Ponencia en @LaSalleSaludUAM sobre como Identificar de manera sistemática y adecuada los factores psicosociales que intevienen en los procesos de salud de nuestros pacientes, y abordarlos mediante estrategias de EPS.

1. Perspectivas del Abordaje con
Educación Para la Salud
en Fisioterapia
@_RaulFerrer
Prof. Raúl Ferrer Peña
#EducFisioLaSalle

2. EDUCACIÓN PARA LA SALUD
2

3. “La Educación para la salud (EPS) es una actividad diseñada para
ampliar el conocimiento de la población en relación con la salud y
desarrollar los valores y habilidades personales que promueven la salud”
EDUCACIÓN PARA LA SALUD
2

4. Salud
Educación Para la Salud

5. Enfermedad
Salud
Educación Para la Salud
Prev. 1ª

6. Enfermedad
Salud
Educación Para la Salud
Prev. 1ª Prev. 2ª
Factores de Riesgo

7. Enfermedad
Salud
Educación Terapéutica
Educación Para la Salud
Prev. 1ª Prev. 2ª Prev. 3ª

8. BRAINA JOURNAL OF NEUROLOGY
Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive
to emotional circuits
Javeria A. Hashmi,1
Marwan N. Baliki,1
Lejian Huang,1
Alex T. Baria,1
Souraya Torbey,1
Kristina M. Hermann,1
Thomas J. Schnitzer2
and A. Vania Apkarian1,3,
*
1 Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
2 Department of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
3 Departments of Anaesthesia and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
Correspondence to: A. Vania Apkarian, PhD,
Department of Physiology,
303 E. Chicago,
Tarry Bldg. 5-703,
Chicago, IL 60611
E-mail: a-apkarian@northwestern.edu
Chronic pain conditions are associated with abnormalities in brain structure and function. Moreover, some studies indicate that
brain activity related to the subjective perception of chronic pain may be distinct from activity for acute pain. However, the latter
are based on observations from cross-sectional studies. How brain activity reorganizes with transition from acute to chronic pain
has remained unexplored. Here we study this transition by examining brain activity for rating fluctuations of back pain mag-
nitude. First we compared back pain-related brain activity between subjects who have had the condition for $2 months with no
prior history of back pain for 1 year (early, acute/subacute back pain group, n = 94), to subjects who have lived with back pain
for 410 years (chronic back pain group, n = 59). In a subset of subacute back pain patients, we followed brain activity for back
pain longitudinally over a 1-year period, and compared brain activity between those who recover (recovered acute/sub-acute
back pain group, n = 19) and those in which the back pain persists (persistent acute/sub-acute back pain group, n = 20; based on
a 20% decrease in intensity of back pain in 1 year). We report results in relation to meta-analytic probabilistic maps related to
the terms pain, emotion, and reward (each map is based on 4200 brain imaging studies, derived from neurosynth.org). We
observed that brain activity for back pain in the early, acute/subacute back pain group is limited to regions involved in acute
pain, whereas in the chronic back pain group, activity is confined to emotion-related circuitry. Reward circuitry was equally
doi:10.1093/brain/awt211 Brain 2013: 136; 2751–2768 | 2751
BRAINA JOURNAL OF NEUROLOGY
Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive
to emotional circuits
Javeria A. Hashmi,1
Marwan N. Baliki,1
Lejian Huang,1
Alex T. Baria,1
Souraya Torbey,1
Kristina M. Hermann,1
Thomas J. Schnitzer2
and A. Vania Apkarian1,3,
*
1 Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
2 Department of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
3 Departments of Anaesthesia and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
Correspondence to: A. Vania Apkarian, PhD,
Department of Physiology,
303 E. Chicago,
Tarry Bldg. 5-703,
Chicago, IL 60611
E-mail: a-apkarian@northwestern.edu
Chronic pain conditions are associated with abnormalities in brain structure and function. Moreover, some studies indicate that
brain activity related to the subjective perception of chronic pain may be distinct from activity for acute pain. However, the latter
are based on observations from cross-sectional studies. How brain activity reorganizes with transition from acute to chronic pain
has remained unexplored. Here we study this transition by examining brain activity for rating fluctuations of back pain mag-
nitude. First we compared back pain-related brain activity between subjects who have had the condition for $2 months with no
prior history of back pain for 1 year (early, acute/subacute back pain group, n = 94), to subjects who have lived with back pain
for 410 years (chronic back pain group, n = 59). In a subset of subacute back pain patients, we followed brain activity for back
pain longitudinally over a 1-year period, and compared brain activity between those who recover (recovered acute/sub-acute
back pain group, n = 19) and those in which the back pain persists (persistent acute/sub-acute back pain group, n = 20; based on
a 20% decrease in intensity of back pain in 1 year). We report results in relation to meta-analytic probabilistic maps related to
the terms pain, emotion, and reward (each map is based on 4200 brain imaging studies, derived from neurosynth.org). We
doi:10.1093/brain/awt211 Brain 2013: 136; 2751–2768 | 2751
Figure 3 Longitudinal changes in brain activity underlying spontaneous pain when patients transition from acute to chronic back pa
state. (A) Plots show the scanning calendar dates of subjects with recovering SBP (SBPr) and persistent SBP (SBPp) for all four visits.
Vertical marks represent individual persistent SBP (black) and recovering SBP (grey) subjects. Groups were scanned within the same tim
window (major ticks are years; minor ticks are months). (B) Recovering SBP in contrast to persistent SBP patients exhibited decreased pa
in time. (C) Group average activation maps (P 5 0.01 uncorrected) for recovering and persistent SBP groups at the four visits. Recoverin
0 | Brain 2013: 136; 2751–2768 J. A. Hashmi et al.
J. A. Hashmi et al.
4

9. BRAINA JOURNAL OF NEUROLOGY
Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive
to emotional circuits
Javeria A. Hashmi,1
Marwan N. Baliki,1
Lejian Huang,1
Alex T. Baria,1
Souraya Torbey,1
Kristina M. Hermann,1
Thomas J. Schnitzer2
and A. Vania Apkarian1,3,
*
1 Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
2 Department of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
3 Departments of Anaesthesia and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
Correspondence to: A. Vania Apkarian, PhD,
Department of Physiology,
303 E. Chicago,
Tarry Bldg. 5-703,
Chicago, IL 60611
E-mail: a-apkarian@northwestern.edu
Chronic pain conditions are associated with abnormalities in brain structure and function. Moreover, some studies indicate that
brain activity related to the subjective perception of chronic pain may be distinct from activity for acute pain. However, the latter
are based on observations from cross-sectional studies. How brain activity reorganizes with transition from acute to chronic pain
has remained unexplored. Here we study this transition by examining brain activity for rating fluctuations of back pain mag-
nitude. First we compared back pain-related brain activity between subjects who have had the condition for $2 months with no
prior history of back pain for 1 year (early, acute/subacute back pain group, n = 94), to subjects who have lived with back pain
for 410 years (chronic back pain group, n = 59). In a subset of subacute back pain patients, we followed brain activity for back
pain longitudinally over a 1-year period, and compared brain activity between those who recover (recovered acute/sub-acute
back pain group, n = 19) and those in which the back pain persists (persistent acute/sub-acute back pain group, n = 20; based on
a 20% decrease in intensity of back pain in 1 year). We report results in relation to meta-analytic probabilistic maps related to
the terms pain, emotion, and reward (each map is based on 4200 brain imaging studies, derived from neurosynth.org). We
observed that brain activity for back pain in the early, acute/subacute back pain group is limited to regions involved in acute
pain, whereas in the chronic back pain group, activity is confined to emotion-related circuitry. Reward circuitry was equally
doi:10.1093/brain/awt211 Brain 2013: 136; 2751–2768 | 2751
BRAINA JOURNAL OF NEUROLOGY
Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive
to emotional circuits
Javeria A. Hashmi,1
Marwan N. Baliki,1
Lejian Huang,1
Alex T. Baria,1
Souraya Torbey,1
Kristina M. Hermann,1
Thomas J. Schnitzer2
and A. Vania Apkarian1,3,
*
1 Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
2 Department of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
3 Departments of Anaesthesia and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
Correspondence to: A. Vania Apkarian, PhD,
Department of Physiology,
303 E. Chicago,
Tarry Bldg. 5-703,
Chicago, IL 60611
E-mail: a-apkarian@northwestern.edu
Chronic pain conditions are associated with abnormalities in brain structure and function. Moreover, some studies indicate that
brain activity related to the subjective perception of chronic pain may be distinct from activity for acute pain. However, the latter
are based on observations from cross-sectional studies. How brain activity reorganizes with transition from acute to chronic pain
has remained unexplored. Here we study this transition by examining brain activity for rating fluctuations of back pain mag-
nitude. First we compared back pain-related brain activity between subjects who have had the condition for $2 months with no
prior history of back pain for 1 year (early, acute/subacute back pain group, n = 94), to subjects who have lived with back pain
for 410 years (chronic back pain group, n = 59). In a subset of subacute back pain patients, we followed brain activity for back
pain longitudinally over a 1-year period, and compared brain activity between those who recover (recovered acute/sub-acute
back pain group, n = 19) and those in which the back pain persists (persistent acute/sub-acute back pain group, n = 20; based on
a 20% decrease in intensity of back pain in 1 year). We report results in relation to meta-analytic probabilistic maps related to
the terms pain, emotion, and reward (each map is based on 4200 brain imaging studies, derived from neurosynth.org). We
doi:10.1093/brain/awt211 Brain 2013: 136; 2751–2768 | 2751
Figure 3 Longitudinal changes in brain activity underlying spontaneous pain when patients transition from acute to chronic back pa
state. (A) Plots show the scanning calendar dates of subjects with recovering SBP (SBPr) and persistent SBP (SBPp) for all four visits.
Vertical marks represent individual persistent SBP (black) and recovering SBP (grey) subjects. Groups were scanned within the same tim
window (major ticks are years; minor ticks are months). (B) Recovering SBP in contrast to persistent SBP patients exhibited decreased pa
in time. (C) Group average activation maps (P 5 0.01 uncorrected) for recovering and persistent SBP groups at the four visits. Recoverin
0 | Brain 2013: 136; 2751–2768 J. A. Hashmi et al.
J. A. Hashmi et al.
4

