problem solving in physical therapy

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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

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Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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• v.5(5); Sep-Oct 2020

Psychologically informed physical therapy for musculoskeletal pain: current approaches, implications, and future directions from recent randomized trials

Rogelio a. coronado.

a Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

b Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA

c Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA

Carrie E. Brintz

d Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA

Lindsey C. McKernan

e Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA

f Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN, USA

Hiral Master

Nicole motzny, flavio m. silva, parul m. goyal.

g Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA

Stephen T. Wegener

h Department of Physical Medicine and Rehabilitation, The Johns Hopkins School of Medicine, Baltimore, MD, USA

Kristin R. Archer

Associated data.

Supplemental digital content associated with this article can be found online at http://links.lww.com/PR9/A79 .

Supplemental Digital Content is Available in the Text.

Randomized trials have examined the efficacy of psychologically informed physical therapy methods including graded activity or graded exposure, cognitive-behavioral-based physical therapy, acceptance and commitment-based physical therapy, and internet-based psychological programs compared to traditional physical therapy approaches for musculoskeletal pain. Summary findings suggest that psychologically informed physical therapy is a promising care model; however, more convincing evidence is needed to support widespread adoption, especially in light of clinician training demands.

Psychologically informed physical therapy (PIPT) blends psychological strategies within a physical therapist's treatment approach for the prevention and management of chronic musculoskeletal pain. Several randomized trials have been conducted examining the efficacy of PIPT compared to standard physical therapy on important patient-reported outcomes of disability, physical function, and pain. In this review, we examine recent trials published since 2012 to describe current PIPT methods, discuss implications from findings, and offer future directions. Twenty-two studies, representing 18 trials, were identified. The studied PIPT interventions included (1) graded activity or graded exposure (n = 6), (2) cognitive-behavioral-based physical therapy (n = 9), (3) acceptance and commitment-based physical therapy (n = 1), and (4) internet-based psychological programs with physical therapy (n = 2). Consistent with prior reviews, graded activity is not superior to other forms of physical activity or exercise. In a few recent studies, cognitive-behavioral-based physical therapy had short-term efficacy when compared to a program of standardized exercise. There is a need to further examine approaches integrating alternative strategies including acceptance-based therapies (ie, acceptance and commitment therapy or mindfulness) or internet-based cognitive-behavioral programs within physical therapy. Although PIPT remains a promising care model, more convincing evidence is needed to support widespread adoption, especially in light of training demands and implementation challenges.

1. Introduction

Musculoskeletal pain remains one of the leading health complaints prompting individuals to seek medical care. Not only is musculoskeletal pain highly prevalent in both developed and developing societies, 20 , 62 the effects can dramatically impact quality of life. Estimates suggest that 10.6 million adults within the United States have high-impact pain conditions that result in substantial disability. 70 Musculoskeletal conditions such as low back pain, neck pain, and lower-extremity osteoarthritis are listed among the top diseases contributing to years lived with disability. 20 , 79 The costs associated with managing chronic pain exceeds costs for conditions such as heart disease and cancer. 27

The problem of musculoskeletal pain is complex and there is wide recognition that the optimal management approach uses a biopsychosocial model of care. 28 Psychological factors are considered important risk factors for disability and pain outcomes. 4 Psychologically based treatments that target maladaptive cognitions, emotions, or behavior with physical rehabilitation through multidisciplinary team approaches are more effective than physical treatment alone. 41 However, substantial barriers including access and cost may prevent some patients from receiving this type of care. 67 To address these barriers, recent efforts have focused on training nonpsychologist practitioners to integrate psychological strategies within primary care for prevention and management of chronic pain. 9 , 14 , 57

Psychologically informed physical therapy (PIPT) is an approach initially advocated by Main and George in a 2011 Physical Therapy article. 56 Psychologically informed physical therapy represents a multimodal rehabilitation approach for pain that incorporates behavioral strategies from the mental health realm into physical therapist practice. This integrated form of pain management by a physical therapist is a marked shift in how therapy is commonly delivered. Although most physical therapists would accept the central principles of PIPT and recognize the importance of mitigating psychosocial risk, 21 there may be challenges in delivering PIPT in everyday practice. As an initial step towards PIPT implementation, efficacy of this approach should be clearly established.

To date, there have been several systematic reviews around the topic of PIPT. 1 , 17 , 33 , 75 , 90 These prior reviews have summarized studies focused on different pain conditions (ie, postoperative pain, general musculoskeletal pain, and low back pain) and using a range of PIPT delivery modes (ie, in-person, group-based, and remotely delivered) and control groups (ie, no/minimal treatment, attention control, education, and usual care). Most of the prior studies reviewed have included a PIPT intervention based on cognitive-behavioral approaches. Two meta-analyses by Silva Guerrero et al. 75 and Wilson and Cramp 90 demonstrate that PIPT has a small, but significant, effect on improving physical function, disability, and pain compared to standard physical therapy. In the meta-analysis by Wilson and Cramp, 90 the authors included interventions where the psychological component could be delivered by either a psychologist or physical therapist. This may limit applicability of the review findings to PIPT if adhering to the description by Main and George.

