See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/234010185

Thinking beyond muscles and joints:

Therapists' and patients' attitudes and beliefs
regarding chronic musculoskeletal pain are key
to applying effective treatment

Article in Manual therapy · December 2012

DOI: 10.1016/j.math.2012.11.001 · Source: PubMed

CITATIONS READS

44 499

5 authors, including:

Nathalie Roussel C Paul Van Wilgen

University of Antwerp Transcare Transdisciplinary painmanagem…
88 PUBLICATIONS 804 CITATIONS 137 PUBLICATIONS 1,047 CITATIONS

SEE PROFILE SEE PROFILE

Albère Köke Rob Johannes Smeets

Adelante Zorggroep Maastricht University
84 PUBLICATIONS 2,382 CITATIONS 152 PUBLICATIONS 2,613 CITATIONS

SEE PROFILE SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Rob Johannes Smeets
letting you access and read them immediately. Retrieved on: 08 September 2016
This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/copyright
 Author's personal copy

Manual Therapy 18 (2013) 96e102

Contents lists available at SciVerse ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Masterclass

Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and
beliefs regarding chronic musculoskeletal pain are key to applying effective
treatment
Jo Nijs a, b, d, *, Nathalie Roussel a, c, e, C. Paul van Wilgen f, Albère Köke g, h, Rob Smeets g, h
a
Chronic Pain and Chronic Fatigue Research Group (CHROPIVER), Department of Human Physiology, Faculty of Physical Education & Physiotherapy,
Vrije Universiteit Brussel, Belgium
b
Chronic Pain and Chronic Fatigue Research Group (CHROPIVER), Department of Physiotherapy, Faculty of Physical Education & Physiotherapy,
Vrije Universiteit Brussel, Belgium
c
Chronic Pain and Chronic Fatigue Research Group (CHROPIVER), Division of Musculoskeletal Physiotherapy, Department of Health Care Sciences,
Artesis University College Antwerp, Belgium
d
Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium
e
Faculty of Medicine, Universiteit Antwerpen, Belgium
f
Transcare, Transdisciplinairy Painmanagement Centre, The Netherlands
g
Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
h
Department of Rehabilitation Medicine, Maastricht University Medical Centre, Research school of Caphri, Maastricht, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: It is well established that the biomedical model falls short in explaining chronic musculoskeletal pain.
Received 18 June 2012 Although many musculoskeletal therapists have moved on in their thinking and apply a broad bio-
Received in revised form psychosocial view with regard to chronic pain disorders, the majority of clinicians have received
22 October 2012
a biomedical-focused training/education. Such a biomedical training is likely to influence the therapists’
Accepted 3 November 2012
attitudes and core beliefs toward chronic musculoskeletal pain. Therapists should be aware of the impact
of their own attitudes and beliefs on the patient’s attitudes and beliefs. As patient’s attitudes and beliefs
Keywords:
influence treatment adherence, musculoskeletal therapists should be aware that focusing on the
Chronic pain
Low back pain
biomedical model for chronic musculoskeletal pain is likely to result in poor compliance with evidence
Exercise based treatment guidelines, less treatment adherence and a poorer treatment outcome. Here, we provide
Neck pain clinicians with a 5-step approach toward effective and evidence-based care for patients with chronic
Whiplash musculoskeletal pain. The starting point entails self-reflection: musculoskeletal therapists can easily self-
Adherence assess their attitudes and beliefs regarding chronic musculoskeletal pain. Once the therapist holds
Illness perceptions evidence-based attitudes and beliefs regarding chronic musculoskeletal pain, assessing patients’ atti-
tudes and beliefs will be the natural next step. Such information can be integrated in the clinical
reasoning process, which in turn results in individually-tailored treatment programs that specifically
address the patients’ attitudes and beliefs in order to improve treatment adherence and outcome.
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.

1. Introduction pain: in the majority of patients with chronic musculoskeletal pain,

Chronic musculoskeletal pain is a complex and challenging
medical problem. Therefore, it is a challenging issue for researchers
and clinicians, including manual therapists. Over the past decades,
scientific understanding of chronic musculoskeletal pain has
increased substantially. It is now well established that the biomedical
model falls short in explaining and treating chronic musculoskeletal
* Corresponding author. Vrije Universiteit Brussel, Building L-Mfys, Pleinlaan 2,
BE-1050 Brussels, Belgium. Tel.: þ32 26291154; fax: þ32 26292876.
E-mail address: Jo.Nijs@vub.ac.be (J. Nijs).
URL: http://www.chropiver.be
musculoskeletal dysfunctions are unable to fully explain the complex
clinical picture of pain complaints, disability and distress (Yunus,
2007; Sterling and Kenardy, 2008). Hence, a biopsychosocial
approach to the clinical assessment and treatment is required. More
specifically, evidence from published randomized controlled trials
addressing rehabilitation of chronic musculoskeletal pain has
revealed that self-efficacy, depression, pain catastrophizing and
physical activity should be the primary treatment targets for patients
with chronic musculoskeletal pain (Miles et al., 2011).
In contrast to the increasing evidence for the biopsychosocial
model for chronic musculoskeletal pain (e.g. Guzmán et al., 2001;

