Cited by 180Musculoskeletal pain and rehabilitationPain Management and TreatmentPediatric Pain Management Techniques

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Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions

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Keefe, Francis J, Main, Chris J, George, Steven Z·2018·Physical Therapy

DOI 10.1093/ptj/pzy024PMC PMC7207297

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Abstract

There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples’ responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.

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Figure 1. Conceptual framework for psychologically informed practice. The original framework for psychologically informed practice in the management of low back pain was proposed by Main and George.1 Psychologically informed practice was described as the “middle way,” integrating traditional biomedically based, physical impairment–focused practice with cognitive-behavioral approaches. Adapted with permission of the American Physical Therapy Association from Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research.Phys Ther. 2011;91:820–824.CC BY-NC · PubMed Central

Figure 2. Systematic strategy for training physical therapists in psychologically informed practice. A hierarchy of psychologically informed intervention training should consist of a treatment manual, an experiential workshop, and supervision and monitoring. For the establishment of new training, feedback from mentors and consultants should be a structured part of the process.CC BY-NC · PubMed Central

Figure 3. Overview of key components of psychologically informed physical therapy for the Targeted Interventions to Prevent Chronic Low Back Pain in High Risk Patients trial. With the use of patient-centered communication as the overall model, psychologically informed physical therapy can consist of pain-coping skills, behavioral-based exercise approaches, traditional impairment-based treatment, and a home program. The response to this approach should be monitored and used to determine whether the composition of the psychologically informed physical therapy should be changed.CC BY-NC · PubMed Central