The primary aim and scope of this narrative review was to build upon existing reviews and examine evidence since the publication of Main and George 56 on PIPT vs standard physical therapy approaches for musculoskeletal pain. We modeled our approach similar to the high-quality review by Silva Guerrero et al. 75 by focusing on studies that compare interventions that include psychological strategies delivered by physical therapists to standard physical therapy. Summarizing studies that compare PIPT to standard physical therapy would help establish the transformative value of PIPT. Important advancements to the review by Silva Guerrero et al. 75 involve the inclusion of more recent studies after 2016 and greater description of the individual studies and interventions. Specifically, we aimed to categorize the types of psychological interventions used, report on aspects of dosage and training, and discuss clinical implications and future directions. Our hope is that this review describing recent PIPT methods and data will inspire continued efforts to optimize pain rehabilitation.

The recent peer-reviewed literature was screened by the first author for randomized trials published after 2012 examining the efficacy or effectiveness of PIPT. A P-I-C-O-S strategy was used to guide the literature search. 64 We aimed to review studies that (1) examined adult patients with musculoskeletal pain (Population), (2) included a PIPT intervention delivered by a physical therapist (Intervention), (3) compared PIPT to standard physical therapy (eg, individual in-person exercise, manual therapy, or usual physical therapy care) (Comparator), (4) measured disability, physical function, or pain as an outcome (Outcome), and (5) used a randomized controlled trial design (Study design). Psychologically informed physical therapy search terms combined “psychotherapy,” “psychologically informed,” “psychological based,” “cognitive behavioral,” “acceptance and commitment,” “mindfulness,” and “psychological strategies” with “rehabilitation,” “physical therapy,” and “physiotherapy.” For the purpose of this review of summarizing behavioral change interventions, studies investigating education interventions for pain as the primary treatment component were not considered for inclusion. PubMed, CINAHL, and PsycINFO databases were searched (see Appendix Tables 1–3 for search results, available at http://links.lww.com/PR9/A79 ). Database results and reference lists from prior systematic reviews and studies were screened. Two independent raters (R.A.C. and H.M.) graded relevant studies using the PEDro scale for randomized trial quality. 18 , 55 We summarized PIPT intervention methods and outcome findings.

A total of 943 unique articles from the literature search were screened, with 73 article full-texts being evaluated. Of these, 22 studies representing 18 randomized trials on PIPT were included in this review (see Appendix Table 4 for exclusions, available at http://links.lww.com/PR9/A79 ). The majority of trials were graded as having good to excellent methodological quality (PEDro scores >6/10) (Table ​ (Table1), 1 ), except for studies by Bello et al., 8 Khan et al., 43 Reid et al., 72 Thompson et al., 77 and Vibe Fersum et al. 82 Lower-quality scores in these studies were due to weaknesses in concealed allocation, similarity in groups at baseline, masking of outcome assessment, follow-up rates, or intent-to-treat analysis. As expected, most studies were unable to mask participants or therapists.

Methodological quality of studies.

N, no (item not met); Y, yes (item met).

PEDro items: 1, eligibility criteria were specified; 2, subjects were randomly allocated to groups; 3, allocation was concealed; 4, groups were similar at baseline regarding the most important prognostic indicators; 5, blinding of all subjects; 6, blinding of all therapists who administered therapy; 7, blinding of all assessors who measured at least one outcome; 8, measures of at least one key outcome were obtained from more than 85% of subjects initially allocated to groups; 9, all subjects for whom outcome measures were available received the treatment or control condition as allocated, or where this was not the case, data for at least one key outcome were analyzed by “intention to treat”; 10, results of between-group statistical comparisons are reported for at least one key outcome; 11, study provides both point measures and measures of variability for at least one key outcome.

The conditions studied included chronic low back pain (n = 8), chronic neck pain (n = 2), chronic knee osteoarthritis (n = 2), chronic whiplash-associated disorder (n = 1), chronic hip osteoarthritis (n = 1), chronic pelvic pain (n = 1), acute whiplash-associated disorder (n = 1), acute or subacute low back pain (n = 1), and mixed musculoskeletal pain (n = 1). No studies involving patients undergoing surgery for musculoskeletal pain met our eligibility criteria. Across all studies, the sample size ranged from 20 to 588 patients and the average age of patients ranged from 37.3 to 73.0 years. Follow-up outcome durations ranged from immediate postintervention assessment to 3 years. We categorized PIPT interventions based on the primary psychological strategy: (1) graded activity or graded exposure, (2) cognitive-behavioral-based physical therapy, (3) acceptance and commitment-based physical therapy, and (4) internet-based psychological programs.