1356-689X/$ e see front matter Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2012.11.001
 Author's personal copy
J. Nijs et al. / Manual Therapy 18 (2013) 96e102
Hoffman et al., 2007; Foster et al., 2010; Pool et al., 2010), the
majority of clinicians have received a biomedical-focused training/
education. The biomedical focus applies in part to the manual
therapy profession as well, with a long history of biomechanical-
focused treatments. Such a biomedical training is likely to shape
the therapists’ attitudes and core beliefs toward chronic musculo-
skeletal pain, as evidenced by a randomized trial comparing
biomedical versus biopsychosocial training about low back pain in
physiotherapy students (Domenech et al., 2011).
On the other hand, many musculoskeletal therapists have
moved on in their thinking and apply a broad biopsychosocial view
with regard to chronic pain disorders. Likewise, an increasing
number of musculoskeletal physiotherapy/manual therapy
curricula emphasize the biopsychosocial model, and teach behav-
ioral treatments in addition to hands-on treatment. Manual
therapy journal has contributed substantially to this development:
a large number of published studies and review articles advocate
a broader view to musculoskeletal pain (e.g. Ostelo et al., 2003;
Sterling and Kenardy, 2008; Nijs et al., 2011a; Mutsaers et al., 2012).
In case the therapist holds strong biomedical beliefs regarding
chronic musculoskeletal pain (e.g. chronic low back pain is solely
due to instability of the lumbar spine, improper lifting of heavy
objects or poor posture; manual therapy for chronic whiplash
associated disorders patients should comprise of hands-on muscle
and cervical joint treatment solely), the patient will adopt these
beliefs accordingly. Indeed, there is ample evidence that the ther-
apists’ attitudes and beliefs regarding musculoskeletal pain are
associated with the beliefs of their patients and the clinical
management (i.e. the nature of the treatment provided) (Darlow
et al., 2012). Therapists with a biomedical orientation are more
likely to advise patients to limit physical activities and work,
implying that they ‘teach’ their patients to become fear-avoidant
(Houben et al., 2005a; Holden et al., 2009; Darlow et al., 2012).
Such therapists will unlikely adhere to evidence-based guidelines
for the treatment of chronic musculoskeletal pain (Darlow et al.,
2012). Likewise, the attitudes and beliefs of general practitioners
toward chronic knee pain and knee osteoarthritis are related to the
underuse of exercise in the management of these patients,
including the low physiotherapy referral (Cottrell et al., 2010).
Taken together, musculoskeletal therapists should be aware of
the impact of their own attitudes and beliefs on patient’s attitudes
and beliefs. It should be noted that many patients hold strong
biomedical views on chronic musculoskeletal pain even before
their first visit to their physician or therapist. As patient’s attitudes
and beliefs influence treatment adherence (Nicklas et al., 2010),
musculoskeletal therapists should become aware that focusing on
the biomedical model for chronic musculoskeletal pain is likely to
result in poor compliance with evidence based treatment guide-
lines, less treatment adherence, and poorer treatment outcome
(especially in terms of functional recovery). For instance, research
has taught us that treatment expectancy and credibility are of
prognostic value to rehabilitation outcome in patients with chronic
low back pain (Smeets et al., 2008). The therapists’ beliefs and
attitudes account for the communication between the therapist
and patient, including patient education, which in turn modulates
treatment expectancy and credibility. The expectancy and credi-
bility beliefs can be positively influenced by the therapist, but
focusing on the biomedical model will result in inadequate illness
perceptions in patients, which in turn leads to more negative initial
responses to patients (van Wilgen et al., 2012).
So how can musculoskeletal therapists improve their care
provided to patients with chronic musculoskeletal pain? How can
musculoskeletal therapists improve their compliance with inter-
national guidelines for the treatment of chronic musculoskeletal
pain? Here, we provide clinicians with a 5-step approach toward
97
Fig. 1. 5-Step approach toward accounting for the therapist’s (T) and patient’s (P)
beliefs and attitudes regarding chronic musculoskeletal pain in clinical practice.
effective and evidence-based care for patients with chronic
musculoskeletal pain (Fig. 1). In what follows it is important to
realise that the biopsychosocial model implies integrated clinical
reasoning with respect to biological as well as psychological and
social factors. The biopsychosocial model should not be used to
ignore biomedical factors.
1.1. Self-reflection as a starting point for clinicians treating patients
with chronic musculoskeletal pain
Self-reflection is required for the musculoskeletal health care
professionals, even for those who have moved on in their thinking.
Indeed, it has been demonstrated that previous (biomedical
oriented) treatment by physiotherapists is a risk factor for long-
term sick leave in patients with low back pain (Reme et al.,
2009). This is remarkable and requires self-reflection from all
musculoskeletal therapists treating low back pain patients. It is
crucial to analyze the convictions of the therapists that shape their
behavior toward the chronic musculoskeletal pain patient and the
