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Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Knowledge, behaviors, attitudes and beliefs ofphysiotherapists towards the use of psychologicalinterventions in physiotherapy practice: asystematic review
Christina Driver, Bridie Kean, Florin Oprescu & Geoff P. Lovell
To cite this article: Christina Driver, Bridie Kean, Florin Oprescu & Geoff P. Lovell (2016):Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use ofpsychological interventions in physiotherapy practice: a systematic review, Disability andRehabilitation, DOI: 10.1080/09638288.2016.1223176
To link to this article: http://dx.doi.org/10.1080/09638288.2016.1223176
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REVIEW ARTICLE
Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the useof psychological interventions in physiotherapy practice: a systematic review
Christina Drivera, Bridie Keana,b, Florin Oprescua and Geoff P. Lovellc
aCluster for Health Improvement, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore,Australia; bCentre of Excellence for Applied Sport Science Research, Queensland Academy of Sport, Sunnybank, Australia; cSchool of SocialSciences, University of the Sunshine Coast, Maroochydore, Australia
ABSTRACTPurpose: To systematically review and analyze the literature exploring the knowledge, behaviors, atti-tudes, and beliefs of physiotherapists towards the use of psychological interventions in their practice.Methods: A systematic search was conducted, of articles published between January 1996 and February2016, using selected electronic databases followed by crosschecking of reference and citation lists. Articleswere selected on the basis of the research reported relating to knowledge, behaviors, attitudes or beliefsof physiotherapists towards using a number of different psychological interventions. Quality assessmentwas conducted by three reviewers independently, and thematic analysis of the included studies wasperformed.Results: Fifteen studies were included in the analysis. Results indicate that physiotherapists are aware ofpsychological interventions, are using a variety within practice, and have positive attitudes and beliefstowards their use. However, there are barriers to the incorporation of psychological interventions intotheir practice, including lack of knowledge, time constraints, and role clarity. The desire for further trainingwas also evident.Conclusion: Notwithstanding the reported awareness and use of psychological interventions in physio-therapy practice, barriers to implementation exist indicating that further research is necessary to addresshow to effectively equip physiotherapists, to employ such techniques within their scope of practice.
� IMPLICATIONS FOR REHABILITATION� Physiotherapists use and have positive attitudes and beliefs towards a variety of psychological inter-
ventions including goal setting, positive, and motivational talk, cognitive behavioral therapy strategiesand offering social support.
� Barriers preventing the incorporation of psychological interventions in practice include, lack of know-ledge, time constraints, and role clarity.
� Despite the use of such interventions, physiotherapists identify the need for further training, to bebetter equipped to confidently utilize these in practice.
� These results justify the incorporation of training in psychological interventions in physiotherapistqualifying studies, but also as continued professional development opportunities for physiotherapistscurrently working in the field.
ARTICLE HISTORYReceived 3 March 2016Revised 28 July 2016Accepted 8 August 2016Published online 7 Septem-ber 2016
KEYWORDSPsychological interventions;physiotherapy; biopsychoso-cial; injury; goal setting
Introduction
Disability as a result of disease or injury and consequentialrehabilitation can impact physical, emotional, social, cognitive,and behavioral aspects related to ones’ health.[1] Health professio-nals involved in rehabilitation can have a substantial influence onthe physical, social, and psychological recovery of patients.[2,3]This established connection endorses the importance of adoptinga biopsychosocial perspective for rehabilitation with thoseaffected by disability.
