New Directions for Physical Rehabilitation of Musculoskeletal Pain Conditions

Review

Psychologically informed physical therapy for

musculoskeletal pain: current approaches,
implications, and future directions from recent
randomized trials
Rogelio A. Coronadoa,b,c,*, Carrie E. Brintzd, Lindsey C. McKernanb,e,f, Hiral Mastera, Nicole Motznya,
Flavio M. Silvaa, Parul M. Goyalg, Stephen T. Wegenerh, Kristin R. Archera,b,c,f
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Abstract
Psychologically informed physical therapy (PIPT) blends psychological strategies within a physical therapist’s treatment approach for the
prevention and management of chronic musculoskeletal pain. Several randomized trials have been conducted examining the efficacy of
PIPT compared to standard physical therapy on important patient-reported outcomes of disability, physical function, and pain. In this
review, we examine recent trials published since 2012 to describe current PIPT methods, discuss implications from findings, and offer
future directions. Twenty-two studies, representing 18 trials, were identified. The studied PIPT interventions included (1) graded activity or
graded exposure (n 5 6), (2) cognitive-behavioral-based physical therapy (n 5 9), (3) acceptance and commitment-based physical
therapy (n 5 1), and (4) internet-based psychological programs with physical therapy (n 5 2). Consistent with prior reviews, graded activity
is not superior to other forms of physical activity or exercise. In a few recent studies, cognitive-behavioral-based physical therapy had
short-term efficacy when compared to a program of standardized exercise. There is a need to further examine approaches integrating
alternative strategies including acceptance-based therapies (ie, acceptance and commitment therapy or mindfulness) or internet-based
cognitive-behavioral programs within physical therapy. Although PIPT remains a promising care model, more convincing evidence is
needed to support widespread adoption, especially in light of training demands and implementation challenges.
Keywords: Cognitive-behavioral therapy, Musculoskeletal pain, Physiotherapy, Psychological adaptation, Rehabilitation

1. Introduction substantial disability.70 Musculoskeletal conditions such as low

back pain, neck pain, and lower-extremity osteoarthritis are listed
Musculoskeletal pain remains one of the leading health com- among the top diseases contributing to years lived with
plaints prompting individuals to seek medical care. Not only is
disability.20,79 The costs associated with managing chronic pain
musculoskeletal pain highly prevalent in both developed and
exceeds costs for conditions such as heart disease and cancer.27
developing societies,20,62 the effects can dramatically impact The problem of musculoskeletal pain is complex and there is wide
quality of life. Estimates suggest that 10.6 million adults within the recognition that the optimal management approach uses a biopsy-
United States have high-impact pain conditions that result in chosocial model of care.28 Psychological factors are considered

a
Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA, b Department of Physical Medicine and Rehabilitation, Vanderbilt University
Medical Center, Nashville, TN, USA, c Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA, d Department of
Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA, e Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center,
Nashville, TN, USA, f Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN, USA, g Department of Internal Medicine, Vanderbilt University
Medical Center, Nashville, TN, USA, h Department of Physical Medicine and Rehabilitation, The Johns Hopkins School of Medicine, Baltimore, MD, USA
*Corresponding author. Address: Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 2525 West End Ave, Suite 1200, Nashville, TN 37203. Tel.: 615-
936-4348; fax: 615-936-8500. E-mail address: [email protected] (R.A. Coronado).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the
journal’s Web site (www.painrpts.com).
Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain. This is an open access article
distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share
the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
PR9 5 (2020) e847
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important risk factors for disability and pain outcomes.4 Psycholog- person exercise, manual therapy, or usual physical therapy care)
ically based treatments that target maladaptive cognitions, emotions, (Comparator), (4) measured disability, physical function, or pain as an
or behavior with physical rehabilitation through multidisciplinary team outcome (Outcome), and (5) used a randomized controlled trial
approaches are more effective than physical treatment alone.41 design (Study design). Psychologically informed physical therapy
However, substantial barriers including access and cost may prevent search terms combined “psychotherapy,” “psychologically in-
some patients from receiving this type of care.67 To address these formed,” “psychological based,” “cognitive behavioral,” “accep-
barriers, recent efforts have focused on training nonpsychologist tance and commitment,” “mindfulness,” and “psychological
practitioners to integrate psychological strategies within primary care strategies” with “rehabilitation,” “physical therapy,” and “physiother-
for prevention and management of chronic pain.9,14,57 apy.” For the purpose of this review of summarizing behavioral
Psychologically informed physical therapy (PIPT) is an approach change interventions, studies investigating education interventions
initially advocated by Main and George in a 2011 Physical Therapy for pain as the primary treatment component were not considered
article.56 Psychologically informed physical therapy represents a for inclusion. PubMed, CINAHL, and PsycINFO databases were
multimodal rehabilitation approach for pain that incorporates searched (see Appendix Tables 1–3 for search results, available at
behavioral strategies from the mental health realm into physical http://links.lww.com/PR9/A79). Database results and reference lists
therapist practice. This integrated form of pain management by a from prior systematic reviews and studies were screened. Two
physical therapist is a marked shift in how therapy is commonly independent raters (R.A.C. and H.M.) graded relevant studies using
delivered. Although most physical therapists would accept the the PEDro scale for randomized trial quality.18,55 We summarized
central principles of PIPT and recognize the importance of mitigating PIPT intervention methods and outcome findings.
psychosocial risk,21 there may be challenges in delivering PIPT in
everyday practice. As an initial step towards PIPT implementation,
efficacy of this approach should be clearly established. 3. Results
To date, there have been several systematic reviews around the A total of 943 unique articles from the literature search were
topic of PIPT.1,17,33,75,90 These prior reviews have summarized screened, with 73 article full-texts being evaluated. Of these, 22
studies focused on different pain conditions (ie, postoperative pain, studies representing 18 randomized trials on PIPT were included
general musculoskeletal pain, and low back pain) and using a range in this review (see Appendix Table 4 for exclusions, available at
of PIPT delivery modes (ie, in-person, group-based, and remotely http://links.lww.com/PR9/A79). The majority of trials were
delivered) and control groups (ie, no/minimal treatment, attention graded as having good to excellent methodological quality
control, education, and usual care). Most of the prior studies reviewed (PEDro scores .6/10) (Table 1), except for studies by Bello
have included a PIPT intervention based on cognitive-behavioral
approaches. Two meta-analyses by Silva Guerrero et al.75 and
Wilson and Cramp90 demonstrate that PIPT has a small, but Table 1
significant, effect on improving physical function, disability, and pain Methodological quality of studies.
compared to standard physical therapy. In the meta-analysis by Study 1* 2 3 4 5 6 7 8 9 10 11 PEDro score†
Wilson and Cramp,90 the authors included interventions where the Ariza-Mateos et al.3 Y Y Y Y N N Y Y Y Y Y 8
psychological component could be delivered by either a psychologist Bello et al.8 Y Y Y N N N Y N Y Y Y 6
or physical therapist. This may limit applicability of the review findings
Bennell et al.12 Y Y Y Y N N Y Y Y Y Y 8
to PIPT if adhering to the description by Main and George.