information provided to patients (Laekeman and Basler, 2008),
especially because physiotherapists’ attitudes toward musculo-
skeletal pain has been shown to be predictive of their treatment
recommendations (Houben et al., 2005b).
Self-reflection is the first and crucial aspect of the 5-step
approach. Broadening the illness beliefs of the therapist from
a pure biomedical toward a biopsychosocial perspective is likely to
contribute to further improvement of therapeutic strategies and to
an improved outcome (Laekeman and Basler, 2008), especially for
the treatment of chronic pain. In fact, even manual therapists who
learned about the biopsychosocial model might not totally agree
with this perspective and might continue preferring treatments
based on the biomedical model (Laekeman and Basler, 2008).
Hence, it is advocated that all clinicians take this first step. Within
this scope it is important to understand that the biopsychosocial
model broadens our understanding of musculoskeletal pain, rather
than replacing the biomedical model. Biological issues are included
in the biopsychosocial model as well; the biopsychosocial model
does not imply ignoring biological factors.
Musculoskeletal therapists can easily self-assess their own
attitudes and beliefs regarding chronic musculoskeletal pain by
filling out self-reported measures themselves. Ruminating about
pain and hypervigilance to somatic signs can be easily assessed
with short self-reported measures with excellent psychometric
properties (e.g. the Pain Catastrophizing Scale,1 Pain Vigilance and
Awareness Questionnaire,2 etc.) (Sullivan et al., 1995; Van Damme
et al., 2002; Kraaimaat and Evers, 2003). These questionnaires,
validated on patients, should be filled out by the therapist
1
http://synergytherapiesofkc.com/forms/PCS-Pain%20Catastrophizing%20Scale.
pdf.
2
The questionnaire can be obtained in the original publications of the measure.
 Author's personal copy
98 J. Nijs et al. / Manual Therapy 18 (2013) 96e102
imagining he/she is experiencing musculoskeletal pain. Scoring
and interpretation is identical as applied in patients (e.g. higher
scores on the Pain Catastrophizing Scale and Pain Vigilance and
Awareness Questionnaire reflect more catastrophic thoughts and
pain hypervigilance, respectively). Alternatively, one can use the
Photograph Series of Daily Activities (PHODA), an instrument to
determine the perceived harmfulness of daily activities in patients
with chronic pain (Leeuw et al., 2007a; Trost et al., 2009).
In addition, musculoskeletal therapists can fill out specific
measures for assessing the therapist’s beliefs and attitudes regarding
chronic pain (management). The Pain Attitudes and Beliefs Scale for
Physiotherapists (PABS-PT3) is specifically designed for that purpose.
It is a self-reported measure that discriminates between a biomed-
ical and a biopsychosocial orientation of therapists with regard to
low back pain management. Each item is scored on a six-point Likert
scale that ranges from totally disagree (score 1) to totally agree
(score 6). For example, a high score on the item ‘Increased pain
indicates new tissue damage or the spread of existing damage’
indicates a biomedical orientation. Agreeing with the item ‘Mental
stress can cause back pain even in the absence of tissue damage’
suggests a biopsychosocial orientation. The PABS-PT is available in
several languages (e.g. English, German, Dutch, Brazilian-Portugese)
and appears to generate reliable and valid data (Ostelo et al., 2003;
Laekeman and Basler, 2008; Magalhães et al., 2011; Mutsaers et al.,
2012). Alternatively, one can use the Health Care Providers’ Pain
and Impairment Relationship Scale (HC-PAIRS) for a valid assess-
ment of attitudes and beliefs of therapists about functional expec-
tation for chronic low back pain patients (Rainville et al., 1995).
The PABS-PT was able to show that physiotherapists in response
to a 2-day training program obtained a more biopsychosocial
orientation, and a decreased biomedical orientation toward the
treatment of neck pain (Vonk et al., 2009). Still, self-report can be
questioned for the measurement of attitudes and beliefs: therapists
who report complying with certain therapeutic guidelines, do not
per se adhere to these during daily practice. A short training program
of 2e3 days (which are common) is unlikely to result in a long-term
behavioral change of the therapist. It requires time, experiences and
specific feedback on personal performance. Likewise, 4 half days of
training in cognitive behavioral therapy did not alter general prac-
titioners’ knowledge and attitudes at six month follow-up (King
et al., 2002). Similar observations were done in a Swedish study,
showing that an 8-day university course for physiotherapists did not
improve outcome in pain patients (Overmeer et al., 2011). However,
the outcome did improve for patients who had a risk of developing
long-term disability and had higher levels of catastrophizing or
depression, but only if the attitudes and beliefs of their therapists
changed during the course (Overmeer et al., 2011).
In case such self-reflection reveals a biomedical orientation, the
musculoskeletal physiotherapist is advised to consult relevant
scientific literature addressing the biopsychosocial nature of chronic
musculoskeletal pain (e.g. Leeuw et al., 2007b; Henschke et al., 2010;
den Hollander et al., 2010; Hassett and Williams, 2011), including its
biopsychosocially-driven treatment (Fig. 2). Next, the therapist with
biomedical orientation is advised to enter a training program for