Over the last two decades, research has increasingly attendedto the psychological component of a biopsychosocial model,investigating the psychological issues associated with the rehabili-tation process. Much of the early research focused on sport-related injuries and rehabilitation,[4] outlining the extent to whichmultiple factors such as cognitions, emotions, social, contextual,
and biological factors can affect rehabilitation outcomes.[5] Morerecently published research has documented the multifacetedexperiences acknowledged by patients living with chronic pain,suggesting that pain was only one component of the suffering,as patients were more affected by the resulting psychologicaldistress, such as worry, isolation, and anguish.[6]
Psychological aspects of rehabilitation have also been investi-gated with regards to conditions, such as chronic pain manage-ment in the elderly, hip fractures, and work disability. Patientssuffering from chronic pain have been found to have increasedrisk of developing depression, anxiety, poor self-esteem, and socialisolation;[7] and the opinion that a biomedical model alone failsto explain the complexity of pain is becoming more accepted.[8]Indeed, it has been suggested that patients recovering from hipfracture are susceptible to reduced self-efficacy and unsupportivecoping strategies, with long-term physical limitations resulting in
CONTACT Christina Driver [email protected] Cluster for Health Improvement, Faculty of Science, Health, Education and Engineering,University of the Sunshine Coast, Maroochydore, Australia� 2016 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION, 2016http://dx.doi.org/10.1080/09638288.2016.1223176
a lack of social engagement, and inability to perform daily tasksand activities.[9] Increase in psychological risk factors, such asthese have resulted in patients encountering emotional conse-quences including frustration, fear avoidance, and decreased cop-ing strategies.[9,10] Sullivan et al. [11] discussed the importanceof addressing psychological risk factors, which can affect rehabili-tation for work disability, as the occurrence of such risk factorsincrease the likelihood that pain-related disability will continue forlonger periods of time. The severity of the injury or disease canalso have substantial acute and long-term psychological effectsdue to varying outcomes and recovery periods associated withrehabilitation,[10] and depression is increasingly being identifiedas a common condition among those living with a long-termdisability.[1]
Physiotherapists (PTs) are traditionally those responsible for theassessing, diagnosing, and treating those who are affected by dis-ability from disease or injury, aiming to restore, maintain andimprove function and ability in patients of all ages with varying lev-els of injury, pain, and health conditions.[12–14] PTs, appear to bewell positioned to adapt their roles and expand their scope of prac-tice, to offer more relevant services and opportunities, aiding in themanagement of the increasing health burdens of the population,and the complex nature of disability.[15] Reports suggest that anevolution of the scope of physiotherapy practice has alreadystarted resulting in patients being increasingly addressed from abiopsychosocial perspective.[16] The previously defined roles andboundaries in the healthcare system including physiotherapy havedeveloped over time to incorporate psychological strategies as anadjunct to physical therapy.[17] Consequently, PTs involved in thetherapy and rehabilitation process for individuals affected by dis-ability, could arguably have an important role to play in addressingpsychological aspects, which may contribute substantially to betterclient care, wellbeing, and rehabilitation outcomes.
Evidence supports the use of psychological interventions dur-ing rehabilitation, to increase adherence to physiotherapy pro-grams, and improve recovery outcomes.[2,11,17,18] Interventionsincluding goal setting, cognitive behavioral therapy (CBT), mentalimagery, relaxation, motivational interviewing, self-talk, andencouraging social support have all been found to be useful toolsto enhance the rehabilitation process.[4,19–26] Historically, theuse of psychological interventions and their significance duringrehabilitation have been driven predominantly by sport psych-ology literature, and more recently the challenges faced by PTs inthe implementation of such interventions in the clinical manage-ment of pain [22,27] have been explored. However, acknowledg-ing the current diverse specialties of practicing PTs and theirexpanding role in healthcare, some literature has also exploredthe effectiveness and feasibility of psychologically orientated inter-ventions in other areas of PT practice.
The expansion of PTs roles has led to the inclusion of PTs in themultidisciplinary care of those with complex mental health condi-tions, particularly aimed at the promotion of physical activity andmanagement of associated co-morbidities, such as cardiorespira-tory disease and diabetes.[28,29] It has been acknowledged thatPTs working with clients with Schizophrenia recognized the import-ance of using holistic interventions to encourage mind-body aware-ness,[30] and that engagement in physical activity can promotepsychological wellbeing.[29,31] Furthermore, research investigatingPT’s involvement in neurological rehabilitation reported that men-tal practice, relaxation, and activity coaching alongside routinephysiotherapy had beneficial effects for their clients.[32,33]
Additional research identified the valuable contribution PTshave in the rehabilitation of those with cancer, HIV/AIDS and clientsin palliative care settings,[34–37] as such conditions often result in
co-morbidities such as chronic pain, emotional distress, and lack ofmobility and functionality.[36,37] PTs play an important role inimproving quality of life and wellbeing in clients, and cancerpatients themselves have expressed the value in PTs being able tooffer a holistic perspective addressing their psychological and phys-ical needs.[35] Despite the body of research addressing the broaderareas of physiotherapy practice and the benefits of psychologicalorientated interventions for clients, the knowledge, behaviors, atti-tudes and beliefs of the PTs themselves towards such interventionsare yet to be systematically researched and documented.