3.1. Graded activity or graded exposure

Graded activity and graded exposure are behavioral strategies informed by an operant conditioning paradigm, which emphasizes the reinforcement of target behaviors through learned consequences. These interventions are derived from the Fear-Avoidance Model of Musculoskeletal Pain, which identifies primary cognitive and affective processes that influence the perception and maintenance of pain. 45 , 86 Specifically, pain-related fear (viewing pain as threatening) and pain catastrophizing (the tendency for patients to exaggerate, focus on, or magnify the threat or seriousness of pain) interact to determine how a patient responds behaviorally to pain, either through avoidance or activity engagement. 71 For those who avoid pain or pain-related stimuli, the absence of pain reinforces the avoidant behavior. When used as a primary coping mechanism, fear-avoidance can lead to hypervigilance, disuse, and increased disability. 23 , 30

Graded activity and exposure directly address avoidance by supporting a patient through repeated engagement in specific (sometimes feared) physical activities or tasks in a paced, collaborative, and goal-directed manner. These behavioral techniques can be easily embedded within a physical therapy episode of care. 29 For graded activity, target activities (or exercises) are selected based on a patient's report of difficulty, chief complaints, or relevance to the pain condition. After establishing a baseline tolerance level, specific activities are performed on a time- or intensity-contingent basis (eg, quota) rather than on a patient's pain response. Positive reinforcement is provided when quotas are reached. The primary goals of graded activity are to increase the patient's tolerance to specific activities that are meaningful to daily functioning and to promote healthy behaviors. Through approaching increased activity, patients also learn to “confront” previously avoided behaviors, thus breaking the reinforcing cycle of fear-avoidance-pain. 86

Five trials examined graded activity against a standard physical therapy group (Table ​ (Table2). 2 ). Results from 4 trials by Bello et al., 8 Khan et al., 43 Macedo et al., 50 and Magalhaes et al. 52 , 54 among patients with chronic low back pain suggest that a course of graded activity does not result in significantly greater short-term (<6 months) or long-term (>1 year) improvements in disability, physical function, or pain compared to other forms of supervised exercise. Likewise, for patients with chronic whiplash-associated disorder, Ludvigsson et al. 48 , 49 , 66 showed no difference in outcomes up to 2 years after a 12-week graded activity program or 12 weeks of progressive neck strengthening. In these trials, varying levels of additional pain strategies such as oral or booklet pain education and basic coping skills training were provided within the graded activity intervention group. Therapists delivering the intervention received varying levels of graded activity training from “brief” sessions to 2-day and 4-day workshops. The prescribed dosage (eg, frequency and duration) of the intervention and control groups was matched in all trials.

Summary of recent graded activity or exposure studies.

BPI, Brief Pain Inventory; MPQ, McGill Pain Questionnaire; NDI, Neck Disability Index; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; PDI, Pain Disability Index; PIPT, psychologically informed physical therapy; PSFS, Patient Specific Functional Scale; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale.

Graded exposure specifically targets activities or tasks that a patient is fearful of due to perceived risks of harm or the pain-related fear that contributes to avoidant behavior. 84 , 85 Patients work with a physical therapist to initially rate their level of fear toward these activities. Patients work in treatment to progressively approach or “confront” feared stimuli in a hierarchical model. Graded exposure proceeds with activities that elicit the least amount of fear and after task mastery, progresses towards those that are most feared. Progression within graded exposure occurs based on changes in fear after exposure, where patients learn that fears may be exaggerated, 30 or a sense of mastery and increased self-efficacy to approach previously avoided tasks. There are 2 mechanisms underlying graded exposure: (1) behavioral mechanism based on habituation to feared stimulus and positive reinforcement for successful completion, and (2) cognitive mechanism based on disconfirmation of fear-based predictions leading to cognitive restructuring. In a trial by Ariza-Mateos et al. 3 among patients with chronic pelvic pain, graded exposure added to manual therapy resulted in greater short-term improvement in disability and pain compared to a manual therapy alone (Table ​ (Table2). 2 ). An introductory session of pain education was included as part of the graded exposure intervention. Therapist training was not described; however, the provider who delivered graded exposure was experienced with the approach. In terms of dosage, patients received graded exposure as an additional weekly 45-minute session of therapy over the 6-week period in addition to the manual therapy sessions.