10. Jonathan C. Hill and Julie M. Fritz Psychosocial Influences on Low Back Pain, Disability, and
Response to Treatment. PHYS THER May 2011 91:712-721
5
Clasificación de factores psicosociales
en relación a su influencia en el tratamiento
Mediadores del Tratamiento:
representan pasos intermedios en el vínculo entre una intervención y el
resultado deseado. (p.e. miedo evitación y exposición graduada para mejorar la función)
Factores Pronóstico para el tratamiento:
Ayudan a estimar un resultado probable del paciente con independencia
del tratamiento elegido. (p.e. depresión en cronificación de la lumbalgia)
Modificadores o Moduladores del Tratamiento:
Medidos al comienzo del tratamiento indican si existe alguna relación
entre la intervención específica y el resultado. (p.e. miedo-evitación en
manipulación lumbar)
1
2
3

11. Jonathan C. Hill and Julie M. Fritz Psychosocial Influences on Low Back Pain, Disability, and
Response to Treatment. PHYS THER May 2011 91:712-721
5
Clasificación de factores psicosociales
en relación a su influencia en el tratamiento
Mediadores del Tratamiento:
representan pasos intermedios en el vínculo entre una intervención y el
resultado deseado. (p.e. miedo evitación y exposición graduada para mejorar la función)
Factores Pronóstico para el tratamiento:
Ayudan a estimar un resultado probable del paciente con independencia
del tratamiento elegido. (p.e. depresión en cronificación de la lumbalgia)
Modificadores o Moduladores del Tratamiento:
Medidos al comienzo del tratamiento indican si existe alguna relación
entre la intervención específica y el resultado. (p.e. miedo-evitación en
manipulación lumbar)
1
2
3

12. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA

13. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia

14. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia Locus de Control

15. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia Locus de Control

16. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia Locus de Control

17. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia Locus de Control
Creencia de gravedad

18. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia Locus de Control
Creencia de gravedad Atribución de causalidad

19. ALGUNOS FACTORES DEL ÁREA EMOCIONAL A TENER EN CUENTA
Autoeficacia Locus de Control
Creencia de gravedad Atribución de causalidad
Otros factores: Catastrofismo, Kinesiofobia, Miedo-Evitación, Otras Estrategias de Afrontamiento, …

20. Pérez Jarauta M J, et al. Manual de Educación para la salud. Gobierno de Navarra. 2006.
7
Distintos autores (Bartoli, Green…), diferentes teorías psicológicas, pedagógicas… y distintos
modelos de análisis de comportamientos (modelo de creencias, clarificación de valores, PRECE-
DE, aprendizaje social…) han realizado importantes aportaciones en este campo.
En este Manual consideramos, además de la dimensión biológica, tres tipos de factores: a) fac-
tores del entorno social, de la sociedad en la que vive, b) factores del entorno próximo (su grupo
familiar, de trabajo y otros) y c) factores personales, del área cognitiva (lo que sabe), del área
emocional (lo que cree y siente) y del área de las habilidades (lo que sabe hacer).
FACTORES RELACIONADOS CON LOS COMPORTAMIENTOS EN SALUD
El conjunto de los factores relacionados con los comportamientos configura las capacidades:
capacidades para manejar la hipertensión arterial, el asma o el infarto agudo de miocardio; para
dejar de fumar, alimentarse de forma saludable, favorecer el desarrollo psicoevolutivo y la estimu-
lación psicomotriz, auditiva y táctil de los hijos e hijas, para afrontar el parto, la parentalidad, el
duelo migratorio o el envejecimiento, etc.
Comportamientos
Capacidades
Entorno próximo
Grupos sociales
primarios
Apoyo social
Área
Cognitiva
Conocimientos
Capacidades
cognitivas
Estilos de
pensamiento
Entorno social
Condiciones de vida
Modelos socioculturales
Recursos y servicios
Factores ambientales
Área
Emocional
Creencias
Actitudes
Valores
Sentimientos
Área de las
Habilidades
Personales
Sociales
Psicomotoras
Factores personales
Toma de decisiones Situaciones
FACTORES RELACIONADOS CON LOS COMPORTAMIENTOS EN SALUD

21. Pérez Jarauta M J, et al. Manual de Educación para la salud. Gobierno de Navarra. 2006.
7
Distintos autores (Bartoli, Green…), diferentes teorías psicológicas, pedagógicas… y distintos
modelos de análisis de comportamientos (modelo de creencias, clarificación de valores, PRECE-
DE, aprendizaje social…) han realizado importantes aportaciones en este campo.
En este Manual consideramos, además de la dimensión biológica, tres tipos de factores: a) fac-
tores del entorno social, de la sociedad en la que vive, b) factores del entorno próximo (su grupo
familiar, de trabajo y otros) y c) factores personales, del área cognitiva (lo que sabe), del área
emocional (lo que cree y siente) y del área de las habilidades (lo que sabe hacer).
FACTORES RELACIONADOS CON LOS COMPORTAMIENTOS EN SALUD
El conjunto de los factores relacionados con los comportamientos configura las capacidades:
capacidades para manejar la hipertensión arterial, el asma o el infarto agudo de miocardio; para
dejar de fumar, alimentarse de forma saludable, favorecer el desarrollo psicoevolutivo y la estimu-
lación psicomotriz, auditiva y táctil de los hijos e hijas, para afrontar el parto, la parentalidad, el
duelo migratorio o el envejecimiento, etc.
Comportamientos
Capacidades
Entorno próximo
Grupos sociales
primarios
Apoyo social
Área
Cognitiva
Conocimientos
Capacidades
cognitivas
Estilos de
pensamiento
Entorno social
Condiciones de vida
Modelos socioculturales
Recursos y servicios
Factores ambientales
Área
Emocional
Creencias
Actitudes
Valores
Sentimientos
Área de las
Habilidades
Personales
Sociales
Psicomotoras
Factores personales
Toma de decisiones Situaciones
FACTORES RELACIONADOS CON LOS COMPORTAMIENTOS EN SALUD

22. Pérez Jarauta M J, et al. Manual de Educación para la salud. Gobierno de Navarra. 2006.
7
Distintos autores (Bartoli, Green…), diferentes teorías psicológicas, pedagógicas… y distintos
modelos de análisis de comportamientos (modelo de creencias, clarificación de valores, PRECE-
DE, aprendizaje social…) han realizado importantes aportaciones en este campo.
En este Manual consideramos, además de la dimensión biológica, tres tipos de factores: a) fac-
tores del entorno social, de la sociedad en la que vive, b) factores del entorno próximo (su grupo
familiar, de trabajo y otros) y c) factores personales, del área cognitiva (lo que sabe), del área
emocional (lo que cree y siente) y del área de las habilidades (lo que sabe hacer).
FACTORES RELACIONADOS CON LOS COMPORTAMIENTOS EN SALUD
El conjunto de los factores relacionados con los comportamientos configura las capacidades:
capacidades para manejar la hipertensión arterial, el asma o el infarto agudo de miocardio; para
dejar de fumar, alimentarse de forma saludable, favorecer el desarrollo psicoevolutivo y la estimu-
lación psicomotriz, auditiva y táctil de los hijos e hijas, para afrontar el parto, la parentalidad, el
duelo migratorio o el envejecimiento, etc.
Comportamientos
Capacidades
Entorno próximo
Grupos sociales
primarios
Apoyo social
Área
Cognitiva
Conocimientos
Capacidades
cognitivas
Estilos de
pensamiento
Entorno social
Condiciones de vida
Modelos socioculturales
Recursos y servicios
Factores ambientales
Área
Emocional
Creencias
Actitudes
Valores
Sentimientos
Área de las
Habilidades
Personales
Sociales
Psicomotoras
Factores personales
Toma de decisiones Situaciones
FACTORES RELACIONADOS CON LOS COMPORTAMIENTOS EN SALUD