With the current shift towards adopting a biopsychosocial per-spective in physiotherapy practice incorporating psychologicalinterventions, it is important to gain insight into how this chang-ing role is perceived by PTs themselves, and to identify the chal-lenges in accepting this role. Previous reviews have synthesizedinformation with regards to limited areas of physiotherapy prac-tice; the integration of psychosocial principles within back painmanagement,[27,38] and psychological interventions utilized bymusculoskeletal PTs predominantly in the UK.[39] However, basedon the aforementioned limitations of previous reviews that appearto lack generalisability to the broader context of physiotherapy, itis important to ascertain an international perspective concerningmultiple facets of physiotherapy practice.
In the light of current healthcare trends encouraging thesepurported changes in PT roles, but the limited and somewhat dis-perse research in this area, this review aims to identify the know-ledge, behaviors, attitudes, and beliefs of PTs towards the use ofpsychological interventions in physiotherapy practice. Specifically,it will be report commonly utilized psychological interventionswithin physiotherapy practice; what are the attitudes towardssuch interventions, including any potential differences across prac-tice areas; what are PTs most commonly identified barriers; andwhat if any PTs perceive are their key training needs with regardsto psychological interventions. The result of such a review couldhave important implications for the design of training and supportfor PTs, including the associated benefits for their patients’ recov-ery and wellbeing.
Methods
Literature search
A systematic literature search [40] was conducted using onlinedatabase search engines including Scopus, Web of Science,PubMed, and PsychInfo, followed by crosschecking reference andcitation lists. The search was performed by the first author betweenJanuary 2016 and February 2016. Search strategies focused on theinitial inclusion of titles and/or abstracts containing the key words“physiotherapy” OR “physiotherapists” OR “physical therapy,” thenfurther narrowed down, including key words; “cognitive behavioraltherapy” OR “goal setting” OR “imagery” OR “visualization” OR “self-talk” OR “relaxation” OR “positive reinforcement” OR “motivationalinterviewing” OR “social support” OR “coping strategies” OR“biopsychosocial” OR “psychosocial” OR “psychological”. Key wordsincluded specific psychological interventions and broad terms toaccount for the potential differences in interpretations and labelsof psychological strategies. A final key word search included“knowledge” OR “attitudes” OR “beliefs” OR “behaviors” OR “views”OR “perceptions” (Table 1). Duplicates were removed and theremainder titles and abstracts were assessed for relevance, referringto full text if further information was necessary. Relevant articleswere checked for peer review status, discussed based on the inclu-sion and exclusion criteria (CD, FO, GL), quality assessed (CD, GL,BK) and assessed for risk of bias (CD, GL).
2 C. DRIVER ET AL.
Inclusion and exclusion criteria
Inclusion and exclusion criteria were developed by the researchteam to identify key areas of interest. These criteria were informedby previously published literature, addressing the strengths andlimitations of such research. Table 2 outlines the inclusion andexclusion criteria.
Quality assessment
Guidelines for Critical Review Forms (GCRF) developed by theMcMaster University Occupational Therapy Evidence BasedPractice Research Group [41,42] were used to assess the qualityand risk of bias of the included articles. GCRFs have been used inprevious systematic reviews [43,44] and a PT narrative review.[45]The GCRF were chosen as they can easily be applied to PT-basedresearch and two separate checklists for qualitative and quantita-tive study designs are utilized. Studies that were predominantlyquantitative with a very small component of qualitative (surveyswith short answer responses) were assessed as quantitative.
Articles were scored based on meeting certain criteria andrecorded to give each article an overall quality score. The criteriafor the quantitative assessment were adapted slightly, due to allthe quantitative studies reviewed being survey based. The GCRFassessment items referring to outcomes and interventions wereconsequently omitted as this was not the focus of the currentreview. The GCRF results section was also amended to reflect thedescriptive nature of survey results, hence removing the statisticalsignificance item. Additionally, the item referring to drop outs wasmodified to response rate to better reflect the design of thereviewed studies. The assessment criteria for quantitative researchtherefore included study purpose, literature, design, sample,results, conclusions, and clinical implications. The assessment crite-ria for qualitative research included study purpose, literature,study design, sample, data collection, data analysis, trustworthi-ness, conclusions, and implications. One mark was given if the
criteria were evidently met and no marks were given if the criteriawere not obvious. Qualitative articles were given a score out of 24and quantitative articles were given a score out of 9 and con-verted to percentages. The articles were subjected to blind assess-ment by three of the authors (CD, GL, BK) resulting in agreementscores of 90% or better. The subsequent results were discussed,and any discrepancies in items were deliberated until a consensuswas reached.