The primary aim and scope of this narrative review was to build Bennell et al.10 Y Y Y Y Y Y Y Y Y Y Y 10
upon existing reviews and examine evidence since the publication of Godfrey et al.32 Y Y Y Y N N Y N Y Y Y 7
Main and George56 on PIPT vs standard physical therapy Hunt et al.40 Y Y Y Y N N Y Y Y Y Y 8
approaches for musculoskeletal pain. We modeled our approach
Khan et al.43 Y Y Y Y N N N Y N Y Y 6
similar to the high-quality review by Silva Guerrero et al.75 by focusing
on studies that compare interventions that include psychological Lee et al.44 Y Y Y Y N N Y N Y Y Y 7
strategies delivered by physical therapists to standard physical Ludvigsson et al.49 Y Y Y Y N N Y Y Y Y Y 8
therapy. Summarizing studies that compare PIPT to standard Macedo et al.50 Y Y Y Y N N Y Y Y Y Y 8
physical therapy would help establish the transformative value of Magalhaes et al.54 Y Y Y Y N N Y Y Y Y Y 8
PIPT. Important advancements to the review by Silva Guerrero 61
Monticone et al. Y Y Y Y N N Y Y Y Y Y 8
et al.75 involve the inclusion of more recent studies after 2016 and
greater description of the individual studies and interventions. Petrozzi et al.69 Y Y Y Y N Y Y Y Y Y Y 9
Specifically, we aimed to categorize the types of psychological Reid et al.72 Y Y N Y N N Y N N Y Y 5
interventions used, report on aspects of dosage and training, and Sterling et al.76 Y Y Y Y N N Y Y Y Y Y 8
discuss clinical implications and future directions. Our hope is that
Thompson et al.77 Y Y Y Y N N N N N Y Y 5
this review describing recent PIPT methods and data will inspire 81
continued efforts to optimize pain rehabilitation. van Erp et al. Y Y Y Y N N Y N Y Y Y 7
Vibe Fersum et al.82 Y Y Y Y N N Y N N Y Y 6
* Item 1 is not included in total score.
2. Methods † PEDro scores of 7/10 or greater are considered good to excellent methodological quality.
N, no (item not met); Y, yes (item met).
The recent peer-reviewed literature was screened by the first author PEDro items: 1, eligibility criteria were specified; 2, subjects were randomly allocated to groups; 3, allocation
for randomized trials published after 2012 examining the efficacy or was concealed; 4, groups were similar at baseline regarding the most important prognostic indicators; 5,
blinding of all subjects; 6, blinding of all therapists who administered therapy; 7, blinding of all assessors who
effectiveness of PIPT. A P-I-C-O-S strategy was used to guide the measured at least one outcome; 8, measures of at least one key outcome were obtained from more than 85%
literature search.64 We aimed to review studies that (1) examined of subjects initially allocated to groups; 9, all subjects for whom outcome measures were available received
adult patients with musculoskeletal pain (Population), (2) included a the treatment or control condition as allocated, or where this was not the case, data for at least one key
outcome were analyzed by “intention to treat”; 10, results of between-group statistical comparisons are
PIPT intervention delivered by a physical therapist (Intervention), (3) reported for at least one key outcome; 11, study provides both point measures and measures of variability for
compared PIPT to standard physical therapy (eg, individual in- at least one key outcome.
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et al.,8 Khan et al.,43 Reid et al.,72 Thompson et al.,77 and Vibe disorder, Ludvigsson et al.48,49,66 showed no difference in
Fersum et al.82 Lower-quality scores in these studies were due to outcomes up to 2 years after a 12-week graded activity program
weaknesses in concealed allocation, similarity in groups at or 12 weeks of progressive neck strengthening. In these trials,
baseline, masking of outcome assessment, follow-up rates, or varying levels of additional pain strategies such as oral or booklet
intent-to-treat analysis. As expected, most studies were unable pain education and basic coping skills training were provided
to mask participants or therapists. within the graded activity intervention group. Therapists delivering
The conditions studied included chronic low back pain (n 5 8), the intervention received varying levels of graded activity training
chronic neck pain (n 5 2), chronic knee osteoarthritis (n 5 2), from “brief” sessions to 2-day and 4-day workshops. The
chronic whiplash-associated disorder (n 5 1), chronic hip prescribed dosage (eg, frequency and duration) of the in-
osteoarthritis (n 5 1), chronic pelvic pain (n 5 1), acute tervention and control groups was matched in all trials.
whiplash-associated disorder (n 5 1), acute or subacute low Graded exposure specifically targets activities or tasks that a
back pain (n 5 1), and mixed musculoskeletal pain (n 5 1). No patient is fearful of due to perceived risks of harm or the pain-
studies involving patients undergoing surgery for musculoskeletal related fear that contributes to avoidant behavior.84,85 Patients
pain met our eligibility criteria. Across all studies, the sample size work with a physical therapist to initially rate their level of fear
ranged from 20 to 588 patients and the average age of patients toward these activities. Patients work in treatment to pro-
ranged from 37.3 to 73.0 years. Follow-up outcome durations gressively approach or “confront” feared stimuli in a hierarchical
ranged from immediate postintervention assessment to 3 years. model. Graded exposure proceeds with activities that elicit the
We categorized PIPT interventions based on the primary least amount of fear and after task mastery, progresses towards
psychological strategy: (1) graded activity or graded exposure, those that are most feared. Progression within graded exposure
(2) cognitive-behavioral-based physical therapy, (3) acceptance occurs based on changes in fear after exposure, where patients
and commitment-based physical therapy, and (4) internet-based learn that fears may be exaggerated,30 or a sense of mastery and
psychological programs. increased self-efficacy to approach previously avoided tasks.
There are 2 mechanisms underlying graded exposure: (1)
behavioral mechanism based on habituation to feared stimulus
3.1. Graded activity or graded exposure
and positive reinforcement for successful completion, and (2)
Graded activity and graded exposure are behavioral strategies cognitive mechanism based on disconfirmation of fear-based
informed by an operant conditioning paradigm, which empha- predictions leading to cognitive restructuring. In a trial by Ariza-
sizes the reinforcement of target behaviors through learned Mateos et al.3 among patients with chronic pelvic pain, graded
consequences. These interventions are derived from the Fear- exposure added to manual therapy resulted in greater short-term
Avoidance Model of Musculoskeletal Pain, which identifies improvement in disability and pain compared to a manual therapy
primary cognitive and affective processes that influence the alone (Table 2). An introductory session of pain education was
perception and maintenance of pain.45,86 Specifically, pain- included as part of the graded exposure intervention. Therapist
related fear (viewing pain as threatening) and pain catastrophizing training was not described; however, the provider who delivered
(the tendency for patients to exaggerate, focus on, or magnify the graded exposure was experienced with the approach. In terms of
threat or seriousness of pain) interact to determine how a patient dosage, patients received graded exposure as an additional
responds behaviorally to pain, either through avoidance or activity weekly 45-minute session of therapy over the 6-week period in
engagement.71 For those who avoid pain or pain-related stimuli, addition to the manual therapy sessions.
