Psychologically Informed Practice for Management

of Low Back Pain: Future Directions in Practice and

Research
Chris J. Main and Steven Z. George
PHYS THER. 2011; 91:820-824.
Originally published online March 30, 2011
doi: 10.2522/ptj.20110060

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 Psychologically Informed Practice
C.J. Main, PhD, FBPsS, is Professor
of Clinical Psychology (Pain Man-
agement), Arthritis Research UK
Primary Care Centre, Keele Uni-
versity, Keele, Staffordshire,
United Kingdom. Mailing address:
Calderbank Research Unit, 87 Pal-
atine Rd, West Didsbury, Man-
chester M20 3JQ, United King-
dom. Address all correspondence
to Professor Main at: cjmain@
gmail.com.
S.Z. George, PT, PhD, is Associate
Professor and Assistant Depart-
ment Chair, Department of Phys-
ical Therapy, Center for Pain
Research and Behavioral Health,
University of Florida, PO Box
100154, Gainesville, FL 32610-
0154 (USA). Address all corre-
spondence to Dr George at:
szgeorge@phhp.ufl.edu.
[Main CJ, George SZ. Psychologi-
cally informed practice for man-
agement of low back pain: future
directions in practice and
research. Phys Ther. 2011;91:
820 – 824.]
© 2011 American Physical Therapy
Association
Post a Rapid Response to
this article at:
ptjournal.apta.org
820 f Physical Therapy Volume 91 Number 5
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Psychologically Informed Practice for
Management of Low Back Pain: Future
Directions in Practice and Research
Chris J. Main, Steven Z. George
In this perspective article, a number of conclusions and recommendations are offered
based on the articles in this special issue of PTJ. In this special issue, a new approach
to physical therapy, termed “psychologically informed practice,” is offered as a
“middle way” between narrowly focused standard physical therapist practice based
on biomedical principles and the more cognitive-behavioral approaches developed
originally for the treatment of mental illness. This new approach uses the “flags”
framework, with psychologically informed practice requiring routine and specific
consideration of “yellow flags” and “blue flags” (depending on clinical setting) for
determining risk of poor outcome and identifying the potential for treatment modi-
fication— but with cognizance of the overall environment or context in which the
clinician must operate. This context includes professional culture, health care policy,
and insurance reimbursement (potential “black flags”). The primary goal of this
approach is to prevent the development of unnecessary pain-associated activity
limitations. The approach is based on the identification of normal psychological
processes that affect the perception of pain and the response to it as an expected and
normal part of the musculoskeletal pain experience and that are potentially modifi-
able. The potential for linking risk identification with targeted treatment has been
discussed, this article focuses on the potential implications for training and imple-
mentation, drawing on experience in developing training programs in which the
trainees have welcomed this new approach, viewing it as a helpful extension of their
basic professional training. Indeed, this new approach can be viewed as evolutionary
rather than revolutionary, in that it builds upon the established professional expertise
of physical therapists, but incorporates systematic attention to the psychosocial
factors that are associated with outcome of treatment.
May 2011

I
n most health care systems, phys-
ical therapists are well placed to
identify and address psychosocial
risk factors for the development of
chronic low back pain. However, a
biomedical perspective persists in
the education and practice of many
physical therapists,1 even though
cognitive and behavioral approaches
to rehabilitation for low back pain
are well established.2 Many physical
therapists feel ill equipped to deal
with psychosocial factors, possibly
because most training is biomedical
in orientation, with limited exposure
to biopsychosocial management
models.3 In our opinion, addressing
the continuum of physical and psy-
chosocial factors in patients with
low back pain should be part of nor-
mal clinical management for physical
therapists.
Psychologically Informed
Practice as a New Approach
to Physical Therapy
The articles in this special issue illus-
trate various facets of psychologi-
cally informed practice, ranging
from risk determination to the use of
interventions to implement reactiva-
tion. In the Figure, we have posi-
tioned “Psychologically Informed
Practice” between narrowly focused
standard physical therapist practice
based on biomedical principles and
the clinical approaches developed
originally for the treatment of mental
illness. In the Figure, we also have
attempted to integrate the appropri-
ate “flag” decisions that must be
made by clinicians in various con-
texts,4 –7 with appropriate color cod-
ing representing the focus of the dif-
ferent flags. The referents for the
different flags are illustrated in sum-
mary form in Table 1 of the Nicholas
et al5 article in this special issue.