Data analysis and synthesis
Thematic analysis of the included articles results was conductedfollowing the six steps outlined by Braun and Clarke,[46] catego-rizing the results into themes addressing the aims of the review.Consistent with previous reviews involving multiple researchdesigns,[45] a meta-analysis method of synthesis was not adopteddue to the heterogeneity of the included studies.
Study identification
Initial search strategies as described resulted in 947 studies beingidentified through database searches and nine additional studiesthrough citation and reference checking, one of which wasretrieved by contacting the author.[47] Screening by way of dupli-cate removal resulted in 802 studies, and further screening pro-duced 100 studies to be assessed for eligibility. Evaluationthrough title and abstract assessment followed resulting in a totalof 41 studies being identified as relevant. Peer review status waschecked and subsequent assessment and discussion by three ofthe authors based on the inclusion and exclusion criteria resultedin the final inclusion of 17 studies. Twenty-four studies wereexcluded from the final review, as they did not meet eligibility cri-teria (Figure 1).
Quality assessment of the remainder studies identified that 16articles achieved 75% or over (one scored 67%), and had low risk
Table 1. Search strategy.
Database Type of search Keywords and strategyNo. of articles
retrieved
PubMed Title and abstract Physiotherapists OR physiotherapy OR physical therapyAND Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral ther-
apy OR goal setting OR imagery OR visualization OR self-talk OR relaxation ORpositive reinforcement OR motivational interviewing OR social support OR copingstrategies
AND knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views
248
PsychInfo Abstract Physiotherapists OR physiotherapy OR physical therapyAND Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral ther-
apy OR goal setting OR imagery OR visualization OR self-talk OR relaxation ORpositive reinforcement OR motivational interviewing OR social support OR copingstrategies
AND knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views
190
Web of science Title, then within search results Physiotherapists OR physiotherapy OR physical therapyWithin search results:Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral therapy
OR goal setting OR imagery OR visualization OR self-talk OR relaxation OR positivereinforcement OR motivational interviewing OR social support OR coping strategies
Within search results:Knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views
172
Scopus Title, then within search results Physiotherapists OR physiotherapy OR physical therapyWithin search results:Bio-psychosocial OR psychosocial OR psychological OR cognitive behavioral therapy
OR goal setting OR imagery OR visualization OR self-talk OR relaxation OR positivereinforcement OR motivational interviewing OR social support OR coping strategies
Within search results:Knowledge OR beliefs OR attitudes OR behaviors OR perceptions OR views
337
Crosschecking reference and citation lists 9
PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 3
of bias. However, after quality assessment it was decided that afurther two studies were to be excluded from the review.[3,48]Through in depth analysis of the results, it was established thatboth studies did not separate the results of health professionals,athletic trainers and PTs, therefore could not be used to general-ize to the PT population specifically, consequently falling outside
the inclusion criteria. Table 3, summarizes the 15 included studiesand quality assessment results.
The studies included PTs from the US,[49,50] the UK,[51–57]Australia,[47,58–61] New Zealand,[47] and Canada.[47] One inter-national study did not report on the nationality ofrespondents.[62]
Table 2. Inclusion/exclusion criteria.
Inclusion criteria Exclusion criteria
� Research centered on qualified physiotherapists (or physical therapists)� Involved at least one psychological intervention from the list below:
� Goal setting� Imagery/visualization� Self-talk� Relaxation� Positive reinforcement� Motivational interviewing� Cognitive behavioral therapy� Coping strategies� Social support
� Involved the discussion of knowledge, beliefs, attitudes, behaviors, views, per-ceptions, or similar concepts
� Peer reviewed and in any language� Published between January 1996 and February 2016� All study designs included
� Review articles� Involved only the testing of outcomes when using psychological interventionswith patients, rather than the perception of the physiotherapists using them
� Discussion of nonspecific psychological aspects as opposed to specific psycho-logical interventions
� Studies involving physiotherapy students and therefore not practicing� Studies not involving physiotherapists� For the purpose of this review, studies involving only athletic trainers wereomitted due to the difference in role characteristics, compared tophysiotherapists
Figure 1. Prisma flow chart.