3.2. Cognitive-behavioral-based physical therapy

Cognitive-behavioral therapy (CBT) is a widely known and effective psychological intervention for chronic pain. 89 The premise of CBT is that cognitive and behavioral factors, including a person's thoughts, beliefs, and actions, play a key role in the development or maintenance of chronic pain. 78 Cognitive-behavioral therapy provides patients with a repertoire of techniques to improve self-management of pain, enhance patient confidence in their ability to manage pain, and increase perceived control over pain. 5 Cognitive-behavioral therapy techniques aim to identify and decrease maladaptive behaviors, bolster positive coping, address dysfunctional thoughts and beliefs influencing pain, and increase confidence in pain self-management. Although specific techniques vary from clinician-to-clinician, components typically include elements of education, skill training (ie, goal setting, activity pacing, relaxation techniques [eg, deep breathing] or distraction, and problem solving), and skill application and maintenance in the patient's daily life. 24

Nine trials examined a cognitive-behavioral-based physical therapy approach (Table ​ (Table3). 3 ). There was a range of CBT components across the physical therapy interventions, with most including education, goal setting, problem solving, and pain-coping skills. In all trials, physical therapists were trained to deliver the psychological-based intervention—mostly through workshop format and some offering ongoing supervision or feedback from a psychologist. Four trials compared cognitive-behavioral-based physical therapy to standardized exercise, 10 , 40 , 76 , 77 whereas 5 trials compared to a multimodal (eg, manual therapy and exercise) or pragmatic rehabilitation program. 44 , 61 , 72 , 81 , 82

Summary of recent cognitive-behavioral-based physical therapy studies.

IBMT, interactive behavioral modification program; NDI, Neck Disability Index; NPDS, Neck Pain and Disability Scale; NPQ, Northwick Park Questionnaire; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; QBPDS, Quebec Back Pain Disability Score; PIPT, psychologically informed physical therapy; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Five trials reported no difference between the cognitive-behavioral-based physical therapy group compared to control. 40 , 44 , 61 , 72 , 81 Of these 5 trials, 4 trials included a control group of multimodal or pragmatic rehabilitation, 44 , 61 , 72 , 81 whereas the remaining trial was a small pilot study. 40 In the small pilot study of 20 patients, Hunt et al. 40 established the feasibility of a pain-coping skills training program that was later tested in a larger randomized trial. In trials by Lee et al. 44 and Reid et al., 72 the cognitive-behavioral intervention was developed for utilization within distinctive settings of work rehabilitation and home health care, respectively.

Studies by Bennell et al., 10 Sterling et al., 76 Thompson et al., 77 and Vibe Fersum et al. 82 , 83 showed greater efficacy after cognitive-behavioral-based physical therapy for an outcome of function, disability, or pain. Bennell et al. 10 and Thompson et al. 77 showed greater short-term efficacy compared to a standard therapy group, whereas Sterling et al. 76 and Vibe Fersum et al. 82 , 83 reported greater efficacy in disability and pain at 1 year (or longer for Vibe Fersum et al.). In a 3-arm randomized trial by Bennell et al., 10 a 12-week, 10-session pain-coping skills training program combined with exercise resulted in greater effects on physical function up to 32 weeks compared to a group consisting of exercise alone for patients with knee osteoarthritis. There were duration differences between groups, with the pain-coping skills and exercise sessions lasting 70 minutes per session and the exercise only group lasting 25 minutes per session. Therapist training for delivering the pain-coping skills intervention was rigorous involving a 4-day workshop, therapist accreditation, ongoing supervision, and feedback provided by an experienced psychologist.

Sterling et al. 76 and Thompson et al. 77 examined a cognitive-behavioral-based physical therapy intervention for patients with cervical spine conditions. Sterling et al. 76 provided 10 sessions over 6 weeks of stress inoculation training—a cognitive-behavioral approach focused on helping patients manage stress-related anxiety—to patients with acute whiplash-associated disorder and found greater treatment efficacy in disability and pain up to 1 year. The target sample was patients at risk for poor recovery with moderate disability (based on Neck Disability Index) and hyperarousal symptoms (based on Posttraumatic Stress Diagnostic Scale) at initial presentation. Duration was matched at 50-minute sessions for both stress inoculation with exercise and exercise alone groups. Similar to the study by Bennell et al., 10 Sterling et al. 76 used a psychologist and physician-led workshop, therapist accreditation, and a training booster session. Thompson et al. 77 combined interactive behavioral modification therapy with progressive exercises for patients with chronic neck pain. Thompson et al. 77 did not find differences in disability between the interactive behavioral modification therapy with exercise and exercise groups but did report greater pain reduction in the intervention group. Patients in the behavioral therapy group required more time with physical therapists (90 minutes per session) compared to the exercise group (40 minutes per session). Specific training for the interactive behavioral modification therapy was not described; however, therapists who delivered this intervention were reported to have prior experience in delivering pain management programs.

Vibe Fersum et al. 82 , 83 examined a 12-week classification-based cognitive functional therapy approach for chronic low back pain. The distinction with this method compared to previously mentioned PIPT approaches is the use of a classification system. In this system, patient characteristics were used to inform the specific strategies implemented within treatment, providing a targeted or tailored therapy approach. The cognitive functional therapy intervention included 4 components targeting cognitive, specific movement, functional integration, and physical activity. Compared to manual therapy and exercise, patients receiving classification-based cognitive functional therapy showed greater improvement in disability and pain up to 1 year. A follow-up study by Vibe Fersum et al. 83 reported that group differences persisted at 3 years for disability, but not pain intensity. Total number and duration of sessions were similar for each group. Physical therapists delivering the cognitive functional therapy had substantial training and experience (eg, average of 106 hours of training) in this method.