Thus, we recognize that an impor-
tant part of standard practice is to
consider the presence of “red flags”
as indicators of serious pathology.
Psychologically informed practice is
May 2011
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Psychologically Informed Practice for Management of Low Back Pain
characterized by routine and specific
consideration of “yellow flags” and
“blue flags” (depending on clinical
setting) for determining risk of poor
outcome and for identifying the
potential for treatment modification.
We view the approach as fitting best
within a cognitive-behavioral frame-
work, noting that within the field of
clinical health psychology, there has
been increasing interest in the
cognitive-behavioral approach to a
range of conditions.8 We distinguish
psychologically informed practice,
however, from mental health prac-
tice, from which the cognitive-
behavioral approach was developed,
with its primary focus on psychopa-
thology and significant psychiatric
symptoms. Finally, “black flags”4
characterize the overall environment
or context in which the clinician
addressing the other flags must oper-
ate, including professional culture,
health care policy, and insurance
reimbursement. They also include a
range of other contextual factors
such as cultural, subcultural, ethnic,
familial, and economic factors,
which clearly have the potential
both to limit and to provide incen-
tives for psychologically informed
physical therapy practice, but usu-
ally are not addressed in interven-
tions at the individual level.
The shift in focus necessary to
include routine consideration of psy-
chological influences is, in our view,
the logical extension of an evidence-
based secondary prevention
approach within standard physical
therapist practice. The goal, there-
fore, is to not only treat the individ-
ual for current symptoms, as has
been the traditional role of the phys-
ical therapist, but also prevent the
development of unnecessary pain-
associated activity limitations. This
goal may involve changes not only to
clinical management at the level of
the individual patient encounter,
with increased consideration of psy-
chosocial factors, but also to the
Volume 91 Number 5
manner and context of service
design and delivery, incorporating
appropriate incentives for the man-
agement of psychosocial factors.
Special Issue Conclusions
The articles in this issue have cov-
ered a broad canvas, and we now
offer a synopsis of the key issues that
have emerged by highlighting key
recommendations and identifying
potential future directions for prac-
tice and research.
1. Psychologically informed prac-
tice as a new clinical frame-
work. Psychological processes
are an expected and normal part
of the musculoskeletal pain expe-
rience.9 Psychologically informed
practice has the opportunity to
improve clinical and occupational
outcomes through appropriate
consideration of relevant psycho-
social factors. In our summary
Figure, we have located this within
the flags framework, developed in
the context of secondary preven-
tion, in order to highlight practice
within its wider clinical, occupa-
tional, and social contexts.
Available With
This Article at
ptjournal.apta.org
• Symposium Podcast: Download
an audio or video podcast of the
“Enhancing Clinical Practice
Through Psychosocial Perspectives
in the Management of Low Back
Pain” symposium at CSM 2011
with speakers Julie Fritz, Steven Z.
George, Chris J. Main, and
William Shaw. The symposium
was sponsored by APTA’s
Orthopaedic Section.
• Audio Abstracts Podcast
This article was published ahead of
print on March 30, 2011, at
ptjournal.apta.org.
Physical Therapy f 821
Psychologically Informed Practice for Management of Low Back Pain
Consideration of Physical Factors
Standard Practice
Core Philosophy:
Address physical impairments
based on biomedical concepts
Primary Goal:
Reduce symptoms
Figure.
Proposed theoretical framework for the management of low back pain by physical therapists.
2. Influence of psychological fac-
tors on the perception of pain
and development of disability.
Beliefs and emotional and behav-
ioral responses have been long
recognized as important con-
comitants of low back pain and
disability. The literature to date
has focused primarily on the role
of patient beliefs, among which
beliefs about the nature of pain,
fear, pain catastrophizing, and
self-efficacy appear to be particu-
larly important.10 In psychologi-
cally informed practice, these
beliefs are a primary focus of
physical therapists in the manage-
ment of low back pain. It is rec-
ognized that these beliefs are
associated with emotional factors
(eg, anxiety, depression, anger)
and, in turn, influence behavioral
responses. We have taken a view
that a primary focus on such emo-
tional factors is properly a matter
for mental health professionals,
but we recommend that in psy-
chologically informed practice,
they be addressed as potential
obstacles to recovery within a
cognitive-behavioral framework,
for which currently there is the
822 f Physical Therapy Volume 91 Number 5
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Proposed Management of Low Back Pain
Psychologically Informed Practice
Core Philosophy:
Incorporate patient beliefs, attitudes, and emotional responses
into patient management based on biopsychosocial models
Primary Goal:
Secondary prevention of disability
Consideration of Psychological Factors
strongest evidence base in terms
of efficacy.11 There has been less
attention, although growing inter-
est, in the influence of practitio-
ner beliefs and the extent to
which they influence treatment
delivery and clinical outcome, in
particular changes in behavior (as
the ultimate goal).