the absence of pain reinforces the avoidant behavior. When used
as a primary coping mechanism, fear-avoidance can lead to
3.2. Cognitive-behavioral-based physical therapy
hypervigilance, disuse, and increased disability.23,30
Graded activity and exposure directly address avoidance by Cognitive-behavioral therapy (CBT) is a widely known and
supporting a patient through repeated engagement in specific effective psychological intervention for chronic pain.89 The
(sometimes feared) physical activities or tasks in a paced, premise of CBT is that cognitive and behavioral factors, including
collaborative, and goal-directed manner. These behavioral tech- a person’s thoughts, beliefs, and actions, play a key role in the
niques can be easily embedded within a physical therapy episode of development or maintenance of chronic pain.78 Cognitive-
care.29 For graded activity, target activities (or exercises) are selected behavioral therapy provides patients with a repertoire of
based on a patient’s report of difficulty, chief complaints, or relevance techniques to improve self-management of pain, enhance patient
to the pain condition. After establishing a baseline tolerance level, confidence in their ability to manage pain, and increase perceived
specific activities are performed on a time- or intensity-contingent control over pain.5 Cognitive-behavioral therapy techniques aim
basis (eg, quota) rather than on a patient’s pain response. Positive to identify and decrease maladaptive behaviors, bolster positive
reinforcement is provided when quotas are reached. The primary coping, address dysfunctional thoughts and beliefs influencing
goals of graded activity are to increase the patient’s tolerance to pain, and increase confidence in pain self-management. Al-
specific activities that are meaningful to daily functioning and to though specific techniques vary from clinician-to-clinician,
promote healthy behaviors. Through approaching increased activity, components typically include elements of education, skill training
patients also learn to “confront” previously avoided behaviors, thus (ie, goal setting, activity pacing, relaxation techniques [eg, deep
breaking the reinforcing cycle of fear-avoidance-pain.86 breathing] or distraction, and problem solving), and skill
Five trials examined graded activity against a standard physical application and maintenance in the patient’s daily life.24
therapy group (Table 2). Results from 4 trials by Bello et al.,8 Khan Nine trials examined a cognitive-behavioral-based physical
et al.,43 Macedo et al.,50 and Magalhaes et al.52,54 among therapy approach (Table 3). There was a range of CBT
patients with chronic low back pain suggest that a course of components across the physical therapy interventions, with most
graded activity does not result in significantly greater short-term including education, goal setting, problem solving, and pain-
(,6 months) or long-term (.1 year) improvements in disability, coping skills. In all trials, physical therapists were trained to deliver
physical function, or pain compared to other forms of supervised the psychological-based intervention—mostly through workshop
exercise. Likewise, for patients with chronic whiplash-associated format and some offering ongoing supervision or feedback from a
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Table 2
Summary of recent graded activity or exposure studies.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
Ariza-Mateos et al.3 49 female patients with Graded exposure therapy Manual therapy was Disability: ODI There was a significant
chronic pelvic pain and manual therapy performed to decrease pain Pain interference: BPI difference in
Mean age: 41.9 years included manual therapy, or tension, increase motion, Pain intensity: BPI postintervention and 3-
pain education, and activity- or improve balance or measured at 6 weeks and 3 month disability, with lower
based treatment focused on stability. Manual therapy months disability scores after graded
the patient’s 5 most fearful included soft tissue exposure therapy. There
tasks. Patients were mobilization, myofascial was a significant difference
exposed to tasks based on release, deep pressure in 3-month pain, with lower
least to most fearful. massage, and muscle pain scores after graded
Progressions were based on energy techniques. Patients exposure therapy.
within-session changes in received manual therapy for
fear. Patients performed 45 minutes, 2 times per
graded exposure for a single week, and for 6 weeks.
45-minute session each
week for 6 weeks. Patients
in this group also received
manual therapy similar to
control group.
Bello et al.8 62 patients (31 females) Graded activity included Conventional exercise Physical function: RAND-36 No significant differences in
with chronic low back pain individualized, submaximal, included stretching, Pain intensity: NRS (0–10) physical function, pain
Mean age: 44.0 years and gradually increased strengthening, and core Bodily pain: RAND-36 intensity, or bodily pain
performance of activities stabilization. Physical Measured at 4, 8, and 12 between groups were
(exercises) based on therapists could also include weeks observed.
patient’s baseline lumbar traction, massage,
complaints or limitations. and nonmanipulative
Graded activity exercises therapy. Patients performed
included general exercise for 45 minutes, 2
strengthening and aerobic times per week, and for 12
activity and were directed weeks.
based on quotas. Pain
education and self-
management strategies
were also provided. Patients
performed graded activity
for 45 minutes, 2 times per
week, and for 12 weeks.
Khan et al.43 54 patients (29 females) Graded activity included General exercise included Disability: RMDQ No between-group
with chronic low back pain operant behavioral graded the same general exercise Pain intensity: VAS (0–10) statistical differences were
Mean age: 39.6 years activity, problem-solving program as the cognitive- Measured at 12 weeks reported. Both groups
training, and general behavioral-based physical showed significant
exercises. Graded activity therapy group. Patients improvements in disability
involved gradual increase or attended 3 sessions per and pain.
pacing of activities that were week for 12 weeks.
important to patients with
education to modify
dysfunctional beliefs.
General exercises included
low back and lower-
extremity stretching and
aerobic activity. Patients
attended 3 sessions per
week for 12 weeks.
Ludvigsson et al.48,49 216 patients (142 females) Graded activity and basic Exercise included Disability: NDI, PDI No significant differences in
and Overmeer et al.66 with chronic whiplash- behavioral training included progressive motion and Physical function: PSFS disability, physical function,
associated disorder the same group of exercises strengthening exercises for Pain intensity: VAS (0–100) or pain intensity between the
Mean age: 40.4 years as the exercise group, but the neck region. Exercises Pain Bothersomeness: VAS behavioral-based exercise
the exercises were not were guided based on (0–100) and exercise group were
based on symptom (pain) symptom response and Measured at 3 and 6 observed.
response. An operant- capability. Additional months, and 1 and 2 years
conditioning behavioral exercises could include
approach (graded exercise) back, abdomen, and
was used. Physical scapula strengthening or
therapists delivered pain stretching. The exercise
education and facilitated intervention lasted 12
pain management and weeks.
problem-solving strategies.
Patients were encouraged to
practice skills at home. The
graded exercise and basic
behavioral training lasted 12
weeks.
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Table 2 (continued)
Summary of recent graded activity or exposure studies.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
Macedo et al.50 172 patients (102 females) Graded activity included Motor control exercise was Disability: RMDQ No significant differences in
with chronic low back pain individualized and focused on motor control Physical function: PSFS disability, physical function,
Mean age: 49.2 years submaximal exercises that principles and aimed at Physical health: SF-36 or physical health between
were progressed on a time- regaining control and Pain intensity: NRS (0–10) groups were observed.
contingent manner (eg, daily coordination of the spine Measured at 2, 6, and 12
quotas) and through goals and pelvis. Exercises were months
set by the patient and selected based on
therapist. The exercises impairments and patient
were based on activities goals. A thorough
patients reported as movement-based
problematic due to back assessment was performed
pain. Additional cognitive- to examine movement
behavioral strategies were patterns, posture, and
used by the physical activation. Specific motor
therapists and included control exercises were
positive reinforcement, pain prescribed, and manual or
education, addressing ultrasound feedback was
negative behaviors or used to enhance learning for
anxiety, and managing proper performance.
relapses. Patients attended Exercises were progressed
twelve 1-hour sessions over based on symptom
8 weeks and 2 booster response (pain) and towards
sessions at 4 and 10 functional activity. Patients
months. attended twelve 1-hour
sessions over 8 weeks and 2
booster sessions at 4 and 10
months.