23. ALGUNOS MODELOS DE EDUCACIÓN PARA LA SALUD
• Modelo Preventivista: basado en conocimientos sobre normas adecuadas
• Modelo Educativista: basado en el cambio a estilos de vida saludables.
• Modelo de Desarrollo Personal: Basado en hacer al sujeto responsable de su salud
Pérez Jarauta M J, et al. Manual de Educación para la salud. Gobierno de Navarra. 2006.

24. ALGUNOS MODELOS DE EDUCACIÓN PARA LA SALUD
• Modelo Preventivista: basado en conocimientos sobre normas adecuadas
• Modelo Educativista: basado en el cambio a estilos de vida saludables.
• Modelo de Desarrollo Personal: Basado en hacer al sujeto responsable de su salud
Pérez Jarauta M J, et al. Manual de Educación para la salud. Gobierno de Navarra. 2006.

25. Características:
JAMA. 2002;288(19):2469-2475 9

26. Lo que enseña: Habilidades en como actuar ante los problemas
Características:
JAMA. 2002;288(19):2469-2475 9

27. Lo que enseña: Habilidades en como actuar ante los problemas
Características:
JAMA. 2002;288(19):2469-2475
Cómo se formulan los problemas: El paciente identifica los problemas que pueden estar o no
relacionados con su salud
9

28. Lo que enseña: Habilidades en como actuar ante los problemas
Relación entre la educación y la enfermedad: La educación ofrece habilidades de resolución relevantes
relativas a las consecuencias de los problemas
Características:
JAMA. 2002;288(19):2469-2475
Cómo se formulan los problemas: El paciente identifica los problemas que pueden estar o no
relacionados con su salud
9

29. Lo que enseña: Habilidades en como actuar ante los problemas
Relación entre la educación y la enfermedad: La educación ofrece habilidades de resolución relevantes
relativas a las consecuencias de los problemas
Cuál es la teoría propuesta: Más confianza del paciente en su autoeficacia redunda en mejores resultados
Características:
JAMA. 2002;288(19):2469-2475
Cómo se formulan los problemas: El paciente identifica los problemas que pueden estar o no
relacionados con su salud
9

30. Lo que enseña: Habilidades en como actuar ante los problemas
Relación entre la educación y la enfermedad: La educación ofrece habilidades de resolución relevantes
relativas a las consecuencias de los problemas
Cuál es la teoría propuesta: Más confianza del paciente en su autoeficacia redunda en mejores resultados
Cuál es el objetivo: Mejorar la autoeficacia para mejorar los resultados
Características:
JAMA. 2002;288(19):2469-2475
Cómo se formulan los problemas: El paciente identifica los problemas que pueden estar o no
relacionados con su salud
9

31. Lo que enseña: Habilidades en como actuar ante los problemas
Relación entre la educación y la enfermedad: La educación ofrece habilidades de resolución relevantes
relativas a las consecuencias de los problemas
Cuál es la teoría propuesta: Más confianza del paciente en su autoeficacia redunda en mejores resultados
Cuál es el objetivo: Mejorar la autoeficacia para mejorar los resultados
Quién es el educador: Un profesional sanitario, un paciente experto o un líder semejante, a menudo en
grupos.
Características:
JAMA. 2002;288(19):2469-2475
Cómo se formulan los problemas: El paciente identifica los problemas que pueden estar o no
relacionados con su salud
9

32. Effect of Primary Care–Based Education on Reassurance
in Patients With Acute Low Back Pain
Systematic Review and Meta-analysis
Adrian C. Traeger, MPhty; Markus Hübscher, PhD; Nicholas Henschke, PhD; G. Lorimer Moseley, PhD;
Hopin Lee, MPhty; James H. McAuley, PhD
IMPORTANCE Reassurance is a core aspect of daily medical practice, yet little is known on how
it can be achieved.
OBJECTIVE To determine whether patient education in primary care increases reassurance in
patients with acute or subacute low back pain (LBP).
DATA SOURCES Medline, EMBASE, Cochrane Central Register for Controlled Trials, and
PsychINFO databases were searched to June 2014.
DESIGN Systematic review and meta-analysis of randomized and nonrandomized clinical
trials.
STUDY SELECTION To be eligible, studies needed to be controlled trials of patient education
for LBP that were delivered in primary care and measured reassurance after the intervention.
Eligibility criteria were applied, and studies were selected by 2 independent authors.
MAIN OUTCOMES AND MEASURES The primary outcomes were reassurance in the short and
long term and health care utilization at 12 months.
Invited Commentary
Supplemental content at
jamainternalmedicine.com
Research
Original Investigation | LESS IS MORE
JAMA Intern Med.Published online March 23. 2015 10

33. Effect of Primary Care–Based Education on Reassurance
in Patients With Acute Low Back Pain
Systematic Review and Meta-analysis
Adrian C. Traeger, MPhty; Markus Hübscher, PhD; Nicholas Henschke, PhD; G. Lorimer Moseley, PhD;
Hopin Lee, MPhty; James H. McAuley, PhD
IMPORTANCE Reassurance is a core aspect of daily medical practice, yet little is known on how
it can be achieved.
OBJECTIVE To determine whether patient education in primary care increases reassurance in
patients with acute or subacute low back pain (LBP).
DATA SOURCES Medline, EMBASE, Cochrane Central Register for Controlled Trials, and
PsychINFO databases were searched to June 2014.
DESIGN Systematic review and meta-analysis of randomized and nonrandomized clinical
trials.
STUDY SELECTION To be eligible, studies needed to be controlled trials of patient education
for LBP that were delivered in primary care and measured reassurance after the intervention.
Eligibility criteria were applied, and studies were selected by 2 independent authors.
MAIN OUTCOMES AND MEASURES The primary outcomes were reassurance in the short and
long term and health care utilization at 12 months.
Invited Commentary
Supplemental content at
jamainternalmedicine.com
Research
Original Investigation | LESS IS MORE
JAMA Intern Med.Published online March 23. 2015 10
Consuelo, Alivio…

