Treating more than just the back in chronic low back pain

‘Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review’ (Synnott et al, 2015)

There is considerable evidence that when people have chronic low back pain (LBP), several factors can be involved in delaying their recovery and/or their ability to enjoy a good quality of life. This is often assumed by patients and clinicians to involve structural changes seen on x-rays or MRI scans, and physical factors such as the way people with LBP move. However, it appears that a range of non-physical factors such as stress, fear, depression, poor job satisfaction and what people with LBP think is “wrong” with their back are at least as important in the prognosis of a person with LBP. While the precise mix of factors involved in their LBP might vary for individual patients, most patients with chronic LBP will present with at least some need for these non-physical factors to be addressed (O Sullivan 2012).

Unfortunately, professionals who treat people with LBP (e.g. doctors, surgeons, physiotherapists and chiropractors) have been mostly trained to deal with physical and structural factors in LBP. Consequently, it is not clear whether non-physical factors are adequately recognised by healthcare professionals treating people with LBP, and how confident they are in addressing these factors in treatment.

We recently completed a systematic review and metasynthesis (open-access) that looked at twelve studies in which physiotherapists were interviewed through focus groups or semi-structured interviews on their experiences of treating people with chronic LBP. The review found that physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion of these involving factors such as family and work issues, as well as unhelpful patient expectations.

Patients with LBP were often stigmatised as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors. For example, if a person with LBP showed little interest in rehabilitation, they were criticised as being lazy and unmotivated rather than considering that this behaviour may be an indication of depression or other factors.

Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat these factors in people with LBP. Consequently, the physiotherapists questioned whether there was any point in even looking for these factors, as managing them effectively was considered to be beyond their expertise.

While the results of this systematic review are specific to physiotherapists’ experience of treating patients with chronic LBP, the reported deficits in training are consistent with a recently published systematic review by Alexanders et al. (2015). In this review, the author explored musculoskeletal physiotherapists’ experiences of implementing psychological interventions within a varying musculoskeletal caseload. Similar to our findings, physiotherapists recognised the intrinsic role of psychological intervention in the rehabilitation of patients, yet physiotherapists reported being insufficiently trained to optimise the use of such interventions in practice.

The review conducted by our team did not consider how these findings generalise to other healthcare professionals, though it is likely to be very similar across professions, with many healthcare professionals demonstrating negative LBP beliefs and maintenance of a biomedical approach toward treatment in practice (Ali and Thomson, 2009; Darlow et al. 2012). Considering the importance of these factors in helping people with LBP achieve lasting improvements in pain and quality of life, there is a need for physiotherapists – and other healthcare professionals – to increase competence in their identification and management.

It remains a concern that the evidence for the effectiveness of psychological interventions for chronic LBP is quite modest even when delivered by psychologists (Henschke et al.2010; Williams et al. 2012). While evidence for integrated multimodal interventions in chronic LBP is emerging, it remains clear that health care professionals need to undergo training in a proven and effective biopsychosocially orientated intervention to address all contributing factors holistically

Building on this systematic review, we have conducted two qualitative research studies examining physiotherapists’ perceptions of the identification and treatment of the psychosocial dimensions of chronic LBP after additional training. The aim of these qualitative studies was to explore whether such training influences physiotherapists’ perceived competence to identify and treat the psychosocial dimensions of chronic LBP in practice. The results of these studies are currently being prepared for publication.

About Aoife Synnott

Aoife SynnottAoife is a recent graduate of the BSc Physiotherapy programme at the University of Limerick, Ireland. She has a keen interest in chronic LBP and qualitative research. To date, Aoife has completed research combining her two interests as part of a Health Research Board of Ireland Summer Scholarship and her Final Year Research Project under the supervision of Dr. Kieran O’Sullivan ( These projects have involved interviewing physiotherapists who have received additional training in the identification and management of “non-physical” factors in LBP, to determine their experience of treating the biopsychosocial dimensions of chronic LBP after biopsychosocially orientated training.


Alexanders, J., Anderson, A. and Henderson, S. (2015). Musculoskeletal physiotherapists’ use of psychological interventions: a systematic review of therapists’ perceptions and practice. Physiotherapy. 101, 95-102.

Ali N, Thomson D. A comparison of the knowledge of chronic pain and its management between final year physiotherapy and medical students. Eur J Pain 2009; 13:38-50.

Darlow B, Fullen BM, Dean S, et al. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review. Eur J Pain 2012; 16:3- 17.

Henschke, N., Ostelo, R.W., van Tulder, M.V., Vlaeyen, J.W., Morley, S. et al. (2010). Behavioural treatment for chronic low-back pain.Cochrane Databases Syst Rev. 7 (7)

O’Sullivan, P. (2012) ‘It’s time for change with the management of non-specific chronic low back pain‘, British Journal of Sports Medicine, 46(4), 224-227.

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P. and 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‘, Journal of Physiotherapy, 2(61), 68-76.

Williams. AC de C., Eccleston, C. and Morley, S. (2012). Psychological therapies for the management of chronic painCochrane Databases Syst Rev. 11