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The Critical Role of Nutrition Care to Improve Pain Management: A Global Call to Action for Physical Therapist Practice
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Longitudinal Monitoring of Pain Associated Distress With the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Tool: Predicting Reduction in Pain Intensity and Disability
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Self-citation
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Background
Preferred Communication Strategies Used by Physical Therapists in Chronic Pain Rehabilitation: A Qualitative Systematic Review and Meta-Synthesis
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“28 Consistent with prior reviews in the field of pain rehabilitation, 11,29 we conducted a meta-synthesis following procedures recommended by Sandelowski, Barroso, and Voils 30 because this method is particularly suited for synthesis of data from qualitative studies using varied methodologies.”
Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral–Based Physical Therapy Outcomes From a Randomized Controlled Trial
Coronado, R. A., Master, H., Bley, J. A., Robinette, P. E., Sterling, E. K., O’Brien, M. T., Henry, A. L., Pennings, J. S., Vanston, S. W., Myczkowski, B., et al. (2022) · Physical Therapy · doi:10.1093/ptj/pzac091 · Cited by 15
Injury-related Psychological Distress and the Association with Perceived Running Ability in Injured Runners
Maschke, B., Palmsten, A., Nelson, E. O., Obermeier, M. C., Reams, M., Heiderscheit, B., Russell, H. C., & Chmielewski, T. (2021) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2021.12.005 · Cited by 15
The Psychologically Informed Practice Consultation Roadmap: A Clinical Implementation Strategy
Main, C. J., Simon, C. B., Beneciuk, J. M., Greco, C. M., George, S. Z., & Ballengee, L. A. (2023) · Physical Therapy · doi:10.1093/ptj/pzad048 · Cited by 14
Self-citation
RETRACTED ARTICLE: An integrated multi-criteria decision-making approach for identifying the risk level of musculoskeletal disorders among handheld device users
Jain, R., Rana, K. B., & Meena, M. L. (2021) · Soft Computing · doi:10.1007/s00500-021-05592-w · Cited by 14
Retracted
Use of Mental Health Interventions by Physiotherapists to Treat Individuals with Chronic Conditions: A Systematic Scoping Review
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Using hypnosis in clinical practice for the management of chronic pain: A qualitative study
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Differences in Pain Experience Among Different Racial and Ethnic Groups
Lane, E., Barnes, C., & Fritz, J. M. (2024) · Physical Therapy · doi:10.1093/ptj/pzae001 · Cited by 13
The Effectiveness of Combined Exercise and Self-Determination Theory Programmes on Chronic Low Back Pain: A Systematic Review and Metanalysis
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Preoperative and postoperative psychologically informed physical therapy: A systematic review of randomized trials among patients with degenerative spine, hip, and knee conditions
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Psychologically informed approaches to chronic low back pain: Exploring musculoskeletal physiotherapists' attitudes and beliefs
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“There is a robust evidence base supporting the use of psychological interventions, primarily cognitive behavioural approaches, in LBP and their superiority to minimal or no treatment (Artus et al., 2010; Keefe et al., 2018; Keller, Hayden, Bombardier, & van Tulder, 2007; National Institute for Health and Clinical Exce…”
BackgroundInfluential
Physiotherapy informed by Acceptance and Commitment Therapy for chronic low back pain: A mixed‐methods treatment fidelity evaluation
Galea Holmes, M. N., Wileman, V., Hassan, S., Denning, J., Critchley, D., Norton, S., McCracken, L. M., & Godfrey, E. (2022) · British Journal of Health Psychology · doi:10.1111/bjhp.12583 · Cited by 13
Process of change for people with knee osteoarthritis undergoing cognitive functional therapy: a replicated single-case experimental design study
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“For instance, co-care with psychologists may provide targeted strategies for management of contextual stress and co-morbid mental health [17,50,61].”
Background
Psychologically Informed Practice in Audiological Rehabilitation: Audiologist Perceived Barriers, Facilitators, and Preparedness
Laird, E., Bryant, C., Barr, C., & Bennett, R. J. (2022) · Ear and Hearing · doi:10.1097/aud.0000000000001257 · Cited by 12
“Psychologically informed practice recognizes the role of psychological factors in health and extends these models by incorporating psychological frameworks, such as cognitivebehavioral therapy, behavior change theory, and health psychology, emphasizing healthcare professional training, and utilizing standardized guide…”
BackgroundMethod
Pain phenotyping and investigation of outcomes in physical therapy: An exploratory study in patients with low back pain
Wilson, A. T., Riley, J. L., Bishop, M. D., Beneciuk, J. M., Cruz‐Almeida, Y., Markut, K. A., Redd, C., LeBlond, N. D., Pham, P. H., Shirey, D., et al. (2023) · PLoS ONE · doi:10.1371/journal.pone.0281517 · Cited by 14
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“Communication is key for establishing a therapeutic alliance (defined as collaboration between therapeutic participants to facilitate healing), which in turn is key for improved outcomes [60,95-97].”
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Sullivan, M. B., Hill, K., Ballengee, L. A., Knoblach, D., Fowler, C., Haun, J., & Saenger, M. (2023) · Global Advances in Integrative Medicine and Health · doi:10.1177/27536130231209751 · Cited by 10
“22,31,32,34,35 31-34 The lack of clear competencies, rationale, framework, and clinical models that are feasible and acceptable make it dif ﬁ cult to develop, adopt, and apply best practices for the spread and adoption of PiPT programs.”
Background
Comparison of clinical and biomechanical characteristics between individuals with lower limb amputation with and without lower back pain: A systematic review and meta-analysis
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Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study
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“Development of more powerful new non-pharmacologic analgesics has become a national priority [20].”
Background
Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review
Aldanyowi, S. N. (2023) · Life · doi:10.3390/life13122351 · Cited by 11
“Widespread adoption also faces challenges around provider training, costs and reimbursements, and the development of appropriate clinical protocols [44–46].”
Background
The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: a randomized clinical trial
Day, M. A., Ciol, M. A., Mendoza, M. E., Borckardt, J. J., Ehde, D. M., Newman, A. K., Chan, J. F., Drever, S. A., Friedly, J. L., Burns, J. W., et al. (2024) · BMC Medicine · doi:10.1186/s12916-024-03383-2 · Cited by 15
“Keefe and colleagues have emphasized the importance of systematic training strategies with manuals, experiential learning, supervision, monitoring, and feedback in pre-paring professionals such as physiotherapists to deliver psychologically informed practice [51–54].”