34. Effect of Primary Care–Based Education on Reassurance
in Patients With Acute Low Back Pain
Systematic Review and Meta-analysis
Adrian C. Traeger, MPhty; Markus Hübscher, PhD; Nicholas Henschke, PhD; G. Lorimer Moseley, PhD;
Hopin Lee, MPhty; James H. McAuley, PhD
IMPORTANCE Reassurance is a core aspect of daily medical practice, yet little is known on how
it can be achieved.
OBJECTIVE To determine whether patient education in primary care increases reassurance in
patients with acute or subacute low back pain (LBP).
DATA SOURCES Medline, EMBASE, Cochrane Central Register for Controlled Trials, and
PsychINFO databases were searched to June 2014.
DESIGN Systematic review and meta-analysis of randomized and nonrandomized clinical
trials.
STUDY SELECTION To be eligible, studies needed to be controlled trials of patient education
for LBP that were delivered in primary care and measured reassurance after the intervention.
Eligibility criteria were applied, and studies were selected by 2 independent authors.
MAIN OUTCOMES AND MEASURES The primary outcomes were reassurance in the short and
long term and health care utilization at 12 months.
Invited Commentary
Supplemental content at
jamainternalmedicine.com
Research
Original Investigation | LESS IS MORE
JAMA Intern Med.Published online March 23. 2015Pooled effect sizes remained stable when we accounted for (SMD, −0.14; 95% CI, −0.28 to 0.00) (Figure 3). The mean rate
Figure 1. Effects of Patient Education vs Usual Care/Control Education on Reassurance
Favors
(experimental)
–2 20 1
SMD (IV, Random, 95% CI)
–1
Weight, %
Favors
(control)SMD (SE)Source
Short term
SMD
(IV, Random, 95% CI)
7.1–0.89 (0.19)Burton et al,57 1999 –0.89 (–1.26 to –0.52)
5.0–0.76 (0.26)Storheim et al,65 2003 –0.76 (–1.27 to –0.25)
5.0–0.38 (0.26)Hill et al,55 2011 –0.38 (–0.89 to 0.13)
5.0–0.31 (0.26)Roberts et al,54 2002 –0.31 (–0.82 to 0.20)
12.1–0.30 (0.07)Leonhardt et al,56 2008 –0.30 (–0.44 to –0.16)
10.5–0.23 (0.11)Jellema et al,62 2005 –0.23 (–0.45 to –0.01)
6.8–0.18 (0.20)Bücker et al,51 2010 –0.18 (–0.57 to 0.21)
8.3–0.15 (0.16)Deyo et al,60 1987 –0.15 (–0.46 to 0.16)
10.9–0.12 (0.10)Hagen et al,52 2000 –0.12 (–0.32 to 0.08)
10.9–0.01 (0.10)Hay et al,61 2005 –0.01 (–0.21 to 0.19)
Heterogeneity: τ2=0.04; χ 2 =35.60 (P <.001); I2=69%
100.00Subtotal (95% CI)
11
–0.21 (–0.36 to –0.07)
9.60.08 (0.13)Pengel et al,53 2007 0.08 (–0.17 to 0.33)
8.70.17 (0.15)Cherkin et al,59 1996 0.17 (–0.12 to 0.46)
Test for overall effect: z =2.90 (P =.004)
Long term
8.4–0.56 (0.18)Burton et al,57 1999 –0.56 (–0.91 to –0.21)
22.3–0.25 (0.07)Leonhardt et al,56 2008 –0.25 (–0.39 to –0.11)
4.7–0.22 (0.26)Hill et al,55 2011 –0.22 (–0.73 to 0.29)
5.0–0.16 (0.25)Roberts et al,54 2002 –0.16 (–0.65 to 0.33)
15.5–0.13 (0.11)Jellema et al,62 2005 –0.13 (–0.35 to 0.09)
8.4–0.09 (0.18)Pengel et al,53 2007 –0.09 (–0.44 to 0.26)
18.7–0.04 (0.09)Hagen et al,52 2000 –0.04 (–0.22 to 0.14)
17.10.04 (0.10)Hay et al,61 2005 0.04 (–0.16 to 0.24)
Heterogeneity: τ2=0.01; χ2 =12.55 (P =.08); I2=44%
100.00Subtotal (95% CI)
7
–0.15 (–0.27 to –0.03)
Test for overall effect: z =2.46 (P =.01)
IV indicates inverse variance; SMD, standardized mean difference.
Research Original Investigation Reassurance in Patients With Acute Low Back Pain
suggests that effective reassurance involves a shift in a pa-
tient’s cognitive appraisal of their health problem. Reap-
Interpretation
Our data suggest that when practitioners are trained to de-
Figure 2. Differences in Short-term Effects of Patient Education Interventions on Reassurance, When Interventions Are Stratified
According to the Deliverer of the Intervention
Favors
(experimental)
–2 20 1
SMD (IV, Random, 95% CI)
–1
Weight, %
Favors
(control)SMD (SE)Source
Physiotherapist
SMD
(IV, Random, 95% CI)
5.3–0.28 (0.25)Hill et al,55 2011 –0.28 (–0.77 to 0.21)
10.9–0.01 (0.10)Hay et al,61 2005 –0.01 (–0.21 to 0.19)
9.50.08 (0.13)Pengel et al,53 2007 0.08 (–0.17 to 0.33)
Heterogeneity: τ2=0.00; χ2 =1.64 (P =.44); I2=0%
25.7Subtotal (95% CI)
2
–0.00 (–0.15 to 0.14)
Test for overall effect: z =0.06 (P =.96)
Physician
7.1–0.89 (0.19)Burton et al,57 1999 –0.89 (–1.26 to –0.52)
5.0–0.76 (0.26)Storheim et al,65 2003 –0.76 (–1.27 to –0.25)
5.0–0.31 (0.26)Roberts et al,54 2002 –0.31 (–0.82 to 0.20)
10.4–0.24 (0.11)Jellema et al,62 2005 –0.24 (–0.46 to –0.02)
6.8–0.18 (0.20)Bücker et al,51 2010 –0.18 (–0.57 to 0.21)
10.9–0.12 (0.10)Hagen et al,52 2000 –0.12 (–0.32 to 0.08)
Heterogeneity: τ2=0.06; χ2 =16.65 (P =.005); I2=70%
45.2Subtotal (95% CI)
5
–0.38 (–0.63 to –0.14)
Test for overall effect: z =3.06 (P =.002)
Nurse
12.2–0.30 (0.07)Leonhardt et al,56 2008 –0.30 (–0.44 to –0.16)
8.3–0.15 (0.16)Deyo et al,60 1987 –0.15 (–0.46 to 0.16)
8.70.17 (0.15)Cherkin et al,59 1996 0.17 (–0.12 to 0.46)
Heterogeneity: τ2=0.05; χ2=8.21 (P =.02); I2=76%
29.1Subtotal (95% CI)
2
2
–0.11 (–0.40 to 0.17)
Test for overall effect: z =0.78 (P =.44)
Heterogeneity: τ2=0.04; χ 2 =35.26 (P <.001); I2=69%
100.00Total (95% CI)
11
–0.21 (–0.35 to –0.07)
Test for overall effect: z =2.87 (P =.004)
Test for subgroup differences: χ2 =6.69 (P =.04); I2=70.1%
IV indicates inverse variance; SMD, standardized mean difference.
Figure 3. Effects of Patient Education vs Usual Care/Control Education on the Number of Primary Care Visits in the 12 Months After Intervention
Favors
(experimental)
–2 20 1
SMD (IV, Random, 95% CI)
–1
Weight, %
Favors
(control)SMD (SE)Source
SMD
(IV, Random, 95% CI)
7.0–0.41 (0.27)Hill et al,55 2011 –0.41 (–0.94 to 0.12)
15.7–0.33 (0.18)Pengel et al,53 2007 –0.33 (–0.68 to 0.02)
11.6–0.21 (0.21)Deyo et al,60 1987 –0.21 (–0.62 to 0.20)
19.9–0.15 (0.16)Roland et al,64 1989 –0.15 (–0.46 to 0.16)
14.1–0.06 (0.19)Cherkin et al,59 1996 –0.06 (–0.43 to 0.31)
14.10 (0.19)Karjalainen et al,63 2003 0.00 (–0.37 to 0.37)
17.60.03 (0.17)Hay et al,61 2005 0.03 (–0.30 to 0.36)
Heterogeneity: τ2=0.00; χ2 =3.95 (P =.68); I2=0%
100.00Total (95% CI)
6
–0.14 (–0.28 to 0.00)
Test for overall effect: z =1.93 (P =.05)
IV indicates inverse variance; SMD, standardized mean difference.
Research Original Investigation Reassurance in Patients With Acute Low Back Pain
14 estudios. (n=4872)
10
Número de visitas:
Efecto a corto y largo plazo:

35. Effect of Primary Care–Based Education on Reassurance
in Patients With Acute Low Back Pain
Systematic Review and Meta-analysis
Adrian C. Traeger, MPhty; Markus Hübscher, PhD; Nicholas Henschke, PhD; G. Lorimer Moseley, PhD;
Hopin Lee, MPhty; James H. McAuley, PhD
IMPORTANCE Reassurance is a core aspect of daily medical practice, yet little is known on how
it can be achieved.
OBJECTIVE To determine whether patient education in primary care increases reassurance in
patients with acute or subacute low back pain (LBP).
DATA SOURCES Medline, EMBASE, Cochrane Central Register for Controlled Trials, and
PsychINFO databases were searched to June 2014.
DESIGN Systematic review and meta-analysis of randomized and nonrandomized clinical
trials.
STUDY SELECTION To be eligible, studies needed to be controlled trials of patient education
for LBP that were delivered in primary care and measured reassurance after the intervention.
Eligibility criteria were applied, and studies were selected by 2 independent authors.
MAIN OUTCOMES AND MEASURES The primary outcomes were reassurance in the short and
long term and health care utilization at 12 months.
DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent authors and
entered into a standardized form. A random-effects meta-analysis tested the effects of
patient education compared with usual care on measures of reassurance. To investigate the
effect of study characteristics, we performed a preplanned subgroup analysis. Studies were
stratified according to duration, content, and provider of patient education.
RESULTS We included 14 trials (n = 4872) of patient education interventions. Trials assessed
reassurance with questionnaires of fear, worry, anxiety, catastrophization, and health care
utilization. There is moderate- to high-quality evidence that patient education increases
reassurance more than usual care/control education in the short term (standardized mean
difference [SMD], −0.21; 95% CI, −0.35 to −0.06) and long term (SMD, −0.15; 95% CI, −0.27
to −0.03). Interventions delivered by physicians were significantly more reassuring than
those delivered by other primary care practitioners (eg, physiotherapist or nurse). There is
moderate-quality evidence that patient education reduces LBP-related primary care visits
more than usual care/control education (SMD, −0.14; 95% CI, −0.28 to −0.00 at a 12-month
follow-up). The number needed to treat to prevent 1 LBP-related visit to primary care was 17.
CONCLUSIONS AND RELEVANCE There is moderate- to high-quality evidence that patient
education in primary care can provide long-term reassurance for patients with acute or
subacute LBP.
Invited Commentary
Supplemental content at
jamainternalmedicine.com
Author Affiliations: Neuroscience
Research Australia, Sydney, Australia
(Traeger, Hübscher, Moseley, Lee,
McAuley); School of Medical
Sciences, University of New South
Wales, Sydney, Australia (Traeger,
Lee, McAuley); Institute of Public
Health, University of Heidelberg,
Heidelberg, Germany (Henschke);
Sansom Institute for Health Research,
University of South Australia,
Adelaide, South Australia, Australia
(Moseley).
Corresponding Author: James H.
McAuley, PhD, Neuroscience
Research
Original Investigation | LESS IS MORE
JAMA Intern Med.Published online March 23. 2015
Figure 2. Differences in Short-term Effects of Patient Education Interventions on Reassurance, When Interventions Are Stratified
According to the Deliverer of the Intervention
Favors
(experimental)
–2 20 1
SMD (IV, Random, 95% CI)
–1
Weight, %
Favors
(control)SMD (SE)Source
Physiotherapist
SMD
(IV, Random, 95% CI)
5.3–0.28 (0.25)Hill et al,55 2011 –0.28 (–0.77 to 0.21)
10.9–0.01 (0.10)Hay et al,61 2005 –0.01 (–0.21 to 0.19)
9.50.08 (0.13)Pengel et al,53 2007 0.08 (–0.17 to 0.33)
Heterogeneity: τ2=0.00; χ2 =1.64 (P =.44); I2=0%
25.7Subtotal (95% CI)
2
–0.00 (–0.15 to 0.14)
Test for overall effect: z =0.06 (P =.96)
Physician
7.1–0.89 (0.19)Burton et al,57 1999 –0.89 (–1.26 to –0.52)
5.0–0.76 (0.26)Storheim et al,65 2003 –0.76 (–1.27 to –0.25)
5.0–0.31 (0.26)Roberts et al,54 2002 –0.31 (–0.82 to 0.20)
10.4–0.24 (0.11)Jellema et al,62 2005 –0.24 (–0.46 to –0.02)
6.8–0.18 (0.20)Bücker et al,51 2010 –0.18 (–0.57 to 0.21)
10.9–0.12 (0.10)Hagen et al,52 2000 –0.12 (–0.32 to 0.08)
Heterogeneity: τ2=0.06; χ2 =16.65 (P =.005); I2=70%
45.2Subtotal (95% CI)
5
–0.38 (–0.63 to –0.14)
Test for overall effect: z =3.06 (P =.002)
Nurse
12.2–0.30 (0.07)Leonhardt et al,56 2008 –0.30 (–0.44 to –0.16)
8.3–0.15 (0.16)Deyo et al,60 1987 –0.15 (–0.46 to 0.16)
8.70.17 (0.15)Cherkin et al,59 1996 0.17 (–0.12 to 0.46)
Heterogeneity: τ2=0.05; χ2=8.21 (P =.02); I2=76%
29.1Subtotal (95% CI)
2
2
–0.11 (–0.40 to 0.17)
Test for overall effect: z =0.78 (P =.44)
Heterogeneity: τ2=0.04; χ 2 =35.26 (P <.001); I2=69%
100.00Total (95% CI)
11
–0.21 (–0.35 to –0.07)
Test for overall effect: z =2.87 (P =.004)
Test for subgroup differences: χ2 =6.69 (P =.04); I2=70.1%
IV indicates inverse variance; SMD, standardized mean difference.
Figure 3. Effects of Patient Education vs Usual Care/Control Education on the Number of Primary Care Visits in the 12 Months After Intervention
Research Original Investigation Reassurance in Patients With Acute Low Back Pain
11

36. Effect of Primary Care–Based Education on Reassurance
in Patients With Acute Low Back Pain
Systematic Review and Meta-analysis
Adrian C. Traeger, MPhty; Markus Hübscher, PhD; Nicholas Henschke, PhD; G. Lorimer Moseley, PhD;
Hopin Lee, MPhty; James H. McAuley, PhD
IMPORTANCE Reassurance is a core aspect of daily medical practice, yet little is known on how
it can be achieved.
OBJECTIVE To determine whether patient education in primary care increases reassurance in
patients with acute or subacute low back pain (LBP).
DATA SOURCES Medline, EMBASE, Cochrane Central Register for Controlled Trials, and
PsychINFO databases were searched to June 2014.
DESIGN Systematic review and meta-analysis of randomized and nonrandomized clinical
trials.
STUDY SELECTION To be eligible, studies needed to be controlled trials of patient education
for LBP that were delivered in primary care and measured reassurance after the intervention.
Eligibility criteria were applied, and studies were selected by 2 independent authors.
MAIN OUTCOMES AND MEASURES The primary outcomes were reassurance in the short and
long term and health care utilization at 12 months.
DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent authors and
entered into a standardized form. A random-effects meta-analysis tested the effects of
patient education compared with usual care on measures of reassurance. To investigate the
effect of study characteristics, we performed a preplanned subgroup analysis. Studies were
stratified according to duration, content, and provider of patient education.
RESULTS We included 14 trials (n = 4872) of patient education interventions. Trials assessed
reassurance with questionnaires of fear, worry, anxiety, catastrophization, and health care
utilization. There is moderate- to high-quality evidence that patient education increases
reassurance more than usual care/control education in the short term (standardized mean
difference [SMD], −0.21; 95% CI, −0.35 to −0.06) and long term (SMD, −0.15; 95% CI, −0.27
to −0.03). Interventions delivered by physicians were significantly more reassuring than
those delivered by other primary care practitioners (eg, physiotherapist or nurse). There is
moderate-quality evidence that patient education reduces LBP-related primary care visits
more than usual care/control education (SMD, −0.14; 95% CI, −0.28 to −0.00 at a 12-month
follow-up). The number needed to treat to prevent 1 LBP-related visit to primary care was 17.
CONCLUSIONS AND RELEVANCE There is moderate- to high-quality evidence that patient
education in primary care can provide long-term reassurance for patients with acute or
subacute LBP.
Invited Commentary
Supplemental content at
jamainternalmedicine.com
Author Affiliations: Neuroscience
Research Australia, Sydney, Australia
(Traeger, Hübscher, Moseley, Lee,
McAuley); School of Medical
Sciences, University of New South
Wales, Sydney, Australia (Traeger,
Lee, McAuley); Institute of Public
Health, University of Heidelberg,
Heidelberg, Germany (Henschke);
Sansom Institute for Health Research,
University of South Australia,
Adelaide, South Australia, Australia
(Moseley).
Corresponding Author: James H.
McAuley, PhD, Neuroscience
Research
Original Investigation | LESS IS MORE
JAMA Intern Med.Published online March 23. 2015
Figure 2. Differences in Short-term Effects of Patient Education Interventions on Reassurance, When Interventions Are Stratified
According to the Deliverer of the Intervention
Favors
(experimental)
–2 20 1
SMD (IV, Random, 95% CI)
–1
Weight, %
Favors
(control)SMD (SE)Source
Physiotherapist
SMD
(IV, Random, 95% CI)
5.3–0.28 (0.25)Hill et al,55 2011 –0.28 (–0.77 to 0.21)
10.9–0.01 (0.10)Hay et al,61 2005 –0.01 (–0.21 to 0.19)
9.50.08 (0.13)Pengel et al,53 2007 0.08 (–0.17 to 0.33)
Heterogeneity: τ2=0.00; χ2 =1.64 (P =.44); I2=0%
25.7Subtotal (95% CI)
2
–0.00 (–0.15 to 0.14)
Test for overall effect: z =0.06 (P =.96)
Physician
7.1–0.89 (0.19)Burton et al,57 1999 –0.89 (–1.26 to –0.52)
5.0–0.76 (0.26)Storheim et al,65 2003 –0.76 (–1.27 to –0.25)
5.0–0.31 (0.26)Roberts et al,54 2002 –0.31 (–0.82 to 0.20)
10.4–0.24 (0.11)Jellema et al,62 2005 –0.24 (–0.46 to –0.02)
6.8–0.18 (0.20)Bücker et al,51 2010 –0.18 (–0.57 to 0.21)
10.9–0.12 (0.10)Hagen et al,52 2000 –0.12 (–0.32 to 0.08)
Heterogeneity: τ2=0.06; χ2 =16.65 (P =.005); I2=70%
45.2Subtotal (95% CI)
5
–0.38 (–0.63 to –0.14)
Test for overall effect: z =3.06 (P =.002)
Nurse
12.2–0.30 (0.07)Leonhardt et al,56 2008 –0.30 (–0.44 to –0.16)
8.3–0.15 (0.16)Deyo et al,60 1987 –0.15 (–0.46 to 0.16)
8.70.17 (0.15)Cherkin et al,59 1996 0.17 (–0.12 to 0.46)
Heterogeneity: τ2=0.05; χ2=8.21 (P =.02); I2=76%
29.1Subtotal (95% CI)
2
2
–0.11 (–0.40 to 0.17)
Test for overall effect: z =0.78 (P =.44)
Heterogeneity: τ2=0.04; χ 2 =35.26 (P <.001); I2=69%
100.00Total (95% CI)
11
–0.21 (–0.35 to –0.07)
Test for overall effect: z =2.87 (P =.004)
Test for subgroup differences: χ2 =6.69 (P =.04); I2=70.1%
IV indicates inverse variance; SMD, standardized mean difference.
Figure 3. Effects of Patient Education vs Usual Care/Control Education on the Number of Primary Care Visits in the 12 Months After Intervention
Research Original Investigation Reassurance in Patients With Acute Low Back Pain
11