3.3. Acceptance and commitment-based physical therapy

As can be seen from the previous studies, CBT has been the prime intervention underlying PIPT. This is largely based on the evidence of effectiveness for CBT in chronic pain. 89 Acceptance and commitment therapy (ACT) is a “third wave” cognitive-behavioral intervention initially developed for psychological disorders. 59 , 74 However, ACT has a growing evidence base for addressing chronic pain. 39 Acceptance and commitment therapy uses techniques including mindfulness, acceptance, and behavioral change strategies to increase internal flexibility and help patients reconnect with core values to lead more fulfilling lives in the presence of chronic pain. 39 Recognizing that some aspects of the chronic pain experience cannot be altered, ACT shifts focus on pain or symptom reduction towards promoting “acceptance” and simultaneous patient achievement of value-oriented goals such as improved physical functioning. The aim of ACT is to reduce experiential avoidance (avoiding unwanted sensations, thoughts, and emotions) and promote psychological flexibility through openness (acceptance and cognitive defusion [seeing thoughts as mental events that come and go, without letting them drive behavior]), awareness (present-moment contact and self-as-context [being able to observe internal experiences without identifying with them]), and activity engagement (clarifying values and committed action). 25

One study by Godfrey et al. 32 has evaluated a physical therapy approach informed by acceptance and commitment therapy (PACT) (Table ​ (Table4). 4 ). The PACT intervention was a brief intervention spanning 3 individual visits (eg, two 1-hour in-person visits and one 20-minute telephone session) over 1 month. The strategies implemented within PACT aimed to promote self-management and psychological flexibility. 31 Specific strategies included shifting focus, value-based goal setting and adjustment, mindfulness exercises, action plans, identification of support system, and skills application. At 3 months, patients receiving PACT compared to usual physical therapy had greater improvement in disability, physical function, and physical health. This difference was not maintained at 1 year. There was no difference in pain intensity ratings between groups at any time point, which could be expected, given the PACT focus on functioning as opposed to reductions in pain. Physical therapists involved in delivering PACT were initially trained in a 2-day workshop led by psychologists with expertise in ACT and were required to apply the intervention with practice patients. 31 , 32 Workshop training involved education, experiential exercises, role playing, and problem solving. Supervision, feedback, and assessment of skill were provided by the team of trainers and further training was delivered as needed. Qualitative reports by the physical therapists indicated that PACT was feasible and acceptable. Although adherence to PACT was high, Godfrey et al. 53 noted that only a few ACT methods were delivered by physical therapists across sessions. The total mean total duration of therapy time was marginally less than usual physical therapy (2 hours compared to 3 hours).

Summary of recent acceptance and commitment-based physical therapy studies.

NRS, numeric rating scale; PACT, physical therapy approach informed by acceptance and commitment therapy; PIPT, psychologically informed physical therapy; PSFS, Patient Specific Functional Scale; RMDQ, Roland Morris Disability Questionnaire.

3.4. Internet-based psychological programs and physical therapy

The advanced training and clinic session time required to deliver specific CBT or ACT-based strategies are potential barriers to PIPT implementation. Moreover, physical therapists may struggle with delivering psychological strategies because these may be perceived as out of their scope of practice or comfort level. 6 Internet-based psychological programs (or applications) for pain offer a potential solution for providing PIPT in a more scalable manner, especially when integrated with therapy. 11 Several widely available programs exist and have been presented in the literature.

Two studies have examined the efficacy of combining internet-based psychological programs with physical therapy (Table ​ (Table5). 5 ). Petrozzi et al. 69 randomized patients undergoing physical therapy (or chiropractic care) to receive access to MoodGYM—a free, noncondition-specific, 5-module CBT-based program that addresses patient's thoughts, feelings, and stressors. The authors reported no added benefit of including MoodGYM above what was reported by patients receiving physical therapy alone. 69 It is possible that the lack of specificity of the program or poor adherence, which was not objectively tracked in the trial, could have impacted findings. In addition, MoodGYM was not integrated as part of clinical treatment. In other words, providers did not seem to reinforce program content or help patients apply the skills learned. This was a similar approach taken by Bennell et al. 12 who had patients' access and complete PainCOACH, an interactive 8-module program emphasizing pain-coping skills, before undergoing a standard exercise program for hip pain. Similar long-term clinical outcomes were observed compared to internet education and standard exercise. The lack of integration by Bennell et al. 12 enhanced methodological rigor (ie, blinding of therapists), 13 but may explain the lack of added long-term benefit.