4 C. DRIVER ET AL.
Table3.
Summaryof
includ
edarticlesandresults
ofqu
ality
assessment.
Authors
Stud
yaim
Metho
dology
and
participants
Keyfin
ding
sLimitatio
nsQAScore
Quant/9
Qual/2
4
Holdenet
al.[61]
Gaininsigh
tinto
Australian
PT’sknow
ledg
e,percep-
tions,u
sage
andtrain-
ingof
motivational
strategies
forLower
back
pain
(LBP)and
return
toactivity.
Quantitativedesign
.Online
crosssectionaln
ation-
wideclosed
questio
nsurvey.P
Tsweremem
-bersof
the
Musculoskeletal
Group
oftheAu
stralian
Physiotherapy
Associationworking
with
patientswith
LBP
n¼170
MostPTsfeltitwas
extrem
elyimpo
rtantto
usemotivationalstrategiesforLBP
tohelp
return
tousuala
ctivity.C
ommon
barriers
repo
rted
weretim
econ-
straints
andlack
oftraining
.Active
goal
settingmostrecogn
ized
strategy
butno
tmostcommon
lyused,d
ueto
time.Transtheoretical
Mod
elbased
coun
selingwas
theleastused.P
Tsrepo
rted
active
goal
settingas
most
common
training
received
atun
dergradu
atelevela
ndtraining
increasedcon-
fidence
andperceivedeffectiveness.How
ever,go
alsettingon
lyperceivedas
mod
eratelyeffective.Manyfamiliar
with
CBT,andperceivedas
mod
erately
effective,bu
tbarriers
includ
edlack
oftraining
.Trainingin
CBTresultedin
increasedconfidence
butno
tperceivedeffectiveness.Halfof
PTsfamiliar
with
MI,repo
rted
usingitsometimes
andperceivedas
mod
eratelyeffective.
Mostused
praise
andencouragem
entwith
everypatient.
Treatm
entfid
elity
dueto
lack
ofun
derstand
ingof
motivationalstrategies
listed.
Self-selectionbias
andsampleheavily
weigh
tedtowards
one
statein
Australia.O
nly
targeted
PTsworking
with
LBPpatients.
8/9
Lloydet
al.[57]
ExplorePTsexperiences
andperceptio
nsof
usingcollabo
rativego
alsettingwith
stroke
patientsin
theUK.
Qualitativedesign
.Semi-structuredface
toface
interviews.UKPTs
basedin
stroke
units
at3NationalH
ealth
Serviceho
spitals.n
¼9
PTsacknow
ledg
edthat
patients’health,p
ersonala
ndenvironm
entalfactors
affected
psycho
logicaladjustm
entto
post
stroke
cond
ition
andeffectiveness
ofgo
alsetting.
Goalsettin
gskillsevolvedover
timethroug
hinform
allearn-
ingandwereinstinctive.PTswereno
table
toidentifystructureor
atheoret-
icalfoun
datio
nof
theirknow
ledg
e.Develop
ingatherapeutic
relatio
nship
was
impo
rtantto
PTsto
enable
effectivecollabo
rativego
alsettingandPTs
believedthat
thisem
powered
patientsto
take
anactiverole.G
enerallyPTs
feltthat
collabo
rativego
alsettingiscomplex
andfurthertraining
andexperi-
ence
increasedconfidence.
Did
notreachdata
satur-
ationdu
eto
timecon-
straints
therefore
theoriesestablishedare
provisional.Sample
selected
dueto
locatio
nto
theresearcher.
21/24
Nielsen
etal.[58]
Investigatetheop
inions
andexperiences
ofPTs
whilstimplem
entin
gCB
Tinto
theirpractice
inAu
stralia.
Qualitativedesign
.Semi-structuredph
one
interviews.Au
stralian
PTstrainedin
pain
cop-
ingskillstraining
and
working
with
knee
osteoarthritispatients.
n¼8
PT’shadoverallp
ositive
experiencewith
CBTwhich
enabledthem
toencourage
patientsto
take
anactiverole
intheirrehabilitation/pain
managem
ent.Most
used
relaxatio
nandself-talkstrategies
forcoping
.PTs
feel
CBTisrelevant
andapprop
riate
fortheirpracticebu
texpressedthat
somePTslack
adequate
know
ledg
eto
deal
with
thedepthof
issues.B
arriersto
useof
CBTinclud
e;lack
ofknow
ledg
e,skills,tim
e,cost
andscop
eof
practice.Training
inCB
Tat
postgraduate
levelsug
gested.