evidence-based management of chronic musculoskeletal pain.
1.2. Assessment of attitudes and beliefs in patients with chronic
musculoskeletal pain
Once the therapist holds evidence-based attitudes and beliefs
regarding chronic musculoskeletal pain, he/she will likely include
patients’ attitudes and beliefs in his/her standard assessment for
3 4
The questionnaire can be obtained in the appendix of Ostelo et al. (2003).
Fig. 2. Self-reflection for musculoskeletal therapists treating patients with chronic
musculoskeletal pain.
examining chronic musculoskeletal pain patients. This can be
accomplished by in-depth questioning of the patient (interview). If
warranted, the abovementioned measures can be used by clinicians
to assess pain cognitions. For examining fear-avoidant beliefs, one
can use the Tampa Scale Kinesiophobia (Vlaeyen et al., 1995) or the
Fear Avoidance Beliefs Questionnaire (Waddell et al., 1993), espe-
cially for assessing chronic low back pain patients (both measures
are less suited for assessing patients with chronic pain in the neck or
in peripheral joints). Besides these specific questionnaires, broader
ones like the Örebro Musculoskeletal Pain Screening Questionnaire
enable assessing a combination of psychosocial predictors for
chronicity, as shown extensively in studies exploring the predictive
capacity of this measure for chronicity in acute low back pain (Gabel
et al., 2011; Sattelmayer et al., 2012; Nonclercq and Berquin, 2012).
In addition, the patients’ perceptions about their medical
problem are of prime importance for guiding the educational part
of the treatment, as evidenced by a large prospective cohort study
of low back pain patients seen in primary care (Foster et al., 2010).
The study revealed that patients’ perceptions that the problem will
last long, that many symptoms are related to their back problem,
their weak beliefs about self-control and low confidence in their
own ability to perform activities despite the pain, were even better
predictors of disability at 6 months than fear avoidance, cata-
strophizing or depression (Foster et al., 2010).
In daily practice, illness perceptions can be questioned or
assessed by use of the brief Illness Perception Questionnaire4
(Broadbent et al., 2006). Illness perceptions reflect the patient’s
personal understanding of the illness in terms of identity, cause,
time-line, consequences, personal control, and care and cure of
their pain (Leventhal et al., 2003). Illness perceptions are based on
former experiences and provided information. When the cause,
course and consequences of an illness are indistinct, patients
typically have negative beliefs about their illness. Negative illness
perceptions in chronic pain patients are associated with malad-
aptive illness behavior, dysfunctioning, poor treatment adherence
and treatment outcome. For instance, the perception of constant
back strain when working, and negative expectations for return to
work, are important predictors (odds ratio’s > 4) for not returning
to work in patients with low back pain (Reme et al., 2009).
http://www.uib.no/ipq/.
 Author's personal copy
J. Nijs et al. / Manual Therapy 18 (2013) 96e102
Conversely, adequate pain beliefs lead to increased confidence,
which in turn leads to increased activity levels. The information,
addressing pain perceptions and coping strategies, should be used
by the therapist to tailor the individual education sessions (see
below). Education and counseling are capable of adjusting negative
illness perceptions in patients with chronic musculoskeletal pain.
1.3. Clinical reasoning including reconceptualizations
As is the case with the therapists’ attitudes and beliefs about
chronic musculoskeletal pain, patients can have a biological or
biopsychosocial orientation toward chronic musculoskeletal pain.
For example, a patient with chronic whiplash associated disorders
is convinced that the initial neck trauma caused severe cervical
damage that remains invisible to modern imaging methods.
Another patient with moderate hip osteoarthritis believes that hip
cartilage “is melting away due to erosion” (i.e. a biomedical illness
perception e dimension cause). Such a patient holds the following
beliefs regarding treatment: “I will not participate in exercise
therapy because it will worsen my hip pain and hence the erosion
of my cartilage” (fear avoidance beliefs and dimension care and
cure of illness perceptions). It is clear that initiating a treatment like
graded activity, which targets active behavior rather than pain
relief and uses a time-contingent approach to physical activity, is
unlikely to be successful in patients with inappropriate illness
perceptions. Prior to commencing treatment in such cases the gap
between the perceptions of the patient and the health care
professional about pain and its treatment should be narrowed.
Therefore, it is crucial to reconceptualize pain before initiating the
treatment. This can be accomplished by patient education (Nijs
et al., 2011a) or cognitive treatment of illness perceptions
(Siemonsma et al., 2010).
Some patients do have a biopsychosocial orientation toward
their chronic musculoskeletal pain problem. Even then, education
is warranted to complete their understanding of the disorder and to
improve their attitudes toward the treatment. For instance,
a patient with chronic shoulder pain with a biopsychosocial
orientation toward his medical problem may have very low
expectations of a positive treatment outcome. Then the therapist
