training in CBT increased their

confidence, but not perceived effectiveness for rehabilitation.Therefore, research should investigate further the practicality andlogistics of PTs being able to offer this type of intervention andtheir experiences associated with it, as the need for educationregarding the most relevant interventions, and guidance on howto approach behavior change when addressing such issues isapparent. The clinical reasoning model recently proposed byElv�en et al. [71] for PTs, begins to consider this approach; how-ever, further investigation into the effectiveness of such a modeland its applicability within practice is warranted.

This review also highlighted the limited use of mental imageryamongst PTs. Some studies speculate a misunderstanding of thetechnique, and lack of knowledge as the main reasons for theabsence of mental imagery use,[50,51] nevertheless this is not vali-dated in the present studies. Evidence suggests that various formsof mental imagery can have positive effects on adherence torehabilitation,[24,67] re-learning of movements, anxiety, pain lev-els,[23] and coping strategies.[24] Consequently, it may be benefi-cial to address the apparent lack of interest in mental imagerytechniques, to tackle potential barriers and facilitate knowledgeand application in PT practice.

There were notable disparities with regards to reported use ofrelaxation techniques and social support. It is inevitable that prac-tice variations occur, and decision processes of PTs will differwhen deciding which interventions to employ, particularly ifencompassing a patient-centered approach. Accordingly, insightinto the decision processes of PTs when assessing the psycho-logical needs of their patients could prove valuable in evaluatingthe appropriateness, and consequential effectiveness of a chosenintervention.

Attitudes and beliefs

In the studies reviewed, PTs acknowledged the psychologicaleffects associated with rehabilitation. This suggests that the psy-chological impact of disability from injury or disease is evident inclients engaging in physiotherapy, and potentially at a level thatmay affect rehabilitation outcomes. Although most of the studiesinvolved sports injuries, these findings are consistent withresearch regarding other areas of PT practice where it has beenreported that depression, anxiety, and poor self-esteem are com-monly recognized conditions in those living with chronic pain, dis-ability, and cancer.[1,7,72] Additionally, after injuries such as hipfracture, frustration, fear avoidance, and decreased coping strat-egies were evident.[9,10] Psychological support was seen by somePTs in this review as a professional responsibility, and within theboundaries of practice is an essential part of therapy and rehabili-tation.[51,54] PTs also expressed that a therapeutic relationship iscentral to physiotherapy practice, and helped guide the use ofappropriate interventions.[54,56,57,62]

The patient-practitioner relationship has been implicated as akey determinant of adherence to rehabilitation,[2] and researchersadvocate that listening, supporting emotional responses, andencouraging hope are essential components to facilitate effectivepatient-centered practice.[73] Aguilar et al. [74] reported that gain-ing patient trust, understanding individual patient characteristicsand addressing patient-centered care, was considered to be anessential component of PTs professional values. Patients them-selves have also reported the role of PTs as pivotal in improvingrecovery after injury and during cancer treatment, by providingpractical and individualized care and strategies,[10,35] endorsingthe expanding role of PTs.

PTs in the studies reviewed expressed that psychological inter-ventions were beneficial to encourage proactive rehabilitation and

PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 9

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adherence to physiotherapy programs. Adherence is a pivotal fac-tor affecting progress and outcomes, and ultimately increasedadherence leads to enhanced rehabilitation both psychologicallyand physically.[4,26,67,75] Much research has investigated theeffects of various types of psychological support during rehabilita-tion specifically with regards to adherence and determinants thatincrease adherence. Levy et al. [68] suggested that in preliminarystages of rehabilitation, education about the injury and its severity(effective communication), task orientated goal setting, andencouraging a positive mindset can help to enhance patientbehavior, setting strong foundations for the recovery process andconsequently increasing adherence. Additionally, Medley andPowell [25] reviewed the use of motivational interviewing afteracquired brain injury, proposing a framework to potentially directclinical practice. Through the incorporation of motivational inter-viewing, Medley and Powell’s [25] model aims to increase self-awareness, intrinsic motivation and consequently, engagement inrehabilitation, and is driven by theories such as self-determinationtheory,[76] stages of change,[77] and self-efficacy.[78] However,there is an identifiable need to test such methods in clinical andindividual settings, and the level of underpinning knowledge inpsychological principles may surpass the current level of know-ledge expected for physiotherapy practice. This notion is endorsedby Holden et al. [61] who reported that training in motivationalinterviewing did not increase confidence or frequency of use inPTs surveyed. Nevertheless, as the attitudes of PTs towards suchapproaches are positive, the opportunity to teach PTs and equipthem with the skills to confidently utilize certain strategies shouldbe taken, to ensure client adherence and optimal outcomes.