Magalhaes et al.52,54 66 patients (49 females) Graded activity included Exercise included back and Disability: RMDQ No significant differences in
with chronic low back pain progressive and lower-extremity stretching, Physical function: SF-36 disability, physical function,
Mean age: 46.9 years submaximal aerobic and abdominal strengthening, Pain intensity: NRS (0–10) pain intensity, or pain quality
strengthening exercises and motor control exercises. Pain quality: MPQ between groups were
aimed at improving physical No other cointerventions Measured at 6 weeks, and observed.
fitness and stimulating such as manual therapy 3 and 6 months
change in behavior and were included. Patients
attitude. Exercises were attended twelve 1-hour
selected based on patient sessions, twice per week,
report of difficulty, for 6 weeks.
prescribed based on
moderate level of activity,
and progressed on a time-
contingent basis. Patients
also received an educational
booklet. Patients attended
twelve 1-hour sessions,
twice per week, for 6 weeks.
BPI, Brief Pain Inventory; MPQ, McGill Pain Questionnaire; NDI, Neck Disability Index; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; PDI, Pain Disability Index; PIPT, psychologically informed physical therapy; PSFS,
Patient Specific Functional Scale; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale.

psychologist. Four trials compared cognitive-behavioral-based greater short-term efficacy compared to a standard therapy group,
physical therapy to standardized exercise,10,40,76,77 whereas 5 whereas Sterling et al.76 and Vibe Fersum et al.82,83 reported
trials compared to a multimodal (eg, manual therapy and greater efficacy in disability and pain at 1 year (or longer for Vibe
exercise) or pragmatic rehabilitation program.44,61,72,81,82 Fersum et al.). In a 3-arm randomized trial by Bennell et al.,10 a 12-
Five trials reported no difference between the cognitive- week, 10-session pain-coping skills training program combined
behavioral-based physical therapy group compared to con- with exercise resulted in greater effects on physical function up to
trol.40,44,61,72,81 Of these 5 trials, 4 trials included a control group 32 weeks compared to a group consisting of exercise alone for
of multimodal or pragmatic rehabilitation,44,61,72,81 whereas the patients with knee osteoarthritis. There were duration differences
remaining trial was a small pilot study.40 In the small pilot study of between groups, with the pain-coping skills and exercise sessions
20 patients, Hunt et al.40 established the feasibility of a pain- lasting 70 minutes per session and the exercise only group lasting
coping skills training program that was later tested in a larger 25 minutes per session. Therapist training for delivering the pain-
randomized trial. In trials by Lee et al.44 and Reid et al.,72 the coping skills intervention was rigorous involving a 4-day workshop,
cognitive-behavioral intervention was developed for utilization therapist accreditation, ongoing supervision, and feedback pro-
within distinctive settings of work rehabilitation and home health vided by an experienced psychologist.
care, respectively. Sterling et al.76 and Thompson et al.77 examined a cognitive-
Studies by Bennell et al.,10 Sterling et al.,76 Thompson et al.,77 behavioral-based physical therapy intervention for patients with
and Vibe Fersum et al.82,83 showed greater efficacy after cognitive- cervical spine conditions. Sterling et al.76 provided 10 sessions
behavioral-based physical therapy for an outcome of function, over 6 weeks of stress inoculation training—a cognitive-
disability, or pain. Bennell et al.10 and Thompson et al.77 showed behavioral approach focused on helping patients manage
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Table 3
Summary of recent cognitive-behavioral-based physical therapy studies.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
Bennell 222 patients (133 females) with Pain-coping skills training Exercise included 6 Physical function: WOMAC The combined pain-coping
et al.10 chronic knee osteoarthritis involved 10 physical therapist- strengthening exercises for function skills training and exercise
Mean age: 63.4 years delivered modules covering the lower-extremity muscles. Pain intensity: VAS (0–100) group showed greater
pain education and cognitive Patients were provided Pain: WOMAC pain improvement in physical
and behavioral pain-coping weights, elastic bands, and Measured at 12, 32, and 52 function at 12 and 32 weeks
skills and application. Pain- handouts for home use. weeks compared to exercise. At 12
coping skills included activity- Patients were instructed to weeks, there were no
rest cycling, pleasant activity perform exercises 4 times per significant differences
scheduling, problem solving, week for 12 weeks and 3 between groups for overall
addressing negative thoughts, times per week thereafter. pain intensity. However, the
pleasant imagery, counting Patients attended 10 pain-coping skills training and
backwards, and auditory individual sessions over 12 exercise showed greater
stimulation. Patients were weeks. Each session lasted reductions in walking pain
encouraged to practice skills. 25 minutes. intensity than exercise. At 32
Patients attended 10 individual weeks, the combined group
sessions over 12 weeks. Each also showed greater
session lasted 45 minutes. improvement in pain intensity
Pain-coping skills training and and WOMAC pain.
exercise (as described in other
groups) were integrated.
Patients attended 10 individual
sessions over 12 weeks. Each
session lasted 70 minutes.
Hunt et al.40 20 patients (12 females) with Pain-coping skills training and Nondirective counseling and Physical function: WOMAC No significant differences in
chronic knee osteoarthritis exercise included a combined exercise included the same function physical function or pain
Mean age: 62.5 years intervention of online pain- exercise intervention as the Pain intensity: NRS (0–10) between groups were
coping modules and home pain-coping group. In Pain: WOMAC pain observed.
exercises. Pain-coping skills addition, patients Measured at 11 weeks
training involved 10 physical participating in open
therapist-delivered modules discussions with the therapist
covering pain education and to discuss any osteoarthritis-
cognitive and behavioral pain- related problems. Specific
coping skills and application. advice was not provided by
Pain-coping skills included the therapist. Patients
activity-rest cycling, pleasant attended 10 weekly individual
activity scheduling, problem sessions for nondirective
solving, addressing negative counseling and exercise.
thoughts, pleasant imagery,
counting backwards, and
auditory stimulation. Exercises
included 6 strengthening
exercises for the lower-
extremity muscles and a
preplanned walking program.
Patients were provided weights,
elastic bands, and handouts for
home use. Patients attended 10
weekly individual sessions for
pain-coping skills training and
exercise.
Lee et al.44 47 patients (23 females) with Cognitive-behavioral-based Work rehabilitation included Disability: RMDQ, ODI No significant differences in
acute or subacute low back work rehabilitation included a conventional individual Pain intensity: NRS (0–10) disability or pain intensity
pain physical therapy program physical therapy based on Measured at discharge between groups were
Mean age: 37.3 years focused on physical function symptom presentation and observed.
and based on cognitive- response. Treatment could
behavioral principles. include a combination of
Treatment included graded modalities (interferential
activity, pacing techniques, therapy, transcutaneous
work conditioning, return to electrical nerve stimulation,
work goal setting, self- traction), manual therapy, and
management, job analysis, and exercise. Work rehabilitation
ergonomics. Cognitive- could last up to 3 months.
behavioral-based work
rehabilitation could last up to 3
months.