In developing interventions, we
believe that distinguishing modi-
fiable from nonmodifiable psy-
chosocial factors is a critical part
of the process, as each may have
differing roles in patient manage-
ment. For example, a nonmodifi-
able psychological factor may be
a powerful predictor of outcome,
yet be inappropriate as a treat-
ment target.
Finally, we must emphasize that
we are not advocating complete
disregard of biomedical
approaches. We are mindful of
the importance of red flags as
indicators of the need for urgent
specialist opinion, and we recog-
nize further the important influ-
ence of biomedical factors as an
integral part of musculoskeletal
Mental Health
Practice
Core Philosophy:
Identify and treat
mental illness
Primary Goal:
Minimize the impact of
psychological disorder on
well-being and function
management. However, current
evidence suggests that these fac-
tors should be included within a
broader framework of assessment
and management.
3. Implications for training. Rele-
vant training is a key building
block for the development of pro-
fessional practice, and current
training paradigms constitute a
significant potential barrier to
the established of psychologically
informed practice.3 In our view, a
fundamental appraisal of the
approach to professional physical
therapist education and within
continuing education is required.
This appraisal requires wider con-
sideration of existing professional
culture, as well as current reim-
bursement structures. There is a
need specifically to revisit the
Normative Model of Physical
Therapist Professional Educa-
tion12 to ensure that psychologi-
cal factors and pain perception
are handled appropriately in pro-
fessional curricula and that phys-
ical therapists develop this key
understanding and expertise to
May 2011

aid in clinical management of
these patients.
Practicing physical therapists will
need additional specific training if
a psychological informed practice
approach is to be successfully
implemented. This approach
involves both a philosophical and
a practical change in education.
Physical therapists will have to
understand their professional
practice within newer evidence-
based models of pain perception,
pain behavior, and the develop-
ment of disability. Psychologically
informed practice will require a
new type of training to ensure
a standardized and validated
approach. A concerted effort will
be needed to facilitate the devel-
opment of such changes in train-
ing and clinical practice.
Implicit in much of our analysis
has been recommendation of a
broadening in the role of the
physical therapist as not only a
treating clinician, but also a clini-
cian attempting to establish
guided self-management. This rec-
ommendation also has implica-
tions for the focus of education
and the nature of the educational
process. In the context of second-
ary prevention in particular, the
primary goal is to help develop
and establish relevant, helpful,
and sustained behavior change in
our patients. As such, the educa-
tion of our physical therapists
needs to include a clear focus on
the determinants of behavior
change and how to embed these
determinants of behavior change
within treatment. There may be
important lessons from imple-
mentation science13 that might be
usefully applied to our clinical
interventions.
May 2011
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Psychologically Informed Practice for Management of Low Back Pain
4. Linking risk identification, clin-
ical decision making, and
delivery of interventions. The
relationship between (1) a public
health perspective toward risk
identification treatment targeting
and (2) the design of interven-
tions at an individual level is
bridged by clinical decision mak-
ing, a process that is as yet insuf-
ficiently understood. Cutoffs on
questionnaires can help identify
those individuals at risk for poor
(or indeed good) outcome from
treatment, but such scores are ill
equipped to do more than iden-
tify types of patients for which
different outcomes (as a group)
can be predicted. Identification of
increased risk may involve more
than just identification of an ele-
vated score—which, in terms of
individual treatment outcome, is
insufficiently accurate and whose
relationship with potential treat-
ment modifiers and integration
into clinical decision making are
still far from established. In
addressing these major chal-
lenges, we may have to recognize
the limitations in the use of sim-
ple cutoff scores and consider
novel approaches to decision
making that take fuller account of
data that are continuously distrib-
uted, while balancing pragmatic
considerations of interpretability
and ease of use.