Perceived barriers

Lack of knowledge and skills from limited formal training in psy-chological interventions contributed to PTs perceived barriers.Scott-Dempster et al. [56] and Lloyd et al. [57] noted that althoughPTs interviewed reported being experienced in activity pacing andgoal setting respectively, they struggled to explicitly define theirmethods or a theoretical foundation for their knowledge. PTsexpressed that some skills evolved over time, but the focus andapplication of such strategies changed with experience.[57] This issubstantiated in previous research, where it is evident that a vastarray of practice variations exists in the literature with confusionstill apparent amongst PTs. This suggests that a lack of knowledgeand understanding of how, and when to implement psychologicalinterventions may be hindering practice outcomes.[27]

In this review, PTs perceived need to prioritize physical carewas expressed as a barrier. This concept has also been consideredby Mudge et al. [73] in an auto-ethnographical study of physio-therapy practice, highlighting that traditionally the role of PTs wasto address the biomechanical perspective first. Accordingly, astime constraints can inhibit implementation of psychological inter-ventions in practice, the consequential need to prioritize the phys-ical component of rehabilitation, coincides as a barrier resulting inthe potential neglect of a biopsychosocial approach to care.Mudge et al. [73] further described how PTs may still resist theadoption of a biopsychosocial approach, due to the traditionalperceptions of physiotherapy practice, and feel a lack of role clar-ity may inhibit progression away from a biomedical model. This issupported further in the current review where PTs reported bar-riers were associated with role clarity and scope of practice,[51,54]publics’ expectations of PTs,[57,58] and a lack of clarity of whenreferral to a psychologist would be appropriate.[51,58]

The overlapping of roles from physical therapist to psycho-logical therapist may be confusing for both patient and PT.

Although PTs are increasingly accepting this concept even if notfully acknowledged, conflicts may arise about the appropriate con-text and nature of this role.[54] In this review, Barlow et al. [79]indicated that PTs working with clients suffering from chronicpain as a result of physical injury encountered difficulties, and feltconfused, frustrated and unskilled when it came to treating theirclients from a biopsychosocial perspective. Additional researchcorroborates this viewpoint, reporting that rehabilitation staffdealing with elderly patients with orthopedic conditions, believedthey did not have the skills to manage psychological risk factorsidentified in patients and felt they had limited access to psycholo-gists or adequate referral schemes.[9] PTs working in palliativecare similarly described encountering difficulties when dealingwith emotional responses of patients when trying to adapt to lim-ited functionality.[34]

There appears to only be a small body of literature investigat-ing the barriers inhibiting the incorporation of psychological inter-ventions in physiotherapy practice. With considerable evidencepresenting the benefits of psychological interventions as part of abiopsychosocial model of care, it is paramount for further researchto explore potential barriers, in all areas of physiotherapy practice.This would enable a deeper understanding of how such barrierscan be addressed, and what action is necessary to facilitate theuse of appropriate psychological interventions in physiotherapypractice.

Training needs

PTs have described the value of continually updating their know-ledge to ensure professional practice,[74] yet the current reviewsuggests that psychological skills are not being taught at a levelthat is making an impact in the physiotherapy setting. Forexample, goal setting strategies used by PTs in the reviewed stud-ies were largely reported as PT driven and collaboration withpatients proved challenging. Therefore, education aimed towardseffective goal setting using frameworks such as Scobbie et al’s.[63] may be beneficial. Ford and Gordon [80] advocated thatthose working in rehabilitation should be trained to encourageactive participation, aiming to increase patient adherence throughmotivation, education, and realistic goal setting.