should invest time in educating the patient about the expectations
for care, in order to change the maladaptive perception of a nega-
tive treatment outcome.
Another example relates to social support provided by the
significant other. Some patients with a broad biopsychosocial view
on their pain problem are unaware of the importance of social
support for recovery. Social support is often of prognostic value for
recovery in patients with musculoskeletal pain (e.g. Buitenhuis
et al., 2003; Nijs et al., 2011b), including return to work. If
a patient’s husband is convinced that the medical committee
should provide a drug or surgical treatment for handling his wife’s
chronic pain problem, then he is unlikely to support a bio-
psychosocially-driven rehabilitation program. This will in turn
negatively impact upon rehabilitation outcome. Hence, discussing
the issue of social support with the patient can be of prime
importance for enhancing social support throughout the treatment
period and beyond (e.g. the patient may become motivated to
involve a significant other in the treatment).
2. Education
Education is a powerful tool in clinical practice. Beside the
specific content of the education it also requires specific skills. Fig. 3
provides a diagram summarizing the major steps clinicians should
take when providing patient education according to modern peda-
gogy. Addressing the content of the education, pain (neuro)
99
physiology education has been studied extensively in a variety of
chronic musculoskeletal pain disorders (e.g. chronic low back pain,
chronic whiplash associated disorders, fibromyalgia), with nothing
but positive results (Louw et al., 2011). It requires an in-depth
education of altered central nervous system processing of nocicep-
tive and non-nociceptive input. Pain physiology education addresses
maladaptive cognitions and illness perceptions. The innovative
aspect of pain physiology education is the use of neurophysiology
(i.e. the mechanism of central sensitization) to change the percep-
tions about pain and how to cope with it. This makes it appropriate
even for cases reluctant to the biopsychosocial model. For practice
guidelines, the readers are referred to Nijs et al. (2011a).
The specific skills required to educate patients are mostly
communication skills. Of importance here is that a Socratic-style
dialogue of education (Siemonsma et al., 2008) is preferred over
‘lecturing’ to the patient. The therapist activates the patients’
thoughts processes by naïvely questioning about illness percep-
tions and potential strategies for improving health (Siemonsma
et al., 2008). This approach is in line with motivational interview-
ing. When combined with physiotherapy, motivational interview-
ing improves motivational factors and treatment outcomes in
people with low back pain (Vong et al., 2011).
Another innovative approach which can be used by muscu-
loskeletal physiotherapists to change illness perceptions and
hence behavior is psychological inoculation, a method targeting
barriers for behavioral change (Farchi and Gidron, 2010). In
psychological inoculation, the therapist introduces the technique
by explaining that he/she will provide the patient with a number
of challenging statements addressing cognitive barriers for not
adopting healthy behavior (the ‘vaccine’). The patient is asked to
reject (the ‘antibody’) the statement, and at the same time to
motivate the rejection of the statement. In a chronic whiplash
patient having poor expectations for treatment outcome, the
therapist provides the following statement: “I am certain that you
feel that on this planet, there isn’t a single way to improve your
health status”. The patient is likely to reject such a statement, and
is guided toward speaking out loud about the (small) light at the
end of the tunnel. As is the case with the Socratic-style dialogue
of education, psychological education guides the patient toward
finding the solution for their health issues themselves. As
opposed to having the therapist ‘teach’ the patient what to do,
this might be a more powerful way of changing the patient’s
behavior (e.g. increasing physical activity).
In addition to (or together with) pain physiology education,
musculoskeletal therapists can educate their chronic pain patients
about aspects of the biopsychosocial model. For instance, the fear-
avoidance model (Leeuw et al., 2007b) can be used to educate fear-
avoidant patients and to open the path for effective (graded
activity) treatment. Alternatively, a patient with persistent
behavior regarding physical activity (continuing a high level of
physical activity in spite of physical limitations) can gain increased
understanding of their pain disorder by understanding the basic
principles of self-discrepancies (Waters et al., 2004; Huijnen et al.,
2011). In case of persistent behavior, the patients’ evaluation of
their actual self is likely to differ from their view of who he/she
ideally would like to be (ideal self) or feel he/she ought to be (ought
self), or from the patients’ perceptions of how significant others
wish they could be (ideal-other self) or ought to be (ought-other
self) (Waters et al., 2004; Huijnen et al., 2011).
In line with the education, it is important to address the
perpetuating factors for chronicity throughout the treatment.
Factors like pain catastrophizing, self-efficacy, depressive thoughts
and physical inactivity are some out of the many important
psychosocial factors known to perpetuate chronic musculoskeletal
pain.
 Author's personal copy