Summary of PIPT studies with use of internet-based programs.

NRS, numeric rating scale; PIPT, psychologically informed physical therapy; PSFS - Patient Specific Functional Scale; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

4. Discussion

4.1. summary of findings.

Summary findings from recent trials point to a few important observations. First, there continues to be evidence that graded activity is not a superior approach for chronic low back pain compared to other forms of exercise. This has been highlighted in earlier systematic reviews of the literature. 46 , 51 , 80 In the current review, none of the included studies on graded activity showed greater efficacy in improving outcomes compared to standard physical therapy. Second, despite the apparent accessibility and feasibility, internet-based psychological programs provided to patients in physical therapy do not seem to contribute to better outcomes compared to physical therapy alone. Issues related to low adherence to the online program, lack of support or integration of learned skills within therapy, or issues with program specificity may explain the apparent lack of additional benefit. Finally, as often is the case, there are areas that lack clear conclusions.

4.2. Comparison to prior reviews

Prior systematic reviews have summarized evidence on efficacy of graded activity 46 , 51 , 80 and PIPT. 1 , 17 , 33 , 75 , 90 Overall, our results are largely consistent with these reviews, which show promising effects for PIPT, namely in-person cognitive-behavioral-based physical therapy. Prior reviews have differed in their focus for condition (ie, postoperative pain, 17 general musculoskeletal pain, 1 , 75 low back pain, 33 and chronic pain 90 ) and comparators. We intended a broad condition focus that would include both nonoperative and postoperative patients, but did not find any postoperative studies that directly compared PIPT to standard physical therapy. A few notable postoperative PIPT studies that did not meet this specific criterion, but should be considered when determining the value of postoperative PIPT, include studies by Archer et al., 2 Lotzke et al., 47 Riddle et al., 73 Peolsson et al., 68 and Wibault et al. 88 Most of these postoperative studies compared a PIPT approach to usual postoperative care, which may have included physical therapy.

We did include similar PIPT studies as prior reviews, but also more recent trials. In contrast to prior reviews, we report summary findings related to ACT-based physical therapy and internet-based psychological programs offered in conjunction with physical therapy. These novel approaches have potential implications and can inform future directions. For example, CBT represents the most common psychological approach that has shaped PIPT. The evidence for cognitive-behavioral-based physical therapy is summarized in this review and in prior meta-analyses. 75 , 90 However, more recent psychological approaches such as ACT, mindfulness, and positive psychology may provide novel strategies to integrate within physical therapy. Our review suggests that ACT-based physical therapy may be a beneficial approach for chronic pain. 32 In the context of personalized medicine, targeted psychological strategies may need to consider not only psychological risk factors commonly addressed with CBT, but also whether boosting resiliency characteristics such as positive affect, hope, or optimism can translate to meaningful clinical outcome effects. 26 , 34

4.3. Clinical implications and future directions

Results from recent studies examining in-person CBT-based physical therapy approaches are mixed. These findings may suggest a lack of robust superiority for PIPT compared to pragmatically delivered physical therapy. 65 It is possible that traditional physical therapy interventions such as exercise could impart similar benefits to psychological-based interventions through shared or nonspecific mechanisms. 60 Before settling on these conclusions, the quality of the randomized trials and the need to examine additional factors that may impact the role of this class of intervention should be considered. For example, half of the “positive effects” studies on cognitive-behavioral-based physical therapy were judged to be of lower methodological quality, which could bias these results. Studies demonstrating efficacy of cognitive-behavioral-based physical therapy tended to have larger sample sizes compared to trials showing no difference, suggesting a higher likelihood to detect small differences in outcomes. The exception was the study by Reid et al. 72 (>500 patients) that reported no difference in efficacy for cognitive-behavioral-based physical therapy. Reid et al. 72 acknowledge that their trial may have been affected by low psychological strategy implementation by physical therapists. The main implementation challenges were time to deliver the intervention (additional 15–20 minutes), which interfered with addressing other patient issues, and low utilization of written material or practice techniques by patients. High-quality studies by Bennell et al., 10 Sterling et al., 76 and Godfrey et al. 32 as well as the study by Vibe Fersum et al., 82 , 83 which show greater efficacy after cognitive-behavioral-based physical therapy, describe rigorous training and implementation protocols. Moreover, most of these trials involve collaboration with a clinical psychologist and/or rehabilitation physician, 10 , 76 which may be an important component of both training and fidelity.

Cognitive-behavioral therapy, delivered by psychologists, is an intervention with relatively good outcome effects for chronic pain. 22 If CBT-based interventions delivered by physical therapists are similarly efficacious as traditional therapy, this begs the question of why this may be the case. Unlike CBT, physical therapy is often not standardized or protocolized. Thus, there are no established dosage and content parameters that are widely accepted as effective. In the current review, we found variability in the structure of PIPT in terms of total number, frequency and duration of sessions, and length of the treatment program. We did not observe an apparent pattern that would describe the impact of these parameters on treatment efficacy. For example, Godfrey et al. 31 reported beneficial effects after their relatively brief PIPT intervention. Optimizing parameters related to PIPT dosage and content is an important area for further exploration.