In a review of sport psychology education for those working ininjury rehabilitation, Heaney et al. [81] concluded that psycho-logical intervention training could be implemented effectively inboth undergraduate and postgraduate degree programs.However, it was also highlighted that due to the large body ofprofessionals already practicing without such experience, the needto facilitate training for qualified professionals particularly is para-mount. This was evident in the current review where further train-ing in CBT was regarded as important specifically at apostgraduate level, as the need for clinical experience beforetraining in such interventions was perceived as beneficial.[58]

The Ottawa Charter for Health Promotion [82] established thatin order to accomplish reorientation of health services, a focus onprofessional education and training was essential to modify theperceptions of those involved in healthcare, transferring the focusto a whole person approach. The ongoing progression towards abiopsychosocial perspective incorporating psychological interven-tions in rehabilitation is prompting the evaluation of trainingreceived by health professionals involved.[83] Heaney et al. [84]established that the psychological content of physiotherapy pro-grams in UK universities was inconsistent and varied, however, itwas noted that this consisted predominantly of psychologicaleffects of disability, and behavior change. Although the PTs in thecurrent review did not specify behavior change as a training

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desire specifically, techniques described that aim to increasemotivation, enhance self-confidence, and encourage participationare all crucial components of behavior change models.Accordingly, the need for behavior change training in physiother-apy practice is vital, in order to support patients as they adapt tonew levels of functionality, and the incorporation of behavioralchange approaches with traditional physiotherapy practice hasbeen shown to result in improved rehabilitation outcomes.[71]

Limitations and future directions

Although a systematic search strategy was applied, it is acknowl-edged that appropriate studies may have unintentionally beenoverlooked, and as unpublished papers were not included, thismay affect conclusions drawn. The heterogeneity of the includedstudies presents issues with regards to generalisability, as theemphasis of psychological interventions differed between thestudies. Nonetheless, the information extracted provides valuableinsight and can be utilized to formulate further research ques-tions. The individual studies have their own limitations that havebeen outlined in Table 3.

The reviewed studies present an international perspective ofthe knowledge, behaviors, attitudes and beliefs of PTs towardsthe use of psychological interventions in multiple practice set-tings. Although the included studies predominantly involved PTsworking with sports injuries and chronic pain (due to the lack ofliterature considering other specialities), common themes wereobvious, across all practice settings. Nonetheless, in light of cur-rent research emphasizing the importance of physiotherapy acrossa range of settings including oncology, HIV/AIDS, palliative care,neurological rehabilitation, and complex mental health; futureresearch should investigate PTs perceptions towards the use ofpsychological interventions across a range of areas, from a cross-sectional perspective. Such information could provide insight in towhether PTs are accepting the role of offering a biopsychosocialmodel of care, incorporating psychological strategies.

This review highlights the demand for knowledge regardingeffective application of psychological interventions in physiother-apy practice. This could direct future research to a gain deeperunderstanding of how to successfully address barriers to imple-mentation and initiate specifically designed, evidence-based pro-fessional development training programs for practicing PTs. Thismay contribute to enabling PTs to confidently utilize psychologicalinterventions during practice. In the long term, such initiativescould improve adherence, rehabilitation outcomes, and quality oflife in all those affected by disability from injury or disease, whilstpotentially reducing chronic conditions, risk of re-injury, and dayslost at work. This could impact substantially on helping to reducethe burden on healthcare systems. Furthermore, it would seemvaluable to address from a settings perspective how clinics, hospi-tals, and practices could provide mechanisms to support PTs toconfidently incorporate psychological interventions as part of abiopsychosocial model of care into everyday practice, without thebarriers outlined in the current review, such as practice and con-sultation limitations. If a biopsychosocial approach is to beembraced, practice guidelines need to provide incentives toencourage all PTs to participate in and adhere to evidence-basedrecommendations.[27]

Conclusion

The aim of this systematic review was to identify the knowledge,behaviors, attitudes, and beliefs of PTs towards the use of psycho-logical interventions in physiotherapy practice. Attitudes and

beliefs were overall positive towards the use of psychologicalinterventions in practice across all areas. A variety of techniquesincluding goal setting, CBT, creating variety in exercises, positive,and motivational talk, social support, and mental imagery weredescribed by PTs as interventions used in practice. Nonetheless,substantial barriers preventing incorporation of such techniquesare still apparent, including the need for supplementary trainingin specific psychological interventions such as goal setting, CBT,effective communication, motivational, and behavior changestrategies.

Disclosure statement

The authors report no declarations of interest.

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