100 J. Nijs et al. / Manual Therapy 18 (2013) 96e102

Fig. 3. Individually tailored patient education for those with having chronic musculoskeletal pain.

3. Therapy community agrees that treatment should be biopsychosocial in

Education is typically followed by various components of
a patient-tailored biopsychosocial rehabilitation program, like
stress self-management, graded activity and exercise therapy
(Fig. 3). These and other treatments target the abovementioned
perpetuating factors. A detailed description of such a rehabilitation
program is beyond the scope of this paper, but some issues in
relation to the therapists’ and patients’ attitudes and beliefs are
pointed out here.
First, it is important for clinicians to introduce these treatment
components during the educational sessions, and to explain why
and how the various treatment components are likely to contribute
to recovery. Second, even though the scientific and medical
nature, there is currently no gold standard for the rehabilitation of
all chronic musculoskeletal pain patients. Effectiveness may
depend on the personal characteristics of each patient i.e. his/her
coping strategy with pain. For a heterogenic population like chronic
low back pain no specific type of behavioral therapy is more
effective than another, and there is little or no difference between
behavioral therapy and group exercises for improving pain or
depressive symptoms (Henschke et al., 2010). So active treatment
should correspond with the patient’s individual coping strategies.
Third, exercise therapy is frequently encountered as a central
component of the treatment of patients with chronic musculo-
skeletal pain. Exercise is an effective treatment for various chronic
musculoskeletal pain disorders, including chronic low back pain
 Author's personal copy
J. Nijs et al. / Manual Therapy 18 (2013) 96e102
(van Middelkoop et al., 2010), chronic whiplash associated disor-
ders (Stewart et al., 2007; Teasell et al., 2010), osteoarthritis (Jansen
et al., 2011), and fibromyalgia (Brosseau et al., 2008). Although the
clinical benefits of exercise therapy in these populations are well
established (i.e. evidence based), it should be integrated in
a patient-tailored biopsychosocial rehabilitation program rather
than applied as a stand-alone treatment (e.g. a time-contingent
approach to exercise therapy should be applied). Interventions
such as supervised or individualized exercise therapy and self-
management techniques enhance exercise adherence (Jordan
et al., 2010), and improve self-efficacy, which is one of the main
predictors of treatment outcome for patients with chronic
musculoskeletal pain (Miles et al., 2011).
Fourth, musculoskeletal therapists should be aware of the
potential danger of applying pain contingent stabilization exer-
cises in patients with chronic musculoskeletal pain. Rehabilitation
strategies focusing on nothing else but stabilization exercises for
those with chronic musculoskeletal pain contradict our current
understanding of painemotor interactions (Nijs et al., 2012), and
do not comply with a biopsychosocial approach to chronic
musculoskeletal pain. Indeed, stabilization exercises rely on a pure
biomedical explanation for musculoskeletal pain. It is advocated to
be cautious with stabilization exercises when patients have
moderate or high fear of movement, as such therapy might trigger
more (kinesio)phobic (“I have to keep my back always stable and I
am therefore not allowed to move my back”) and catastrophic
thoughts (e.g. “If I do not continuously activate my stabilization
muscles, my back will be prone to severe injuries.”). Pain-
contingent stabilization exercises are less suited for patients with
a biomedical orientation, but time-contingent stabilization exer-
cises can be integrated in a biopsychosocial treatment program,
comprising of various components like stress management,
education, and activity self-management.
4. Conclusion
Although many musculoskeletal therapists have moved on in
their thinking and apply a broad biopsychosocial view with regard
to chronic pain disorders, the majority have received a biomed-
ical-focused training/education. Such a training shapes the ther-
apists’ attitudes and core beliefs toward chronic musculoskeletal
pain. Therapists should be aware of the impact of their own
attitudes and beliefs on the patients’ attitudes and beliefs, which
in turn affects patients’ behavior and treatment adherence. Self-
reflection is the first and crucial step: musculoskeletal therapists
can easily self-assess their attitudes and beliefs regarding chronic
musculoskeletal pain using valid questionnaires. When such self-
reflection reveals a biomedical orientation, the musculoskeletal
physiotherapist is advised to consult relevant scientific literature
addressing the biopsychosocial nature of chronic musculoskeletal
pain, and to enter a training program for evidence-based
management of chronic musculoskeletal pain. Knowing about
and changing non-favorable cognitions of the therapist is likely to
contribute to further improvement of therapeutic strategies and
to an improved outcome (Laekeman and Basler, 2008). Still,
a behavioral change of therapists is difficult to achieve and typi-
cally requires time.
Once the therapist holds evidence-based attitudes and beliefs
regarding chronic musculoskeletal pain, assessing the patients’
attitudes and beliefs will be the natural next step. Such information
can then be integrated in the clinical reasoning process, which
results in individually-tailored treatment programs that specifically
address the patients’ attitudes and beliefs in order to improve
treatment adherence and outcome.
101
References
Broadbent E, Petrie KJ, Main J, Weinman J. The brief illness perception question-
naire. Journal of Psychosomatic Research 2006;60:631e63.
Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz C-J, et al. Ottawa
panel evidence-based clinical practice guidelines for aerobic fitness exercises in