Monticone 80 patients (60 females) with Cognitive-behavioral-based Physical therapy included a Disability: NPDS No significant differences in
et al.61 chronic neck pain physical therapy involved the multimodal approach of active Physical function: SF-36 disability, physical function, or
Mean age: 49.6 years same multimodal exercise and passive mobilization, Pain intensity: NRS (0–10) pain intensity between groups
program as the physical postural control, stretching Measured at 3 and 12 were observed.
therapy group. In addition, and strengthening exercise, months
physical therapists included and ergonomic advice.
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Table 3 (continued)
Summary of recent cognitive-behavioral-based physical therapy studies.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
cognitive-behavioral strategies Patients were discouraged to
to address patient beliefs, receive other pain
thoughts, and behaviors. management treatments (ie,
Strategies included graded pain medication, physical
activity, addressing escape and modalities). Patients attended
avoidance behaviors, pain and up to twelve 45–50-minute
fear-avoidance model individual sessions,
education, coping and pacing scheduled once or twice per
skills, and graded exposure. week, for a maximum of 12
Patients attended up to twelve weeks.
45–50-minute individual
sessions, scheduled once or
twice per week, for a maximum
of 12 weeks.
Reid et al.72 588 patients (410 females) with Cognitive-behavioral-based Physical therapy included Disability: RMDQ No significant differences in
mixed musculoskeletal pain physical therapy included a 5- pragmatically delivered care Physical function: Functional disability, physical function, or
Mean age: 73.0 years session cognitive-behavioral within the patient’s home. status scale pain intensity between groups
self-management program that Physical therapists completed Pain intensity: NRS (0–10) were observed.
was implemented within home a comprehensive functional Measured at 60 days
care physical therapy. The assessment and evaluation of
sessions focused on topics psychological functioning,
including pain theory, home environment, and use
becoming more active, or need of assistive devices. A
relaxation, deep breathing, treatment plan was generated
imagery, pleasant activity and exercise was prescribed
scheduling, activity pacing, to increase strength, reduce
sleep tips, and managing flare fall risk, and improve motion,
ups. Patients were provided a gait, transfer skills, balance,
booklet reinforcing program coordination, and functioning.
content and encouraged to Home care was delivered in a
practice techniques on their pragmatic manner under the
own. Home care was delivered direction of the physical
in a pragmatic manner under therapist.
the direction of the physical
therapist.
Sterling 108 patients (67 females) with Stress inoculation training and Exercise included Disability: NDI The stress inoculation training
et al.76 acute whiplash-associated exercise combined 6 sessions progressive, individualized Physical health: SF-36 and exercise group showed
disorder of cognitive-behavioral-based exercises to improve Pain intensity: NRS (0–10) greater improvement in
Mean age: 41.3 years training with the same 6-week movement, strength, and Measured at 6 weeks, and 6 disability and pain intensity at
exercise program as the endurance of the neck and and 12 months all time points after
exercise group. Stress shoulder girdle region, and to intervention. There was no
inoculation training facilitated improve eye/hand significant difference in
problem solving and coping coordination. Physical physical health between
strategies for managing stress- therapists also provided groups.
related anxiety. Physical advice on return to normal
therapists taught patients activities and aerobic
strategies to identify and exercise. Manual therapy was
understand stress, develop allowed at the therapist’s
skills for managing stress, and discretion. Patients attended
apply skills in different ten 50-minute exercise
situations. Patients attended sessions over a 6-week
ten 50-minute sessions over a period.
6-week period for stress
inoculation training and
exercise.
Thompson 57 patients (26 females) with Cognitive-behavioral Exercise included Disability: NPQ There was no significant
et al.77 chronic neck pain intervention and exercise progressive, higher-intensity Pain intensity: NRS (0–10) difference in postintervention
Mean age: 47.5 years included the same exercise neck exercises to improve Measured at 6 months disability between groups.
program as the exercise group strength, mobility, and The cognitive-behavioral
and an IBMT. The program endurance. Exercises groups showed a greater
aimed to reduce included cervical isometrics, reduction in pain intensity.
catastrophizing and pain- resisted motion, and
related fear and improve self- stretching. Written
efficacy through interactive information describing that
sessions challenging unhelpful there was no serious cause of
thoughts, emotions, and neck pain and outlining
beliefs. Physical therapists chronic cycle of neck pain was
facilitated cognitive-behavioral provided to patients. Patients
strategies such as goal setting attended four 40-minute
and problem solving. The weekly sessions.
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Table 3 (continued)
Summary of recent cognitive-behavioral-based physical therapy studies.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
cognitive-behavioral
intervention was delivered in
small groups. Patients attended
four 90-minute weekly sessions
for the cognitive-behavioral
intervention and exercise.
van Erp 25 patients (14 females) with Cognitive-behavioral-based Physical therapy included Disability: QBPDS No significant differences in
et al.81 chronic low back pain physical therapy included a individualized physical Pain intensity: NRS (0–10) disability or pain intensity
Mean age: 44.0 years structured 12 session program therapy based on best Measured at between groups were
(Back on Track) that stimulated practices and guidelines for postintervention and 3 observed.
patients to gain insight on pain low back pain. Therapeutic months
mechanisms, behavior and strategies included manual
beliefs, coping styles, goal therapy, core stability, and
setting, and self-management back strengthening. Physical
strategies. Graded activity and therapists directed the
exposure were also included. frequency, duration, and
Patients received a workbook content of sessions. Patients
with homework assignments. attended a maximum of 12
Patients attended four 30- sessions of physical therapy.
minute individual sessions and
eight 60-minute group
sessions.
Vibe Fersum 121 patients (63 females) with Classification-based cognitive Manual therapy and exercise Disability: ODI There were significant
et al.82,83 chronic low back pain functional therapy was an included spine or pelvis Pain intensity: NRS (0–10) differences in disability and
Mean age: 41.5 years individualized classification manipulation or mobilization, Measured at 12 weeks, 12 pain at 12 weeks and 12
approach that addressed general exercise, and/or months, and 3 years months between groups, with
cognitive, movement, and motor control exercise. lower disability and pain
lifestyle behaviors. Physical Inclusion of particular scores after cognitive
therapists based targeted techniques or exercises, and functional therapy. There was
strategies on the patient’s initial dosage of procedures was a significant difference in
presentation and psychosocial based on the discretion of the disability at 3 years between
risk. Four components of the treating therapist. Patients groups, with lower disability
treatment included cognitive, attended a 1-hour initial scores after cognitive
specific movement, targeted evaluation and 30-minute functional therapy. No
functional integration, and follow-up sessions. significant differences in pain
physical activity. Cognitive between groups at 3 years
strategies within the were observed.
intervention included pain and
fear-avoidance education,
problem solving, goal setting,
reflective communication, self-
management, functional
enhancement, and goal
orientation. Patients attended
weekly sessions for the first
2–3 weeks and then 1 session
every 2–3 weeks for the 12-
week duration.