Background
Experiences of training and delivery of Physical therapy informed by Acceptance and Commitment Therapy (PACT): a longitudinal qualitative study
Holmes, M. G., Wileman, V., McCracken, L. M., Critchley, D., March, M. K., Norton, S., Moss-Morris, R. E., Noonan, S., Barcellona, M. G., & Godfrey, E. L. (2020) · Physiotherapy · doi:10.1016/j.physio.2020.12.004 · Cited by 11
“Psychologically-informed physiotherapy acknowledges the need to assess and manage patient beliefs, attitudes and emotional responses towards their condition, as well as physical symptoms and functioning [6].”
BackgroundMethodInfluential
Increasing presence via a more immersive VR system increases virtual reality analgesia and draws more attention into virtual reality in a randomized crossover study
Hoffman, H. G., Seibel, C. C., Coron, L., Simons, L. E., Drever, S. A., May, S. L., Mason, K. P., & Flor, H. (2024) · Frontiers in Virtual Reality · doi:10.3389/frvir.2024.1452486 · Cited by 10
Treatment monitoring as a component of psychologically informed physical therapy: A case series of patients at high risk for persistent low back pain related disability
Beneciuk, J. M., Ballengee, L. A., & George, S. Z. (2019) · Musculoskeletal Science and Practice · doi:10.1016/j.msksp.2019.03.004 · Cited by 14
Self-citation
Mass media campaigns for chronic pain: a scoping review to inform design of future campaigns
Aikman, K., Burtt, L., de Ronde, O., Lim, D. K. W., Stratton, P., Wong, M. H., Grainger, R., & Devan, H. (2020) · Physical Therapy Reviews · doi:10.1080/10833196.2020.1832711 · Cited by 9
Promoting engagement in physical activity in early rheumatoid arthritis: A proof‐of‐concept intervention study
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Efficient Screening for Fear of Movement in Outpatient Settings: Short Form and Computer Adaptive Tests for Fear Avoidance and Negative Pain Coping
Lentz, T. A., Kallen, M. A., Deutscher, D., & George, S. Z. (2021) · Physical Therapy · doi:10.1093/ptj/pzab256 · Cited by 9
Self-citation
Application of the best-worst method approach for prioritizing risk factors of musculoskeletal disorders among mobile device users: A case study
Jain, R., Rana, K. B., Meena, M. L., & Verma, V. (2022) · Work · doi:10.3233/wor-205148 · Cited by 9
“Several factors have been identiﬁed in previous researches which could lead to convert from acute to chronic MSDs [11].”
The theatre of depression: a role for physical therapy
Varela, A. J., & Melvin, A. (2022) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2022.2041136 · Cited by 25
“…musculoskeletal rehabilitation and health behavior literature that pioneered the concept through application of biopsychosocial model (Gochman, 1982; Keefe, Main, and George, 2018; O’Sullivan et al, 2018; Silva Guerrero, Maujean, Campbell, and Sterling, 2018; Wilson, Chaloner, Osborn, and…”
Method
Preventing Suicide: Time to Mobilize the Physical Therapist Workforce
McGrath, R. L., Shephard, S., Hemmings, L., Verdon, S. E., & Parnell, T. (2023) · Physical Therapy · doi:10.1093/ptj/pzad116 · Cited by 8
High kinesiophobia and pain catastrophizing in people with articular cartilage defects in the knee and associations with knee function
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Orthopedic Providers’ Preferences for Education and Training on Psychosocial Clinical Research Initiatives: A Qualitative Investigation
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Digital Rehabilitation for Acute Low Back Pain: A Prospective Longitudinal Cohort Study
Costa, F. M. T. A., Janela, D., Molinos, M., Moulder, R. G., Jr., Laíns, J., Bento, V., Scheer, J. K., Yanamadala, V., Correia, F. D., & Cohen, S. P. (2022) · Journal of Pain Research · doi:10.2147/jpr.s369926 · Cited by 8
“Strengths and Limitations The strengths of this study include the novelty of the approach – amulti-component DCP managed by PTs, which combines exercises with real-time biofeedback within a biopsychosocial framework.(92,93) The digital format favors accessibility, while the regular communication with the same PT may e…”
Background
Optimising management of low back pain through the pain and disability drivers management model: Findings from a pilot cluster nonrandomised controlled trial
Longtin, C., Décary, S., Cook, C. E., Tousignant, M., Lacasse, A., & Tousignant‐Laflamme, Y. (2023) · Musculoskeletal Care · doi:10.1002/msc.1738 · Cited by 10
Patient-defined outcomes for pain, fatigue, emotional distress, and interference with activities did not differ by age for individuals with musculoskeletal pain
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Self-citation
Placebo effects in osteopathy and other manual therapies – What they are and why they matter to clinical practice, education, and research
Hohenschurz‐Schmidt, D., & Liem, T. (2025) · International journal of osteopathic medicine · doi:10.1016/j.ijosm.2025.100762 · Cited by 8
Behavioral therapy for temporomandibular disorders
Ohrbach, R. K., & Sharma, S. (2021) · Frontiers of Oral and Maxillofacial Medicine · doi:10.21037/fomm-20-65 · Cited by 7
“Little evidence exists for the below principles in specifically managing the masticatory system in relation to a TMD; instead we rely upon general principles established elsewhere (64-67).”
Method
Psychological, social and lifestyle screening of people with low back pain treated by physiotherapists in a National Health Service musculoskeletal service: an audit
Singh, G., McNamee, G., Sharpe, L., Lucas, M., Lewis, P. J., Newton, C., O’Sullivan, P., Lin, I. B., & O’Sullivan, K. (2021) · European Journal of Physiotherapy · doi:10.1080/21679169.2021.1950208 · Cited by 7
Adding Physical Impairment to Risk Stratification Improved Outcome Prediction in Low Back Pain
Beneciuk, J. M., & George, S. Z. (2020) · Physical Therapy · doi:10.1093/ptj/pzaa179 · Cited by 7
Self-citation
Exploring physiotherapy practice within hospital-based interprofessional chronic pain clinics in Ontario
Thacker, L., Walsh, R. M., Song, G. S., Khan, H. A., Parmar, P., Vance, K. T., Grant, G., Mesaroli, G., Hunter, J. P., & Vader, K. (2021) · Canadian Journal of Pain · doi:10.1080/24740527.2021.1905508 · Cited by 7
Psychological assessments by manual physiotherapists in the Netherlands in patients with nonspecific low back pain
Hallegraeff, J. M., Zweden, L. V., Oostendorp, R. A. B., & van Trijffel, E. (2021) · Journal of Manual & Manipulative Therapy · doi:10.1080/10669817.2021.1919283 · Cited by 7
Chronic Pain Management Approaches among Spanish Physiotherapists: Influences, Practices, Barriers, and Challenges
Díaz‐Fernández, Á., Cortés‐Pérez, I., Obrero‐Gaitán, E., Martínez, A. R. O., Osuna‐Pérez, M. C., Zagalaz‐Anula, N., & Lomas‐Vega, R. (2024) · Journal of Personalized Medicine · doi:10.3390/jpm14090903 · Cited by 7
Low Back Pain Treatment by Athletic Trainers and Athletic Therapists: Biomedical or Biopsychosocial Orientation?
MacDougall, H. L., George, S. Z., & Dover, G. C. (2019) · Journal of Athletic Training · doi:10.4085/1062-6050-430-17 · Cited by 6
“These skills require practice and feedback from a mentor, an educational approach that is not typically offered in traditional continuing education courses.(35) Consequently, future researchers should aim to critically examine the acquisition of a biopsychosocial treatment orientation through educational bodies and ho…”
BackgroundSelf-citation