the management of fibromyalgia: Part 1. Physical Therapy 2008;88:857e71.
Buitenhuis MD, Spanjer J, Fidler V. Recovery from acute whiplash: the role of coping
styles. Spine 2003;28(9):896e901.
Cottrell E, Roddy E, Foster NE. The attitudes, beliefs and behaviours of GPs regarding
exercise for chronic knee pain: a systematic review. BMC Family Practice 2010;
18(11):4.
Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association
between health care professional attitudes and beliefs and the attitudes and
beliefs, clinical management, and outcomes of patients with low back pain:
a systematic review. European Journal of Pain 2012;16:3e17.
den Hollander M, de Jong JR, Volders S, Goossens MEJB, Smeets RJEM, Vlaeyen JWS.
Fear reduction in patients with chronic pain: a learning theory perspective.
Expert Reviews Neurotherapeutics 2010;10:1733e45.
Domenech J, Sánchez-Zuriaga D, Segura-Ortí E, Espejo-Tort B, Lisón JF. Impact of
biomedical and biopsychosocial training sessions on the attitudes, beliefs, and
recommendations of health care providers about low back pain: a randomized
clinical trial. Pain 2011;152:2557e63.
Farchi M, Gidron Y. The effects of “psychological inoculation” versus ventilation on
the mental resilience of Israeli citizens under continuous war stress. Journal of
Nervous and Mental Disease 2010;198(5):382e4.
Foster NE, Thomas E, Bishop A, Dunn KM, Main CJ. Distinctiveness of psychological
obstacles to recovery in low back pain patients in primary care. Pain 2010;
148(3):398e406.
Gabel CP, Melloh M, Yelland M, Burkett B, Roiko A. Predictive ability of a modified
Örebro Musculoskeletal Pain Questionnaire in an acute/subacute low back pain
working population. European Spine Journal 2011;20(3):449e57.
Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidis-
ciplinary rehabilitation for chronic low back pain: systematic review. British
Medical Journal 2001;322(7301):1511e6.
Hassett AL, Williams DA. Non-pharmacological treatment of chronic widespread
musculoskeletal pain. Best Practice and Research in Clinical Rheumatology
2011;25(2):299e309.
Henschke N, Ostelo RW, van Tulder MW, Vlaeyen JW, Morley S, Assendelft WJ, et al.
Behavioural treatment for chronic low-back pain. Cochrane Database of
Systematic Reviews 2010;7(7):CD002014.
Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological
interventions for chronic low back pain. Health Psychology 2007;26:1e9.
Holden MA, Nicholls EE, Young J, Hay EM, Foster NE. UK-based physical therapists’
attitudes and beliefs regarding exercise and knee osteoarthritis: findings from
a mixed-methods study. Arthritis and Rheumatism 2009;61:1511e21.
Houben RMA, Ostelo RWJG, Vlaeyen JWS, Wolters PMJC, Peters M, Stomp-van den
Berg SGM. Health care providers’ orientations towards common low back pain
predict perceived harmfulness of physical activities and recommendations
regarding return to normal activity. European Journal of Pain 2005a;9:173e83.
Houben RMA, Gijsen A, Peterson J, de Jong PJ, Vlaeyen JWS. Do health care
providers’ attitudes towards back pain predict their treatment recommenda-
tions? Differential predictive validity of implicit and explicit attitude measures.
Pain 2005b;114:491e8.
Huijnen IP, Kindermans HP, Seelen HA, Peters ML, Smeets RJ, Serroyen J, et al. Effects of
self-discrepancies on activity-related behaviour: explaining disability and quality
of life in patients with chronic low back pain. Pain 2011;152(9):2165e72.
Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA. Strength training
alone, exercise therapy alone, and exercise therapy with passive manual
mobilisation each reduce pain and disability in people with knee osteoarthritis:
a systematic review. J Physiother 2011;57(1):11e20.
Jordan JL, Holden MA, Mason EE, Foster NE. Interventions to improve adherence to
exercise for chronic musculoskeletal pain in adults. Cochrane Database Systematic
Reviews 2010;1. http://dx.doi.org/10.1002/14651858.CD005956.pub2. CD005956.
Kraaimaat FW, Evers AWM. Pain-coping strategies in chronic pain patients:
psychometric characteristics of the pain-coping inventory. Journal of Behavioral
Medicine 2003;10(4):343e63.
King M, Davidson O, Taylor F, Haines A, Sharp D, Turner R. Effectiveness of teaching
general practitioners skills in brief cognitive behaviour therapy to treat patients
with depression: randomised controlled trial. British Medical Journal 2002;
324(7343):947e50.
Laekeman MALE, Basler HD. The pain attitudes and beliefs scale for physiothera-
pists: psychometric properties of the German version. Clinical Rehabilitation
2008;22:564e75.
Leeuw M, Goossens ME, van Breukelen GJ, Boersma K, Vlaeyen JW. Measuring
perceived harmfulness of physical activities in patients with chronic low back
pain: the Photograph Series of Daily Activitieseshort electronic version. Journal
of Pain 2007a;8(11):840e9.
Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-
avoidance model of musculoskeletal pain: current state of scientific evidence.
Journal of Behavioral Medicine 2007b;30(1):77e94.
Leventhal H, Brisette I, Leventhal E. The common-sense model of self-regulation of
health and illness. In: Cameron L, Leventhal H, editors. The self-regulation of
health and illness behavior, vol. 3. London: Routledge; 2003. p. 42e65.
 Author's personal copy
102 J. Nijs et al. / Manual Therapy 18 (2013) 96e102
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on
pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of
Physical Medicine and Rehabilitation 2011;92(12):2041e56.
Magalhães MO, Costa LOP, Ferreira ML, Machado LAC. Clinimetric testing of two
instruments that measure attitudes and beliefs of health care providers about
low back pain. Revista Brasileira de Fisioterapia 2011;15:249e56.
Miles CL, Pincus T, Carnes D, Homer KE, Taylor SJC, Bremner SA, et al. Can we
identify how programmes aimed at promoting self-management in musculo-
skeletal pain work and who benefits? A systematic review of sub-group analysis
within RCTs. European Journal of Pain 2011;15:775e82.
Mutsaers J-HAM, Peters R, Pool-Goudzwaard AL, Koes BW, Verhagen AP. Psycho-