This special issue highlights the
importance of measurement of
psychosocial factors in clinical
settings14 and identifies some clin-
ical decision tools that are of
potential utility but that are not as
yet sufficiently validated to be
able to recommend for clinical
practice. In our view, further
work in this area of applied
research in determining the clini-
cal utility of commonly used mea-
sures is a top priority. Ideally,
optimal screening methods
should be validated, and treat-
Volume 91 Number 5
ment programs matched to spe-
cific factors that have the poten-
tial to enhance clinical outcomes
should be evaluated. As a recent
example, randomized trial
designs could consider the
approach used for the Keele
STarT Back trial in the United
Kingdom.15 We note a recent cri-
tique of the flags framework for
the identification and use of
screening procedures.16 These
authors caricature the flags
approach as “reductionist” and
revisit the age-old dispute
between nomothetic and idio-
graphic approaches, with the par-
allel distinction between quantita-
tive and qualitative approaches.
In our opinion, critiques such as
these are interesting and merit
debate, but they do little to
advance clinical management and
seem to have little appreciation of
the “real world,” where—in the
context of massive financial pres-
sures—we have an obligation to
find ways of linking public health
perspectives with clinical inter-
ventions, and to address individ-
ual differences within a wider
perspective.
5. The need to recognize the
socioeconomic context. In our
recommendation of psychologi-
cally informed practice, we are
mindful of the need to recognize
socioeconomic realities. In paral-
lel, we recognize the importance
of health services research
focused on potential cost savings
and reduction in utilization for
use of psychologically informed
approaches to manage low back
pain. Musculoskeletal pain affects
not only the individual patient
but also the individual’s family
and society (in terms of health
care provision and employment).
Indeed, the wider social context
of musculoskeletal pain and dis-
ability (eg, black flags) is as yet
insufficiently understood, but,
Physical Therapy f 823
Psychologically Informed Practice for Management of Low Back Pain
given its importance, it merits
high priority for further study. We
also must acknowledge the eco-
nomics of health care provision,
and in recommending psycholog-
ically informed practice within a
flags framework, it is important to
develop socioeconomic evalua-
tions that fully capture new ser-
vice initiatives. It is equally impor-
tant to ensure that future health
care policy is consistent with
these evaluations and that there is
appropriate incentive for provid-
ing psychologically informed
practice when it is indicated.
In offering a new way of thinking
about low back pain and its manage-
ment, we have recommended a new
approach to physical therapy that
we have called “psychologically
informed practice.” We realize, of
course, that any such endeavor is
open to the charge of ignorance, stu-
pidity, megalomania, or all in combi-
nation. We also know that recogni-
tion of psychosocial aspects of care
has been around for a long time and
that physical therapists already deal
with such issues as part of clinical
practice. We have become aware,
however, that the way in which such
factors are addressed and managed
within the consultation is frequently
unsystematic, likely resulting in sub-
optimal patient outcomes. This
awareness has been reinforced by
our experience in developing train-
ing programs. Although the potential
importance of psychosocial factors
usually is acknowledged by our train-
ees in the programs, they have con-
sistently expressed the view that
their prior professional training did
not equip them sufficiently to incor-
porate such factors effectively
within their clinical practice. We
have attempted, therefore, to pro-
vide guidance on how such an
approach might be developed, while
recognizing the clear challenges
824 f Physical Therapy Volume 91 Number 5
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involved, the additional research that
is needed, and the potential changes
that may have to be made to physical
therapist education practices.
We hope that in offering this special
issue, we will stimulate and encour-
age the development of a broader
approach to physical therapist prac-
tice, with a focus on the identifica-
tion and management of psycholog-
ical and psychosocial obstacles to
recovery of optimal function. We
have developed in this special issue a
primary focus on low back pain, as
this area has been extensively stud-
ied. It is our opinion—and promising
preliminary evidence exists to sup-
port this opinion—that a similar psy-
chologically informed practice
approach is appropriate for other
musculoskeletal pain conditions.
Lessons learned from years of low
back pain research may indeed have
broader application for the general
management of musculoskeletal
pain, although further research is
needed before stronger clinical rec-
ommendations can be made.
Both authors provided concept/idea/project
design and writing. Professor Main provided
project management. Dr George provided
consultation (including review of manuscript
after submission).
This work was presented at the Combined
Sections Meeting of the American Physical
Therapy Association; February 11, 2011,
New Orleans, Louisiana.
This article was submitted February 23, 2011,
and was accepted February 24, 2011.
DOI: 10.2522/ptj.20110060
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May 2011
 Psychologically Informed Practice for Management
of Low Back Pain: Future Directions in Practice and
Research
Chris J. Main and Steven Z. George
PHYS THER. 2011; 91:820-824.
Originally published online March 30, 2011
doi: 10.2522/ptj.20110060

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