IBMT, interactive behavioral modification program; NDI, Neck Disability Index; NPDS, Neck Pain and Disability Scale; NPQ, Northwick Park Questionnaire; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; QBPDS, Quebec Back
Pain Disability Score; PIPT, psychologically informed physical therapy; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

stress-related anxiety—to patients with acute whiplash- therapists (90 minutes per session) compared to the exercise
associated disorder and found greater treatment efficacy in group (40 minutes per session). Specific training for the interactive
disability and pain up to 1 year. The target sample was patients at behavioral modification therapy was not described; however,
risk for poor recovery with moderate disability (based on Neck therapists who delivered this intervention were reported to have
Disability Index) and hyperarousal symptoms (based on Post- prior experience in delivering pain management programs.
traumatic Stress Diagnostic Scale) at initial presentation. Duration Vibe Fersum et al.82,83 examined a 12-week classification-
was matched at 50-minute sessions for both stress inoculation based cognitive functional therapy approach for chronic low back
with exercise and exercise alone groups. Similar to the study by pain. The distinction with this method compared to previously
Bennell et al.,10 Sterling et al.76 used a psychologist and mentioned PIPT approaches is the use of a classification system.
physician-led workshop, therapist accreditation, and a training In this system, patient characteristics were used to inform the
booster session. Thompson et al.77 combined interactive specific strategies implemented within treatment, providing a
behavioral modification therapy with progressive exercises for targeted or tailored therapy approach. The cognitive functional
patients with chronic neck pain. Thompson et al.77 did not find therapy intervention included 4 components targeting cognitive,
differences in disability between the interactive behavioral specific movement, functional integration, and physical activity.
modification therapy with exercise and exercise groups but did Compared to manual therapy and exercise, patients receiving
report greater pain reduction in the intervention group. Patients in classification-based cognitive functional therapy showed greater
the behavioral therapy group required more time with physical improvement in disability and pain up to 1 year. A follow-up study
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by Vibe Fersum et al.83 reported that group differences persisted be expected, given the PACT focus on functioning as opposed to
at 3 years for disability, but not pain intensity. Total number and reductions in pain. Physical therapists involved in delivering PACT
duration of sessions were similar for each group. Physical were initially trained in a 2-day workshop led by psychologists
therapists delivering the cognitive functional therapy had sub- with expertise in ACT and were required to apply the intervention
stantial training and experience (eg, average of 106 hours of with practice patients.31,32 Workshop training involved educa-
training) in this method. tion, experiential exercises, role playing, and problem solving.
Supervision, feedback, and assessment of skill were provided by
the team of trainers and further training was delivered as needed.
3.3. Acceptance and commitment-based physical therapy Qualitative reports by the physical therapists indicated that PACT
As can be seen from the previous studies, CBT has been the was feasible and acceptable. Although adherence to PACT was
prime intervention underlying PIPT. This is largely based on the high, Godfrey et al.53 noted that only a few ACT methods were
evidence of effectiveness for CBT in chronic pain.89 Acceptance delivered by physical therapists across sessions. The total mean
and commitment therapy (ACT) is a “third wave” cognitive- total duration of therapy time was marginally less than usual
behavioral intervention initially developed for psychological physical therapy (2 hours compared to 3 hours).
disorders.59,74 However, ACT has a growing evidence base for
addressing chronic pain.39 Acceptance and commitment therapy
3.4. Internet-based psychological programs and
uses techniques including mindfulness, acceptance, and behav-
physical therapy
ioral change strategies to increase internal flexibility and help
patients reconnect with core values to lead more fulfilling lives in The advanced training and clinic session time required to deliver
the presence of chronic pain.39 Recognizing that some aspects of specific CBT or ACT-based strategies are potential barriers to
the chronic pain experience cannot be altered, ACT shifts focus PIPT implementation. Moreover, physical therapists may struggle
on pain or symptom reduction towards promoting “acceptance” with delivering psychological strategies because these may be
and simultaneous patient achievement of value-oriented goals perceived as out of their scope of practice or comfort level.6
such as improved physical functioning. The aim of ACT is to Internet-based psychological programs (or applications) for pain
reduce experiential avoidance (avoiding unwanted sensations, offer a potential solution for providing PIPT in a more scalable
thoughts, and emotions) and promote psychological flexibility manner, especially when integrated with therapy.11 Several
through openness (acceptance and cognitive defusion [seeing widely available programs exist and have been presented in the
thoughts as mental events that come and go, without letting them literature.
drive behavior]), awareness (present-moment contact and self- Two studies have examined the efficacy of combining internet-
as-context [being able to observe internal experiences without based psychological programs with physical therapy (Table 5).
identifying with them]), and activity engagement (clarifying values Petrozzi et al.69 randomized patients undergoing physical therapy
and committed action).25 (or chiropractic care) to receive access to MoodGYM—a free,
One study by Godfrey et al.32 has evaluated a physical therapy noncondition-specific, 5-module CBT-based program that ad-
approach informed by acceptance and commitment therapy dresses patient’s thoughts, feelings, and stressors. The authors
(PACT) (Table 4). The PACT intervention was a brief intervention reported no added benefit of including MoodGYM above what
spanning 3 individual visits (eg, two 1-hour in-person visits and was reported by patients receiving physical therapy alone.69 It is
one 20-minute telephone session) over 1 month. The strategies possible that the lack of specificity of the program or poor
implemented within PACT aimed to promote self-management adherence, which was not objectively tracked in the trial, could
and psychological flexibility.31 Specific strategies included shift- have impacted findings. In addition, MoodGYM was not in-
ing focus, value-based goal setting and adjustment, mindfulness tegrated as part of clinical treatment. In other words, providers did
exercises, action plans, identification of support system, and not seem to reinforce program content or help patients apply the
skills application. At 3 months, patients receiving PACT com- skills learned. This was a similar approach taken by Bennell
pared to usual physical therapy had greater improvement in et al.12 who had patients’ access and complete PainCOACH, an
disability, physical function, and physical health. This difference interactive 8-module program emphasizing pain-coping skills,
was not maintained at 1 year. There was no difference in pain before undergoing a standard exercise program for hip pain.
intensity ratings between groups at any time point, which could Similar long-term clinical outcomes were observed compared to

Table 4
Summary of recent acceptance and commitment-based physical therapy studies.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
Godfrey 248 patients (147 females) with PACT was a self-management Physical therapy included Disability: RMDQ The PACT group showed greater
et al.32 chronic low back pain promoting intervention that standard physical therapy Physical function: improvement in disability and
Mean age: 47.9 years included two 1-hour in-person treatment that could include PSFS physical function compared to
treatment sessions (2 weeks individual physical therapy or Physical health: SF- physical therapy at 3 months. No
apart) and one 20-minute phone back rehabilitation classes, 12 significant differences were noted
call (1 month later). PACT dynamic control classes, manual Pain intensity: NRS at 12 months In addition, there
included an initial physical therapy, or hydrotherapy. (0–10) were no differences in pain
assessment, identification of Physical therapy was directed by Measured at 3 and between groups at 3 or 12
value-based goals, individualized the providing physical therapists. 12 months months.
exercise, addressing of self-
management barriers and
facilitators, and psychological
flexibility skills training. No
manual therapy was included.