Another possible reason for mixed or comparable outcome findings could relate to the lack of targeting of the PIPT to a population “at risk.” Few of the included studies directly targeted the PIPT intervention to patients exhibiting heightened psychosocial risk. One example of a trial that did was the study by Sterling et al. 76 where patients were screened for hyperarousal symptoms. Psychologically informed physical therapy strategies may not be needed by all patients with musculoskeletal pain. This approach of stratifying patients based on psychosocial risk is not new and there has been success with primary care pathways involving physical therapy for acute back pain. 36 There may be a role for personalized approaches to assess not whether PIPT works, but rather which patients benefit from these augmented rehabilitation treatments and who may not need them or respond. Recent evidence suggests a potential outcome influence for not only psychosocial risk factors, but also resiliency characteristics. 7 , 58 , 87 Future studies should examine whether complex psychological profiles including both risk and resiliency characteristics impact the efficacy of PIPT interventions.

The added cost and burden of integrating PIPT in real-world settings may not outweigh small degrees of additional benefits that have been observed in the literature. For most physical therapists, the PIPT approach represents a considerable shift from traditional physical therapy care. Transformative physical therapy practice may involve greater focus on addressing psychological risk factors, use of psychological techniques that might conflict with physical-focused interventions (in terms of time or priority), and/or adjustments to longer therapy sessions or group-based formats. Each of these practice shifts may come at a “cost” to the therapist or clinic. It was beyond the scope of this review to examine the cost implications (or savings) of a PIPT approach. However, as part of their trial, Bennell et al. 10 did report a higher cost of delivery for PIPT (pain-coping skills and exercise) due to the lengthier treatment sessions, but no difference in cost-effectiveness between groups. Godfrey et al. 32 found no major cost of delivery or utilization differences in their study, but did acknowledge the need for a one-off PIPT training cost. Thompson et al. 77 reported cost savings with their PIPT approach because of the small group format. Although a formal cost-effectiveness analysis was not conducted, Thompson et al. 77 did report no difference in healthcare utilization between groups. Future efforts examining costs supporting a PIPT model of care and cost-effectiveness are needed.

Qualitative reports emphasize physical therapist's concerns and barriers to approaching pain management in a PIPT manner. 38 There is inadequate training in psychological interventions or cognitive-behavioral pain strategies across entry-level physical therapy programs. 37 Postgraduate educational opportunities in PIPT are scarce and may not meet the rigor of training needed to support a PIPT practice model. 15 , 63 For example, successful behavioral intervention training programs often use multiple methods such as workshops, role playing, practice, supervision by a psychologist, and peer feedback to ensure intervention adoption and prevent drift. 35 Several of the described trials used these methods with study physical therapists and often, the results suggested high fidelity to delivering PIPT. Even when implementation rates are low, physical therapists demonstrate ability and confidence to provide PIPT techniques as trained. 72 One of the main challenges in transforming standard practice towards PIPT is the requirement to optimally train physical therapists in delivering cognitive-behavioral-based treatment. Currently, there is no widely accepted standard for PIPT intervention training. 42 Several high-quality studies included rigorous and comprehensive training programs that would be expected to be more effective in preparing physical therapists to deliver standard psychological strategies, but also manage patients with higher psychological burden or handle unanticipated challenges that may arise with this form of therapy. For example, periodic feedback from a psychologist and peer discussion have been important aspects to address unique patient experiences and challenges. 63 This aspect of training may not be feasible for all practice settings. Future research should aim to determine optimal and standardized methods to train, supervise, and monitor physical therapists' use of PIPT strategies.

Although some approaches such as graded activity or graded exposure can be integrated seamlessly into physical therapy, other strategies such as cognitive restructuring and relaxation techniques may require modifications to existing clinical treatment structures (ie, extended treatment time or use of private rooms). Several trials described in this review offered PIPT (with or without exercise) in sessions of 45-, 60-, or 90-minute durations. The increased time for a one-on-one, in-person clinical encounter may not be feasible in some outpatient practice settings and may not yield high likelihood for implementation. 72 There may be a need to examine which specific PIPT components or strategies are the most effective and aim to incorporate only those strategies within standard practice. To the best of our knowledge, there have not been any studies that have examined content optimization for PIPT. The examination of treatment components may require more advanced research designs that will identify the most “active” components of PIPT. 16

Internet-based programs have been developed to help overcome in-person treatment delivery challenges. To date, few studies have examined whether internet-based psychological programs can be integrated within an episode of physical therapy. The studies by Bennell et al. 12 and Petrozzi et al. 69 described PIPT approaches where physical therapists were not tasked with formally integrating internet content or skills, which may be a potential reason for the lack of additional benefit. Prior work in primary care has examined the impact of clinician support or contact on internet program utilization and efficacy. 19 Dear et al. 19 did not observe differences in clinical outcomes when an internet-based program was provided with no, optional, or regular clinician contact. Granted that the internet-based program is well developed and engaging, it is undetermined whether integration within physical therapy is needed. Future research should aim to expand on the current work described in this review to determine whether integrating internet-based programs can lead to more feasible or sustainable PIPT compared to other approaches.