37. 12
¿Estamos preparados para identificar factores psicosociales?

38. 12
¿Estamos preparados para identificar factores psicosociales?
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7

39. 12
¿Estamos preparados para identificar factores psicosociales?
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7
ion
af-
der-
to
for
ach
with
and
cti-
g in
pre-
with
bio-
ugh
, to
rds
the
ute
ian
ng-
fac-
For
nes
ho-
and
ons
. In
ulo-
evi-
etal
onic
al.,
al.,
cial
13),
Given the limited research in physiotherapists' understanding
and practice of psychosocial assessment in musculoskeletal ori-
ented private practice, a qualitative descriptive (QD) research
design (Sandelowski, 2000) was used to explore this issue and
provide further understanding to guide future research. As the
emphasis in this research was to explore different aspects of
physiotherapists' psychosocial assessment to inform current prac-
tice and future research, rather than develop new theory, a
descriptive research design was selected over grounded theory.
Ethical approval was obtained from the Human Research and Ethics
Committee (HREC), University of South Australia. With the aim of
exploring this issue through semi-structured interviews, nine par-
ticipants were recruited through purposeful sampling
(Sandelowski, 2000; Neergaard et al., 2009).
2.1. Participant selection and recruitment
Potential participants were invited to participate through letters
or phone calls in various private physiotherapy practices in Ade-
laide. The principal inclusion criteria were that participants were
registered physiotherapists with a minimum of six months expe-
rience, working in private physiotherapy practice and dealing
predominantly with patients with musculoskeletal problems. The
criterion of minimum work experience was deemed necessary so
that participants had sufficient clinical experience on which to
Table 1
Profile of participants.
Name Age Qualification Experience
Catharine 27 BPT 8 months
Ethan 32 BPT, MPT 11 years
Joshua 25 BPT 3 years
Lachlan 36 BPT, MPT 10 years
Max 34 BPT, MPT 11 years
Noah 33 BPT, MPT 11 years
Oliver 53 BPT, MPT 29 years
Robin 25 BPT, pursuing MPT 2 years
William 27 BPT, MPT 3 years
Abbreviations; BPT ¼ Bachelors of Physiotherapy, MPT ¼ Masters of Physiotherapy.

40. 12
¿Estamos preparados para identificar factores psicosociales?
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7

41. 12
¿Estamos preparados para identificar factores psicosociales?
d Ezzy, 2005),
g independent
06), were con-
questions were
s (Daykin and
o Appendix A)
sment research
on of questions
Five pilot in-
guide. Partici-
experience and
cher conducted
and then tran-
rding of semi-
marily informed
volved reading
sented in each
lar ideas were
es were used to
nscripts. In this
ped together to
These themes
ed and various
were given to
entual themes
hrough the use
erative process
simultaneously
ng modification
g analysis and
he initial three
nquiring about
ssues often led
n conducting a
separate ques-
s in conduction
ts.
hrough several
key summary
searcher) were
, 2005). Cross-
iability of cod-
s and the prin-
ript and results
onsistency was
pts four weeks
nt. To promote
al researcher as
t as a ‘clinician’
s. In addition to
process.
3. Findings
Four main interrelated themes (see Fig. 1) emerged from data
analysis that describe various aspects of the physiotherapists' un-
derstanding of and approaches towards psychosocial assessment in
clinical practice. These themes were: “unclear about what psy-
chosocial means”; assessment based on ‘gut feeling’; limited
training and education; and need for formal training and additional
tools. Each of the four main themes are described and con-
textualised below with participants' own words.
3.1. Theme 1: “unclear about what psychosocial means”
Although most participants initially felt that they could recog-
nise patients' psychosocial factors immediately, on further discus-
sion it appeared they had limited understanding of what
psychosocial factors entail. Many participants in this research
limited their description of psychosocial factors to the factors that
cause delay in recovery or the chronicity of the condition. Some
related psychosocial factors only to the compensable state of pa-
tients such as WorkCover or insurance. While describing psycho-
social factors in their patients, five out of nine participants
categorised their patients as either having or not having psycho-
social factors. They often implied that patients belonging to a
certain group were likely to have psychosocial factors, or if they
have psychosocial factors then they likely belong to a certain group
(e.g. WorkCover, insurance case or chronic condition).
Fig. 1. Four themes identified from data analysis.
ysiotherapists' assessment of patients' psychosocial status: Are we standing on thin ice? A
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7

42. 12
¿Estamos preparados para identificar factores psicosociales?
d Ezzy, 2005),
g independent
06), were con-
questions were
s (Daykin and
o Appendix A)
sment research
on of questions
Five pilot in-
guide. Partici-
experience and
cher conducted
and then tran-
rding of semi-
marily informed
volved reading
sented in each
lar ideas were
es were used to
nscripts. In this
ped together to
These themes
ed and various
were given to
entual themes
hrough the use
erative process
simultaneously
ng modification
g analysis and
he initial three
nquiring about
ssues often led
n conducting a
separate ques-
s in conduction
ts.
hrough several
key summary
searcher) were
, 2005). Cross-
iability of cod-
s and the prin-
ript and results
onsistency was
pts four weeks
nt. To promote
al researcher as
t as a ‘clinician’
s. In addition to
process.
3. Findings
Four main interrelated themes (see Fig. 1) emerged from data
analysis that describe various aspects of the physiotherapists' un-
derstanding of and approaches towards psychosocial assessment in
clinical practice. These themes were: “unclear about what psy-
chosocial means”; assessment based on ‘gut feeling’; limited
training and education; and need for formal training and additional
tools. Each of the four main themes are described and con-
textualised below with participants' own words.
3.1. Theme 1: “unclear about what psychosocial means”
Although most participants initially felt that they could recog-
nise patients' psychosocial factors immediately, on further discus-
sion it appeared they had limited understanding of what
psychosocial factors entail. Many participants in this research
limited their description of psychosocial factors to the factors that
cause delay in recovery or the chronicity of the condition. Some
related psychosocial factors only to the compensable state of pa-
tients such as WorkCover or insurance. While describing psycho-
social factors in their patients, five out of nine participants
categorised their patients as either having or not having psycho-
social factors. They often implied that patients belonging to a
certain group were likely to have psychosocial factors, or if they
have psychosocial factors then they likely belong to a certain group
(e.g. WorkCover, insurance case or chronic condition).
Fig. 1. Four themes identified from data analysis.
ysiotherapists' assessment of patients' psychosocial status: Are we standing on thin ice? A
Entrenamiento
y educación
limitados
Valoración
basada en
corazonadas
Valoración del
estado
Psicosocial por
Fisioterapeutas
Desconocimiento
sobre lo que significa
Psicosocial
Necesidad de
Entrenamiento Formal y
herramientas adicionales
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7

