My message is simple: If you're not interested in low back pain and you're about to toss this issue aside, don't! As co-editors Chris Main and Steven George make clear, the purpose of the special issue published within these covers is “to persuade biomedically oriented physical therapists of the need for a shift in focus…[to include] consideration of psychosocial factors…as potential obstacles…and as worthwhile treatment targets in their own right.”1(p610) I urge everyone to read this issue and substitute a diagnosis that is relevant to your practice or research interest. This issue combines expertise from physical therapists and psychologists to define psychologically informed physical therapist practice, and the content is relevant regardless of clinical specialty.
The authors recognize that physical therapists have been exposed to the importance of psychosocial factors both through their professional education and in the practice setting. It is quite easy, in fact, to find references to this topic in PTJ. I can develop an argument from articles published beginning in the late 1990s through today that we have recognized the importance of psychosocial factors but have not yet figured out what to do about them:
A paper by Jette and Downing2 in 1996 reported that psychological distress is related to poor health in persons enrolled in cardiac rehabilitation programs. The authors concluded by urging physical therapists to identify problems, goals, and interventions that apply to both the physical and psychological impairments of their patients. This is what Main and George argue in their introduction with their concept of the “psychologically informed” physical therapist. In a rich discussion with former Editor in Chief Jules Rothstein and 4 clinical experts3 about the practical implications of the findings of Jette and Downing, no one suggested “how” to address the psychological impairments as part of the physical therapy intervention. Rather, the discussion focused on the need for an assessment tool to identify psychological factors and the need to work with a multidisciplinary team that includes psychologists and social workers.
Ingram4 surveyed physical therapist education program directors to ascertain their opinions on the "essential functions" that students must be able to complete prior to graduation. Although 88% of the 58 directors identified as “definitely essential” the ability to recognize the psychosocial impact of dysfunction and disability and integrate the needs of the patient and family into the plan of care, the only assessment procedure relevant to this essential function was “cognitive/mental status,” and there were no intervention procedures identified in the list of “definitely essential” procedures.4
In the 38th Mary McMillan Lecture,5 Dr. Katherine Shepard bemoaned the lack of a biopsychosocial framework for professional education when she stated that “our [physical therapy] curricula are devoted almost entirely to the biological and physical sciences connected to healing. Where do students actually gain knowledge in ‘The Art of Caring’?”5(p1546–1547)
The Commission on Accreditation of Physical Therapy Education (CAPTE) relies on 2 core documents to understand the profession's view of contemporary practitioners—the Guide to Physical Therapist Practice6 and A Normative Model of Physical Therapist Professional Education.7 The Guide moved thinking forward with the observation that the disablement model typifies physical therapist practice and is the model for understanding and organizing practice. In 2008, APTA endorsed the International Classification of Functioning, Disability and Health (ICF) among the numerous models of “disablement.” The ICF classification system focuses on human functioning and provides a framework to capture how people with a health condition function in their daily life rather than focusing on their diagnosis or the presence or absence of disease.8 The ICF also takes into account the social aspects of disability and does not see disability only as a “medical” or “biological” dysfunction.
The Normative Model defined behavioral sciences as foundational content; however, it was developed through a consensus process in 1994 and 1995 to describe the profession's “preferred prerogatives, perspectives, beliefs, and values relative to physical therapist education.”7(p5) That was more than 15 years ago! Although the Normative Model was revised in 2004 and the view of the contemporary practitioner was tweaked, it is way past time to review the definition of the “contemporary” physical therapist practitioner. Why is this so important? At this time, on-site reviewers for CAPTE use evaluative criteria, based on documents including the Guide and Normative Model, to determine if a professional physical therapist education program prepares graduates who will be "effective contemporary practitioners of physical therapy." One criterion relates to the possibility of preparing a psychologically informed physical therapist:
CC-2. The physical therapist professional curriculum includes content and learning experiences in the behavioral sciences necessary for initial practice of the profession (eg, applied psychology, applied sociology, communication, ethics and values, management, finance, teaching and learning, law, clinical reasoning, evidence-based practice, and applied statistics), including laboratory or other practical experiences.9(p B–27)
So, we have long paid lip service to the influence of psychosocial factors on clinical outcomes, but the time has come to YELL about the importance of these factors. This special issue is deliberate in laying out evidence to support adopting a broader approach for practice that includes a cognitive-behavioral framework, using low back pain as the example.
Main and George ask that the physical therapist identify the psychological and psychosocial barriers to the recovery of function—but they don't ask for it without recognizing the implications in the current health care climate. You will leave this issue of PTJ not only with a theoretical model but with principles and concrete examples to assist in clinical evaluation and treatment as a psychologically informed physical therapist.
In the conclusion of their article, Main and George remark, “we hope that…we will stimulate and encourage the development of a broader approach to physical therapist practice, with a focus on the identification and management of psychological and psychosocial obstacles to recovery of optimal function.”10(p824) This is a call to action for educators, research scientists, and clinicians to move forward with this agenda.
Thank you, Chris and Steve, for this special issue. You coaxed outstanding authors from 2 professions—psychology and physical therapy—into collaborating to lay out a convincing case for the psychologically informed physical therapist.
- © 2011 American Physical Therapy Association