NRS, numeric rating scale; PACT, physical therapy approach informed by acceptance and commitment therapy; PIPT, psychologically informed physical therapy; PSFS, Patient Specific Functional Scale; RMDQ, Roland Morris
Disability Questionnaire.
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Table 5
Summary of PIPT studies with use of internet-based programs.
Study Sample PIPT intervention Standard PT intervention Outcomes Summary results
Bennell 144 patients (82 females) with Internet-based pain-coping Internet-based education and Physical function: WOMAC The internet-based pain-coping
et al.12 chronic hip osteoarthritis skills training, education, and exercise included 8 information function skills group showed
exercise included the same sheets related to arthritis self- Pain intensity: VAS (0–100) immediately greater
internet-based education and care that were provided over the Pain: WOMAC pain improvements in physical
home exercise program as the first 8 weeks of the intervention. Measured at 8, 24, and 52 function at 8 weeks compared
control group. In addition, pain- Topics covered arthritis, pain, weeks to control. This effect did not
coping skills training included 8 physical activity, saving energy, persist at 24 or 52 weeks. No
online modules that patients healthy eating, emotions, and significant differences in pain
accessed during the first 8 tips for hip osteoarthritis. between groups were observed
weeks of the intervention. Pain- Patients were instructed to after intervention.
coping skills modules covered access 1 sheet per week.
relaxation, activity-rest cycling, Exercise included a home-
pleasant activity scheduling, based exercise program that
cognitive restructuring, patients performed 3 times per
pleasant imagery, distraction, week from weeks 8–24.
and problem solving. Patients Patients attended five 30-
were reminded weekly to minute sessions with a physical
complete modules. therapist every 3 weeks. A
physical therapist prescribed
individualized strengthening
exercises for the lower extremity
and hip stretching.
Petrozzi 108 patients (54 females) with Internet-based cognitive- Physical treatment included Disability: RMDQ No significant differences in
et al.69 chronic low back pain behavioral program and pragmatically applied Physical function: PSFS disability, physical function, or
Mean age: 50.4 years physical treatment included the techniques such as spinal Pain intensity: NRS (0–10) pain intensity between groups
same physical treatment as the manipulation, mobilization, soft Measured at 8 weeks, and 6 were observed after
comparison group. Patients tissue massage, and exercise. and 12 months intervention.
attended up to 12 sessions at a Patients also received
frequency and duration based reassurance, advice about
on clinical judgment and patient symptom management,
response. In addition, patients instruction on safe manual
received access to online handling, general postural
cognitive-behavioral program advice, and encouragement to
(MoodGYM). The program stay active. Physical treatment
included 5 modules that explore was provided by a physical
thoughts, feelings, stressors, therapist or chiropractor.
and relationship that contribute Patients attended up to 12
to psychosocial distress, and sessions at a frequency and
promotes strategies for coping duration based on clinical
and problem solving. Patients judgment and patient response.
were instructed to access 1
module per week while
attending physical treatment.
No in-person counseling was
provided as part of the
intervention.
NRS, numeric rating scale; PIPT, psychologically informed physical therapy; PSFS - Patient Specific Functional Scale; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale; WOMAC, Western Ontario and
McMaster Universities Osteoarthritis Index.

internet education and standard exercise. The lack of integration integration of learned skills within therapy, or issues with program
by Bennell et al.12 enhanced methodological rigor (ie, blinding of specificity may explain the apparent lack of additional benefit.
therapists),13 but may explain the lack of added long-term benefit. Finally, as often is the case, there are areas that lack clear
conclusions.
4. Discussion
4.1. Summary of findings 4.2. Comparison to prior reviews
Summary findings from recent trials point to a few important Prior systematic reviews have summarized evidence on efficacy
observations. First, there continues to be evidence that graded of graded activity46,51,80 and PIPT.1,17,33,75,90 Overall, our results
activity is not a superior approach for chronic low back pain are largely consistent with these reviews, which show promising
compared to other forms of exercise. This has been highlighted in effects for PIPT, namely in-person cognitive-behavioral-based
earlier systematic reviews of the literature.46,51,80 In the current physical therapy. Prior reviews have differed in their focus for
review, none of the included studies on graded activity showed condition (ie, postoperative pain,17 general musculoskeletal
greater efficacy in improving outcomes compared to standard pain,1,75 low back pain,33 and chronic pain90) and comparators.
physical therapy. Second, despite the apparent accessibility and We intended a broad condition focus that would include both
feasibility, internet-based psychological programs provided to nonoperative and postoperative patients, but did not find any
patients in physical therapy do not seem to contribute to better postoperative studies that directly compared PIPT to standard
outcomes compared to physical therapy alone. Issues related to physical therapy. A few notable postoperative PIPT studies that
low adherence to the online program, lack of support or did not meet this specific criterion, but should be considered
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when determining the value of postoperative PIPT, include therapy is often not standardized or protocolized. Thus, there are
studies by Archer et al.,2 Lotzke et al.,47 Riddle et al.,73 Peolsson no established dosage and content parameters that are widely
et al.,68 and Wibault et al.88 Most of these postoperative studies accepted as effective. In the current review, we found variability in
compared a PIPT approach to usual postoperative care, which the structure of PIPT in terms of total number, frequency and
may have included physical therapy. duration of sessions, and length of the treatment program. We did
We did include similar PIPT studies as prior reviews, but also not observe an apparent pattern that would describe the impact
more recent trials. In contrast to prior reviews, we report summary of these parameters on treatment efficacy. For example, Godfrey
findings related to ACT-based physical therapy and internet- et al.31 reported beneficial effects after their relatively brief PIPT
based psychological programs offered in conjunction with intervention. Optimizing parameters related to PIPT dosage and
physical therapy. These novel approaches have potential content is an important area for further exploration.
implications and can inform future directions. For example, CBT Another possible reason for mixed or comparable outcome
represents the most common psychological approach that has findings could relate to the lack of targeting of the PIPT to a
shaped PIPT. The evidence for cognitive-behavioral-based population “at risk.” Few of the included studies directly targeted
physical therapy is summarized in this review and in prior meta- the PIPT intervention to patients exhibiting heightened psycho-
analyses.75,90 However, more recent psychological approaches social risk. One example of a trial that did was the study by
such as ACT, mindfulness, and positive psychology may provide Sterling et al.76 where patients were screened for hyperarousal
novel strategies to integrate within physical therapy. Our review symptoms. Psychologically informed physical therapy strategies
suggests that ACT-based physical therapy may be a beneficial may not be needed by all patients with musculoskeletal pain. This
approach for chronic pain.32 In the context of personalized approach of stratifying patients based on psychosocial risk is not
medicine, targeted psychological strategies may need to new and there has been success with primary care pathways
consider not only psychological risk factors commonly addressed involving physical therapy for acute back pain.36 There may be a
with CBT, but also whether boosting resiliency characteristics role for personalized approaches to assess not whether PIPT
such as positive affect, hope, or optimism can translate to works, but rather which patients benefit from these augmented
meaningful clinical outcome effects.26,34 rehabilitation treatments and who may not need them or respond.