43. 12
¿Estamos preparados para identificar factores psicosociales?
d Ezzy, 2005),
g independent
06), were con-
questions were
s (Daykin and
o Appendix A)
sment research
on of questions
Five pilot in-
guide. Partici-
experience and
cher conducted
and then tran-
rding of semi-
marily informed
volved reading
sented in each
lar ideas were
es were used to
nscripts. In this
ped together to
These themes
ed and various
were given to
entual themes
hrough the use
erative process
simultaneously
ng modification
g analysis and
he initial three
nquiring about
ssues often led
n conducting a
separate ques-
s in conduction
ts.
hrough several
key summary
searcher) were
, 2005). Cross-
iability of cod-
s and the prin-
ript and results
onsistency was
pts four weeks
nt. To promote
al researcher as
t as a ‘clinician’
s. In addition to
process.
3. Findings
Four main interrelated themes (see Fig. 1) emerged from data
analysis that describe various aspects of the physiotherapists' un-
derstanding of and approaches towards psychosocial assessment in
clinical practice. These themes were: “unclear about what psy-
chosocial means”; assessment based on ‘gut feeling’; limited
training and education; and need for formal training and additional
tools. Each of the four main themes are described and con-
textualised below with participants' own words.
3.1. Theme 1: “unclear about what psychosocial means”
Although most participants initially felt that they could recog-
nise patients' psychosocial factors immediately, on further discus-
sion it appeared they had limited understanding of what
psychosocial factors entail. Many participants in this research
limited their description of psychosocial factors to the factors that
cause delay in recovery or the chronicity of the condition. Some
related psychosocial factors only to the compensable state of pa-
tients such as WorkCover or insurance. While describing psycho-
social factors in their patients, five out of nine participants
categorised their patients as either having or not having psycho-
social factors. They often implied that patients belonging to a
certain group were likely to have psychosocial factors, or if they
have psychosocial factors then they likely belong to a certain group
(e.g. WorkCover, insurance case or chronic condition).
Fig. 1. Four themes identified from data analysis.
ysiotherapists' assessment of patients' psychosocial status: Are we standing on thin ice? A
Entrenamiento
y educación
limitados
Valoración
basada en
corazonadas
Valoración del
estado
Psicosocial por
Fisioterapeutas
Desconocimiento
sobre lo que significa
Psicosocial
Necesidad de
Entrenamiento Formal y
herramientas adicionales
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7
SPINE Volume 30, Number 11, pp 1316–1322
©2005, Lippincott Williams Wilkins, Inc.
Do Physical Therapists in the United Kingdom
Recognize Psychosocial Factors in Patients With Acute
Low Back Pain?
Annette Bishop, MSc, and Nadine E. Foster, DPhil
Study Design. A cross-sectional, descriptive vignette
survey of practicing, musculoskeletal physical therapists.
Objectives. The aim of this study was to determine if
musculoskeletal physical therapists, in the United King-
dom, recognize when patients with low back pain (LBP)
are at risk of chronicity due to psychosocial factors. A
secondary aim was to explore the advice they give to
patients about work and activities.
Summary of Background Data. Psychosocial factors
have been shown to be important in the progression from
acute LBP to chronic disability. Early identification of in-
dividuals at risk of developing chronic disability is impor-
tant to enable targeted intervention.
Methods. Three vignettes were written based on acute
LBP patients attending for physical therapy and incorpo-
rated into a self-completed postal questionnaire sent to a
simple random sample of musculoskeletal physical thera-
pists in the United Kingdom (n ϭ 900). After one reminder,
20% of nonresponders were sent a further questionnaire
(n ϭ 80). Data were analyzed using the Statistical Package
for the Social Sciences (SPSS version 11).
Results. The response rate was 57.7% (n ϭ 518) with
453 meeting all inclusion criteria. The sample consisted of
physical therapists working in the musculoskeletal field
across all practice settings. Most correctly rated the chro-
nicity risk of the low- and high-risk patient vignettes. Ad-
vice to restrict work and activity was common.
Conclusions. Most physical therapists recognize when
patients are at high risk of developing chronicity, yet
many recommend the patient limit their activity levels
and not work. Advice to “not work” is associated with
more severe perceived spinal pathology, suggesting per-
sistence of the biomedical model for LBP.
Key words: low back pain, physical therapy, recom-
mendations, vignettes. Spine 2005;30:1316–1322
Low back pain (LBP) and disability in particular, con-
tinue to be significant healthcare problems in developed
societies. LBP is a common condition with a lifetime
prevalence of around 58%.1,2
Traditional thinking, that
episodes of LBP resolve rapidly, has been challenged, and
the course of LBP may be one that takes many weeks to
settle and is prone to relapse and recurrence.3,4
The eco-
nomic burden of LBP was estimated to be £10,668 mil-
lion pounds in the United Kingdom in 1998.5
Figures
from the United States estimate LBP to have had a total
impact in the industrial setting alone in excess of $170
billion6
; furthermore, treatment costs for LBP are rising
by at least 7% per year.7
LBP disability and costs of work loss and sickness
benefits rose dramatically toward the end of the 20th
century.8
In response to the increasing disability associ-
ated with LBP, the appropriateness of the biomedical
model has been questioned and a biopsychosocial model
has been proposed to try to improve outcomes for pa-
tients with LBP.8–10
The biopsychosocial model is con-
structed from the key elements of physical functioning,
beliefs and coping, distress, illness behavior, and social
interactions and has been adopted by the World Health
Organisation in the international classification of func-
tioning, disability, and health.11
This model presents a
useful framework to improve the understanding of per-
sistent back pain.12
Early identification of individuals at
risk of developing chronic problems is paramount, as the
risk of long-term incapacity increases with time and it
allows for early use of specific interventions to minimize
barriers to recovery.8,13,14
Available guidelines for
healthcare professionals involved in the management of
LBP have been published in many countries and give
broadly similar recommendations. Recommendations
include advising early return to work and continuation
of normal activities.15,16
Bed rest should be avoided as it
offers no improvement on staying active and may exac-
erbate physical deconditioning and passive coping strat-
egies.17–19
Moreover, physical activity programs have
been shown to be beneficial for LBP.20,21
In the United Kingdom, physical therapists see many
patients with LBP, with estimates varying from 9% to
50%5,22
of LBP patients seeking health care. By recog-
nizing risk factors to poor outcome and using interven-
tions that target physical and psychosocial factors, phys-
ical therapists are well placed to identify and address
From the Department of Physiotherapy Studies and Primary Care Sci-
ences Research Centre, Keele University, Staffordshire, UK.