Authors: Keefe, F. J., Main, C. J., & George, S. Z.
Affiliations: Duke University (US)
Keele University (GB)
Corresponding author: Keefe, Francis J
ORCID: Keefe, Francis J
Main, Chris J
George, Steven Z
Venue: Physical Therapy
Publisher: Oxford University Press (OUP)
Published: 2018-04-16
Volume: 98
Issue: 5
Pages: 398-407
ISSN: 0031-9023 (ISSN-L)
1538-6724
DOI: 10.1093/ptj/pzy024
PMC: PMC7207297
OpenAlex: W2799875742
Cited by: 180
References: 52
Citations by year: 2026: 15 · 2025: 15 · 2024: 18 · 2023: 28 · 2022: 28 · 2021: 32 · 2020: 26 · 2019: 14 · 2018: 4
FWCI: 2.22
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: cc-by-nc
creativecommons.org/licenses/by-nc/4.0/ (vor)
Locations: Physical Therapy (publishedVersion, cc-by-nc)
PubMed Central (publishedVersion, cc-by-nc)
PubMed (publishedVersion)
Funders: National Institute for Arthritis and Musculoskeletal and Skin Diseases (AR055899)
NIH
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
Keywords: chronic musculoskeletal pain, chronic pain, low back pain, pain beliefs, pain anticipation, pain-related disability, non-pharmacological pain management, stratified care, primary care, pain management
MeSH terms: Disability Evaluation, Humans, Pain Measurement, Psychophysiology, Psychotherapy, Risk Assessment, Physical Therapy Modalities, Musculoskeletal Pain, Pain Management

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Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions

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