Recent evidence suggests a potential outcome influence for not
only psychosocial risk factors, but also resiliency characteris-
4.3. Clinical implications and future directions
tics.7,58,87 Future studies should examine whether complex
Results from recent studies examining in-person CBT-based psychological profiles including both risk and resiliency charac-
physical therapy approaches are mixed. These findings may teristics impact the efficacy of PIPT interventions.
suggest a lack of robust superiority for PIPT compared to The added cost and burden of integrating PIPT in real-world
pragmatically delivered physical therapy.65 It is possible that settings may not outweigh small degrees of additional benefits
traditional physical therapy interventions such as exercise could that have been observed in the literature. For most physical
impart similar benefits to psychological-based interventions therapists, the PIPT approach represents a considerable shift
through shared or nonspecific mechanisms.60 Before settling from traditional physical therapy care. Transformative physical
on these conclusions, the quality of the randomized trials and the therapy practice may involve greater focus on addressing
need to examine additional factors that may impact the role of this psychological risk factors, use of psychological techniques that
class of intervention should be considered. For example, half of might conflict with physical-focused interventions (in terms of
the “positive effects” studies on cognitive-behavioral-based time or priority), and/or adjustments to longer therapy sessions or
physical therapy were judged to be of lower methodological group-based formats. Each of these practice shifts may come at
quality, which could bias these results. Studies demonstrating a “cost” to the therapist or clinic. It was beyond the scope of this
efficacy of cognitive-behavioral-based physical therapy tended to review to examine the cost implications (or savings) of a PIPT
have larger sample sizes compared to trials showing no approach. However, as part of their trial, Bennell et al.10 did report
difference, suggesting a higher likelihood to detect small a higher cost of delivery for PIPT (pain-coping skills and exercise)
differences in outcomes. The exception was the study by Reid due to the lengthier treatment sessions, but no difference in cost-
et al.72 (.500 patients) that reported no difference in efficacy for effectiveness between groups. Godfrey et al.32 found no major
cognitive-behavioral-based physical therapy. Reid et al.72 ac- cost of delivery or utilization differences in their study, but did
knowledge that their trial may have been affected by low acknowledge the need for a one-off PIPT training cost.
psychological strategy implementation by physical therapists. Thompson et al.77 reported cost savings with their PIPT approach
The main implementation challenges were time to deliver the because of the small group format. Although a formal cost-
intervention (additional 15–20 minutes), which interfered with effectiveness analysis was not conducted, Thompson et al.77 did
addressing other patient issues, and low utilization of written report no difference in healthcare utilization between groups.
material or practice techniques by patients. High-quality studies Future efforts examining costs supporting a PIPT model of care
by Bennell et al.,10 Sterling et al.,76 and Godfrey et al.32 as well as and cost-effectiveness are needed.
the study by Vibe Fersum et al.,82,83 which show greater efficacy Qualitative reports emphasize physical therapist’s concerns
after cognitive-behavioral-based physical therapy, describe and barriers to approaching pain management in a PIPT
rigorous training and implementation protocols. Moreover, most manner.38 There is inadequate training in psychological interven-
of these trials involve collaboration with a clinical psychologist tions or cognitive-behavioral pain strategies across entry-level
and/or rehabilitation physician,10,76 which may be an important physical therapy programs.37 Postgraduate educational oppor-
component of both training and fidelity. tunities in PIPT are scarce and may not meet the rigor of training
Cognitive-behavioral therapy, delivered by psychologists, is an needed to support a PIPT practice model.15,63 For example,
intervention with relatively good outcome effects for chronic successful behavioral intervention training programs often use
pain.22 If CBT-based interventions delivered by physical thera- multiple methods such as workshops, role playing, practice,
pists are similarly efficacious as traditional therapy, this begs the supervision by a psychologist, and peer feedback to ensure
question of why this may be the case. Unlike CBT, physical intervention adoption and prevent drift.35 Several of the described
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trials used these methods with study physical therapists and programs. Our primary aim was to describe recent approaches
often, the results suggested high fidelity to delivering PIPT. Even and offer clinical implications and possible future directions. We
when implementation rates are low, physical therapists demon- did not meta-analyze outcome data from our included studies
strate ability and confidence to provide PIPT techniques as and are unable to confirm efficacy of specific PIPT approaches.
trained.72 One of the main challenges in transforming standard Despite our structured and comprehensive search strategy, we
practice towards PIPT is the requirement to optimally train cannot confirm that we have identified all studies since 2011
physical therapists in delivering cognitive-behavioral-based meeting our eligibility criteria.
treatment. Currently, there is no widely accepted standard for
PIPT intervention training.42 Several high-quality studies included
rigorous and comprehensive training programs that would be 5. Conclusions
expected to be more effective in preparing physical therapists to Our review summarized findings from recent randomized trials
deliver standard psychological strategies, but also manage that have examined the efficacy of PIPT compared to standard
patients with higher psychological burden or handle unantici- physical therapy approaches in patients with musculoskeletal
pated challenges that may arise with this form of therapy. For pain. Consistent with prior reviews, graded activity is not superior
example, periodic feedback from a psychologist and peer to other forms of physical activity or exercise. A few studies on
discussion have been important aspects to address unique cognitive-behavioral-based physical therapy demonstrated
patient experiences and challenges.63 This aspect of training may short-term efficacy, when compared to a program of standard-
not be feasible for all practice settings. Future research should ized exercise. There is a need to further examine approaches
aim to determine optimal and standardized methods to train, integrating alternative strategies including acceptance-based
supervise, and monitor physical therapists’ use of PIPT therapies (ie, ACT or mindfulness) or internet-based cognitive-
strategies. behavioral programs within physical therapy. Although PIPT
Although some approaches such as graded activity or graded remains a promising care model, more convincing evidence is
exposure can be integrated seamlessly into physical therapy, needed to support widespread adoption, especially in light of
other strategies such as cognitive restructuring and relaxation extensive training demands and implementation challenges.
techniques may require modifications to existing clinical treat-
ment structures (ie, extended treatment time or use of private
rooms). Several trials described in this review offered PIPT (with or Disclosures
without exercise) in sessions of 45-, 60-, or 90-minute durations. The authors have no conflicts of interest to declare.
The increased time for a one-on-one, in-person clinical encounter During manuscript development, R.A. Coronado was sup-
may not be feasible in some outpatient practice settings and may ported by a Vanderbilt Faculty Research Scholars Award.
not yield high likelihood for implementation.72 There may be a
need to examine which specific PIPT components or strategies
are the most effective and aim to incorporate only those strategies Appendix A. Supplemental digital content
within standard practice. To the best of our knowledge, there
Supplemental digital content associated with this article can be
have not been any studies that have examined content
found online at http://links.lww.com/PR9/A79.
optimization for PIPT. The examination of treatment components
may require more advanced research designs that will identify the
Article history:
most “active” components of PIPT.16
Received 31 December 2019
Internet-based programs have been developed to help over-
Received in revised form 13 July 2020
come in-person treatment delivery challenges. To date, few
Accepted 17 July 2020
studies have examined whether internet-based psychological
Available online 23 September 2020
programs can be integrated within an episode of physical
therapy. The studies by Bennell et al.12 and Petrozzi et al.69
described PIPT approaches where physical therapists were not References
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