4.4. Limitations

This is not the first systematic review to summarize evidence on PIPT. We advance prior work by describing characteristics of the psychological approaches informing PIPT and include novel methods such as ACT and internet-based psychological programs. Our primary aim was to describe recent approaches and offer clinical implications and possible future directions. We did not meta-analyze outcome data from our included studies and are unable to confirm efficacy of specific PIPT approaches. Despite our structured and comprehensive search strategy, we cannot confirm that we have identified all studies since 2011 meeting our eligibility criteria.

5. Conclusions

Our review summarized findings from recent randomized trials that have examined the efficacy of PIPT compared to standard physical therapy approaches in patients with musculoskeletal pain. Consistent with prior reviews, graded activity is not superior to other forms of physical activity or exercise. A few studies on cognitive-behavioral-based physical therapy demonstrated short-term efficacy, when compared to a program of standardized exercise. There is a need to further examine approaches integrating alternative strategies including acceptance-based therapies (ie, ACT or mindfulness) or internet-based cognitive-behavioral programs within physical therapy. Although PIPT remains a promising care model, more convincing evidence is needed to support widespread adoption, especially in light of extensive training demands and implementation challenges.

Disclosures

The authors have no conflicts of interest to declare.

During manuscript development, R.A. Coronado was supported by a Vanderbilt Faculty Research Scholars Award.

Appendix A. Supplemental digital content

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site ( www.painrpts.com ).

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Clinical Reasoning Process in Physical Therapy

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Otto D. Payton, Clinical Reasoning Process in Physical Therapy, Physical Therapy , Volume 65, Issue 6, 1 June 1985, Pages 924–928, https://doi.org/10.1093/ptj/65.6.924

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The purpose of this descriptive study was to analyze physical therapists' clinical problem solving and compare the results with physicians' clinical problem solving. Ten skilled physical therapy clinicians were observed as they performed an initial interview with a patient. Their performance was audiotaped and later analyzed. The therapists defined their problem lists and developed treatment plans early in the interview, as they gathered data. This clinical problem-solving sequence is comparable to a method reported in the literature that is used by physicians. This model of clinical problem solving based on actual performance of clinicians can be used to train physical therapy students and, perhaps, to refine clinical evaluation skills.

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Critical Thinking Skills During a Physical Therapist Professional Education Program

Vendrely, Ann PT, EdD, OCS

Ann Vendrely is university professor of physical therapy in the Department of Physical Therapy at Governors State University, 1 University Parkway, University Park, IL 60466 ( [email protected] ).

This study was approved by the Human Subjects Review Board of Governors State University and the Institutional Review Board of Loyola University Chicago. It was completed in partial fulfillment of the requirements for the degree of Doctor of Education at Loyola University Chicago.

Received July 28, 2003, and accepted November 15, 2004.

Background and Purpose. 

The purpose of this study was to determine if critical-thinking skills changed as a result of completing a 27-month, traditional physical therapist (PT) education curriculum at the postbaccalaureate level.

Subjects. 

Forty-two students in graduating classes between 1998 and 2001 who completed the 27-month, master's degree PT professional education program agreed to participate. Subjects were 69% women and 31% men, with a mean age at admission to the program of 26.52 years and a range of 22-38 years.

Methods. 

The California Critical Thinking Skills Test (CCTST), a standardized examination consisting of 34 items in a multiple-choice format that is content neutral and designed for adults, was administered during the first week in the PT education program and again during the last week of the program. The number of correct responses formed the composite score on the test and on each of the three subscales. Each item on the test was categorized into one of three subscales defined as “analysis,” “inference,” and “evaluation.” A paired t test investigated the differences between pretest and posttest scores on the CCTST composite score and three subscale scores.

Results. 

The mean score for the pretest CCTST cumulative of 19.32 was compared to the mean posttest of 20.61. T test results of the pretest and posttest CCTST showed no significant differences at the 0.05 level between the cumulative or sub-scale scores.

Discussion and Conclusion. 

Critical-thinking abilities of PT professional students as measured by the CCTST did not change as a result of participation in a master's degree PT education program. Use of a different instrument or larger sample may provide further information about the critical-thinking skills of PT students. Development of critical-thinking skills appears to be an important goal of professional physical therapist education programs; however, meaningful measurement of changes in critical-thinking skills during the educational process remains difficult.

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