44. 12
¿Estamos preparados para identificar factores psicosociales?
d Ezzy, 2005),
g independent
06), were con-
questions were
s (Daykin and
o Appendix A)
sment research
on of questions
Five pilot in-
guide. Partici-
experience and
cher conducted
and then tran-
rding of semi-
marily informed
volved reading
sented in each
lar ideas were
es were used to
nscripts. In this
ped together to
These themes
ed and various
were given to
entual themes
hrough the use
erative process
simultaneously
ng modification
g analysis and
he initial three
nquiring about
ssues often led
n conducting a
separate ques-
s in conduction
ts.
hrough several
key summary
searcher) were
, 2005). Cross-
iability of cod-
s and the prin-
ript and results
onsistency was
pts four weeks
nt. To promote
al researcher as
t as a ‘clinician’
s. In addition to
process.
3. Findings
Four main interrelated themes (see Fig. 1) emerged from data
analysis that describe various aspects of the physiotherapists' un-
derstanding of and approaches towards psychosocial assessment in
clinical practice. These themes were: “unclear about what psy-
chosocial means”; assessment based on ‘gut feeling’; limited
training and education; and need for formal training and additional
tools. Each of the four main themes are described and con-
textualised below with participants' own words.
3.1. Theme 1: “unclear about what psychosocial means”
Although most participants initially felt that they could recog-
nise patients' psychosocial factors immediately, on further discus-
sion it appeared they had limited understanding of what
psychosocial factors entail. Many participants in this research
limited their description of psychosocial factors to the factors that
cause delay in recovery or the chronicity of the condition. Some
related psychosocial factors only to the compensable state of pa-
tients such as WorkCover or insurance. While describing psycho-
social factors in their patients, five out of nine participants
categorised their patients as either having or not having psycho-
social factors. They often implied that patients belonging to a
certain group were likely to have psychosocial factors, or if they
have psychosocial factors then they likely belong to a certain group
(e.g. WorkCover, insurance case or chronic condition).
Fig. 1. Four themes identified from data analysis.
ysiotherapists' assessment of patients' psychosocial status: Are we standing on thin ice? A
Entrenamiento
y educación
limitados
Valoración
basada en
corazonadas
Valoración del
estado
Psicosocial por
Fisioterapeutas
Desconocimiento
sobre lo que significa
Psicosocial
Necesidad de
Entrenamiento Formal y
herramientas adicionales
Original article
Physiotherapists' assessment of patients' psychosocial status: Are we
standing on thin ice? A qualitative descriptive study
Mukul Singla*
, Mark Jones 1
, Ian Edwards 2
, Saravana Kumar 3
School of Health Science, Division of Health Science, University of South Australia, Australia
a r t i c l e i n f o
Article history:
Received 30 January 2014
Received in revised form
25 June 2014
Accepted 7 October 2014
Keywords:
Psychosocial
Yellow flags
Physiotherapy
Physical therapy
a b s t r a c t
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on
a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times,
especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their
patients' psychosocial status in clinical practice. The aim of this study was to explore private practice
physiotherapists' assessment of patients' psychosocial status.
A qualitative descriptive research design was used in this study. Participants were recruited through
purposeful sampling and potential informants were invited to participate through letters or phone calls
and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted
at the participants' workplaces. Data collection and analysis were conducted simultaneously and com-
mon concepts and themes were recognised, coded and grouped together into themes.
Analysis of the data resulted in identification of various themes related to physiotherapists' assessment
of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the
barriers they face while conducting PS assessment and the suggestions they have provided to overcome
these barriers.
In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding
of the role of PS factors in their patients' clinical presentation. They were also unclear about the
assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from in-
dividual shortcomings to limitations in professional networks and time constraints. The most consistent
barrier highlighted was participants' lack of formal education in PS theory and assessment.
© 2014 Published by Elsevier Ltd.
1. Introduction
Physiotherapists in private practice work with a wide variety of
patient problems incorporating a combination of interview, ques-
tionnaire and physical assessment procedures to guide their man-
agement. There is increasing evidence that psychosocial factors play
an important role in musculoskeletal presentations/conditions,
particularly in the maintenance of musculoskeletal symptoms and
disability (Burton et al., 2004; Heneweer et al., 2007; Menezes Costa
et al., 2009; Main et al., 2010; Raymond et al., 2011; Laisne et al.,
Classification of Functioning, Disability and Health (ICF) recognises
that pain and associated disability can be influenced by a combi-
nation of biomedical (i.e. health condition: diseases, disorders, in-
juries), personal and environmental factors (WHO, 2001).
In the context of the ICF framework psychosocial factors are
conceptualised as contextual factors with personal factors repre-
senting intrinsic individual characteristics such as social back-
ground, coping styles, education, past and current experiences and
the meaning they hold, all of which influence how disability is
experienced by the individual. Environmental factors are broadly
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Manual Therapy xxx (2014) 1e7
SPINE Volume 30, Number 11, pp 1316–1322
©2005, Lippincott Williams Wilkins, Inc.
Do Physical Therapists in the United Kingdom
Recognize Psychosocial Factors in Patients With Acute
Low Back Pain?
Annette Bishop, MSc, and Nadine E. Foster, DPhil
Study Design. A cross-sectional, descriptive vignette
survey of practicing, musculoskeletal physical therapists.
Objectives. The aim of this study was to determine if
musculoskeletal physical therapists, in the United King-
dom, recognize when patients with low back pain (LBP)
are at risk of chronicity due to psychosocial factors. A
secondary aim was to explore the advice they give to
patients about work and activities.
Summary of Background Data. Psychosocial factors
have been shown to be important in the progression from
acute LBP to chronic disability. Early identification of in-
dividuals at risk of developing chronic disability is impor-
tant to enable targeted intervention.
Methods. Three vignettes were written based on acute
LBP patients attending for physical therapy and incorpo-
rated into a self-completed postal questionnaire sent to a
simple random sample of musculoskeletal physical thera-
pists in the United Kingdom (n ϭ 900). After one reminder,
20% of nonresponders were sent a further questionnaire
(n ϭ 80). Data were analyzed using the Statistical Package
for the Social Sciences (SPSS version 11).
Results. The response rate was 57.7% (n ϭ 518) with
453 meeting all inclusion criteria. The sample consisted of
physical therapists working in the musculoskeletal field
across all practice settings. Most correctly rated the chro-
nicity risk of the low- and high-risk patient vignettes. Ad-
vice to restrict work and activity was common.
Conclusions. Most physical therapists recognize when
patients are at high risk of developing chronicity, yet
many recommend the patient limit their activity levels
and not work. Advice to “not work” is associated with
more severe perceived spinal pathology, suggesting per-
sistence of the biomedical model for LBP.
Key words: low back pain, physical therapy, recom-
mendations, vignettes. Spine 2005;30:1316–1322
Low back pain (LBP) and disability in particular, con-
tinue to be significant healthcare problems in developed
societies. LBP is a common condition with a lifetime
prevalence of around 58%.1,2
Traditional thinking, that
episodes of LBP resolve rapidly, has been challenged, and
the course of LBP may be one that takes many weeks to
settle and is prone to relapse and recurrence.3,4
The eco-
nomic burden of LBP was estimated to be £10,668 mil-
lion pounds in the United Kingdom in 1998.5
Figures
from the United States estimate LBP to have had a total
impact in the industrial setting alone in excess of $170
billion6
; furthermore, treatment costs for LBP are rising
by at least 7% per year.7
LBP disability and costs of work loss and sickness
benefits rose dramatically toward the end of the 20th
century.8
In response to the increasing disability associ-
ated with LBP, the appropriateness of the biomedical
model has been questioned and a biopsychosocial model
has been proposed to try to improve outcomes for pa-
tients with LBP.8–10
The biopsychosocial model is con-
structed from the key elements of physical functioning,
beliefs and coping, distress, illness behavior, and social
interactions and has been adopted by the World Health
Organisation in the international classification of func-
tioning, disability, and health.11
This model presents a
useful framework to improve the understanding of per-
sistent back pain.12
Early identification of individuals at
risk of developing chronic problems is paramount, as the
risk of long-term incapacity increases with time and it
allows for early use of specific interventions to minimize
barriers to recovery.8,13,14
Available guidelines for
healthcare professionals involved in the management of
LBP have been published in many countries and give
broadly similar recommendations. Recommendations
include advising early return to work and continuation
of normal activities.15,16
Bed rest should be avoided as it
offers no improvement on staying active and may exac-
erbate physical deconditioning and passive coping strat-
egies.17–19
Moreover, physical activity programs have
been shown to be beneficial for LBP.20,21
In the United Kingdom, physical therapists see many
patients with LBP, with estimates varying from 9% to
50%5,22
of LBP patients seeking health care. By recog-
nizing risk factors to poor outcome and using interven-
tions that target physical and psychosocial factors, phys-
ical therapists are well placed to identify and address
From the Department of Physiotherapy Studies and Primary Care Sci-
ences Research Centre, Keele University, Staffordshire, UK.
found a persistence of a biomedical model in the practice
of many physical therapists.23,24
Available practice guidelines recommend clinical as-
sessment to identify psychosocial factors in the first in-
stance, with the use of validated questionnaires being
reserved for patients who do not make adequate progress
after initial intervention,13,15
as these can be unwieldy
and time-consuming and are not commonly used by
physical therapists, particularly in acute patients or in
primary care situations.22,25,26
The current study aimed to investigate if physical ther-
apists working in the musculoskeletal field, in the United
Kingdom, can identify patients with acute LBP at risk of
developing chronicity from psychosocial factors in com-
mon clinical scenarios. Second, the study aimed to ex-
plore whether the advice that physical therapists provide
to acute LBP patients related to work and activity is
consistent with current published best evidence guide-
lines.
to physical therapy. As a result,
of 112, described by Hurley et
patients in this study. Three p
gnettes, one patient each at low
with a borderline score.
In line with recommendat
tested by a panel of U.K. expe
tion history or clinical experti
ensure the vignettes were realis
strated examples of patients at
chronicity. The experts consis
therapist, one senior physical t
culoskeletal researchers (three
teopath). The cutoff scores, exp
the patients and the percentag
the ALBPSQ risk are summariz
two commented that Patient 1
tors and Patient 2 had more ph
some minor modifications wer
vignette (Patient 2) to reduce th
to aid differentiation with the b
Table 1. ALBPSQ Scores, Expert Agreement, and Risk Rating of the Patient Vignettes
Vignette
ALBPSQ
Score
No. of Experts
Agreeing With
ALBPSQ Risk (n ϭ 6)
Chronicity Risk Relative
to the Other Patients
1 112 4 Moderate
2 102 4 Low
3 139 6 High
Physical Therapists in