metric properties of the pain attitudes and beliefs scale for physiotherapists:
a systematic review. Manual Therapy 2012;17:213e8.
Nonclercq O, Berquin A. Predicting chronicity in acute back pain: validation of
a French translation of the Örebro Musculoskeletal Pain Screening Ques-
tionnaire. Annals of Physical and Rehabilitation Medicine 2012;55(4):
263e78.
Nicklas LB, Dunbar M, Wild M. Adherence to pharmacological treatment of non-
malignant chronic pain: the role of illness perceptions and medication
beliefs. Psychology and Health 2010;25(5):601e15.
Nijs J, van Wilgen CP, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain
central sensitization to patients with ‘unexplained’ chronic musculoskeletal
pain: practice guidelines. Manual Therapy 2011a;16:413e8.
Nijs J, Inghelbrecht E, Daenen L, Hachimi-Idrissi S, Hens L, Willems B, et al. Long-
term functioning following whiplash injury: the role of social support and
personality traits. Clinical Rheumatology 2011b;30:927e35.
Nijs J, Daenen L, Cras P, Struyf F, Roussel N, Oostendorp R. Pain affects motor output:
a review on sensory-motor interaction with focus on clinical implications.
Clinical Journal of Pain 2012;28(2):175e81.
Ostelo RWJG, Stomp-van den Berg SGM, Vlaeyen JWS, Woltersy PMJC, de Vet HCW.
Health care provider’s attitudes and beliefs towards chronic low back pain: the
development of a questionnaire. Manual Therapy 2003;8:214e22.
Overmeer T, Boersma K, Denison E, Linton SJ. Does teaching physical therapists to
deliver a biopsychosocial treatment program result in better patient outcomes?
A randomized controlled trial. Physical Therapy 2011;91(5):804e19.
Pool JJ, Ostelo RW, Knol DL, Vlaeyen JW, Bouter LM, de Vet HC. Is a behavioral
graded activity program more effective than manual therapy in patients with
subacute neck pain? Results of a randomized clinical trial. Spine 2010;35(10):
1017e24.
Rainville J, Bagnall D, Phalen L. Health care providers’ attitudes and beliefs about
functional impairments and chronic back pain. Clinical Journal of Pain 1995;
11(4):287e95.
Reme SE, Hagen EM, Eriksen HR. Expectations, perceptions, and physiotherapy
predict prolonged sick leave in subacute low back pain. BMC Musculoskeletal
Disorders 2009;10:139. http://dx.doi.org/10.1186/1471-2474-10-139.
Sattelmayer M, Lorenz T, Röder C, Hilfiker R. Predictive value of the acute low back
pain screening questionnaire and the Örebro musculoskeletal pain screening
questionnaire for persisting problems. European Spine Journal 2012;(Suppl. 6):
S773e84.
Siemonsma PC, Schröder CD, Roorda LD, Lettinga AT. Benefits of treatment theory in
the design of explanatory trials: cognitive treatment of illness perceptions in
chronic low back pain rehabilitation as an illustrative example. Journal of
Rehabilitation Medicine 2010;42:111e6.
Siemonsma PC, Schröder CD, Dekker JHM, Lettinga AT. The benefits of theory for
clinical practice: cognitive treatment for chronic low back pain patients as an
illustrative example. Disability and Rehabilitation 2008;30:1309e17.
Smeets RJEM, Beelen S, Goossens MEJB, Schouten EGW, Knottnerus JA, Vlaeyen JWS.
Treatment expectancy and credibility are associated with the outcome of both
physical and cognitive behavioral treatment in chronic low back pain. Clinical
Journal of Pain 2008;24:305e15.
Sterling M, Kenardy J. Physical and psychological aspects of whiplash: important
considerations for primary care assessment. Manual Therapy 2008;13:93e102.
Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M.
Randomized controlled trial of exercise for chronic whiplash-associated disor-
ders. Pain 2007;128(1e2):59e68.
Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and
validation. Psychological Assessment 1995;7:524e32.
Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, et al. A research
synthesis of therapeutic interventions for whiplash-associated disorder (WAD):
part 4-noninvasive interventions for chronic WAD. Pain Research & Manage-
ment 2010;15(5):313e22.
Trost Z, France CR, Thomas JS. Examination of the photograph series of daily
activities (PHODA) scale in chronic low back pain patients with high and low
kinesiophobia. Pain 2009;141(3):276e82.
Van Damme S, Crombez G, Bijttebier P, Goubert L, Van Houdenhove B.
A confirmatory factor analysis of the Pain Catastrophizing Scale: invariant factor
structure across clinical and non clinical populations. Pain 2002;96:319e24.
van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van
Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best
Practice & Research Clinical Rheumatology 2010;24(2):193e204.
van Wilgen CP, Koning M, Bouman TK. Initial responses of different health care
professionals to various patients with headache: which are perceived as difficult.
International Journal of Behavioral Medicine 2012 Apr 3 [Epub ahead of print].
Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)
injury in chronic low back pain and its relation to behavioral performance. Pain
1995;62:363e72.
Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in
addition to physical therapy improves motivational factors and treatment
outcomes in people with low back pain: a randomized controlled trial. Archives
of Physical Medicine and Rehabilitation 2011;92(2):176e83.
Vonk F, Pool JJ, Ostelo RW, Verhagen AP. Physiotherapists’ treatment approach
towards neck pain and the influence of a behavioural graded activity training:
an exploratory study. Manual Therapy 2009;14(2):131e7.
Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs
Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back
pain and disability. Pain 1993;52(2):157e68.
Waters SJ, Keefe FJ, Strauman TJ. Self-discrepancy in chronic low back pain: relation
to pain, depression, and psychological distress. Journal of Pain and Symptom
Management 2004;27(3):251e9.
Yunus MB. Role of central sensitization in symptoms beyond muscle pain, and the
evaluation of a patient with widespread pain. Best Practice and Research
Clinical Rheumatology 2007;21:481e97.