Smallsam
plesize
involving
onlypain
managem
ent
techniqu
eswith
knee
osteoarthritispatients.
Samplelim
itedto
two
states
inAu
stralia.
18/24
Scott-Dem
pster
etal.[56]
Discovertheexperiences
andperceptio
nsof
PTs
usingactivity
pacing
with
patientswith
chronicpain
intheUK.
Qualitativedesign
.Semi-structuredface
toface
interviews.UKPTs
experienced
inusing
activity
pacing
with
chronicpain
patients.
n¼6
Activity
pacing
was
identifiedby
PTsas
impo
rtantto
help
patientsadaptto
pain,and
encouraged
patientsto
bemoreproactivein
theirrehabilitation
throug
hassessingtheirow
ncapabilities.PTshigh
lighted
theimpo
rtance
ofa
therapeutic
relatio
nshipbu
tbarriers
includ
edadjustingtheirrole
toa“sit
with
”rather
than
“fixit”
perspective.Activity
pacing
was
notused
inisola-
tionandshou
ldbe
partof
amultifaceted
approach
topain
managem
ent.
Smallsam
pleselected
due
togeog
raph
ical
locatio
nto
theinterviewer.
Limitedto
femalePTs
working
with
chronic
pain
andexperienced
inactivity
pacing
.
21/24
Soun
dyet
al.[62]
Investigatingtheperceived
valueof
socialsupp
ort
toencourageph
ysical
activity
inschizoph
renic
patients.
Qualitativedesign
.Crosssectionalo
pen-ended
survey.P
Tsweremem
-bersof
theInternational
Organizationof
Physiotherapists
inMentalH
ealth
with
atleast1year
experience
ofworking
with
schizo-
phrenicpatients.n¼40
PTsdescrib
edfour
dimension
sof
socialsupp
ort;inform
ational,tang
ible,esteem
andem
otional,andtheimpo
rtance
ofsocial
integration.
PTsidentifiedthe
impo
rtance
ofinform
ationalsup
portthroug
heducationabou
tthebiop
sycho-
social
benefitsof
physical
activity.U
nderstanding
patients’needs,engaging
with
them
,offe
ringencouragem
ent,po
sitivereinforcem
ent,motivational
interviewing,
andotherpsycho
logicalstrategiesweredescrib
edby
PTsas
form
sof
socialsupp
ortto
increase
confidence
andsupp
ortbehavior
change.
PTsperceivedsocial
integration/peer
supp
ortto
beeffectivewith
regardsto
adherenceto
physical
activity.
Low
respon
serate,and
natio
nalitiesof
respon
d-ents
notrepo
rted
sodifficultto
generalize.
Limitedto
specialists
PTsandincomplete
respon
sesto
some
them
es.
16/24
Arvinen-Barrow
etal.[51]
Exam
inePTsperson
alper-
ceptions
abou
ttheuse
ofpsycho
logicalinter-
ventions
insportinjury
rehabilitationin
theUK.
Qualitativedesign
.Sem
i-structured
interviews
with
UKbasedchar-
teredPTsworking
insports
medicine,
recruitedfrom
aprevi-
ousstud
y.n¼7
Psycho
logicalinterventions
areno
ttaug
htto
PTsbu
tmostaw
areof
theirlack
ofform
altraining
.PTs
wereaw
areof
psycho
logicalaspects
ofinjury
and
thinkit’snecessaryto
useinterventio
ns.M
ostPTswereknow
ledg
eablein
encouragingsocialsupp
ortandusinggo
alsetting,
butmainlyPT
directed,
anddescrib
edusingpo
sitivereinforcem
ent.Imageryandrelaxatio
nwere
repo
rted
aslargelyun
derutilized.B
arriers
identifiedwerelim
itedform
altrain-
ing,
timeandrole
clarity.
Self-selectionbias
ofpar-
ticipants,and
small
sampleof
PTson
lyworking
with
sports
injury.
20/24
(continued)
PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 5
Table3.
Continued
Authors
Stud
yaim
Metho
dology
and
participants
Keyfin
ding
sLimitatio
nsQAScore
Quant/9
Qual/2
4
Beissner
etal.[49]
Stud
iedPTsexperiences
with
usingCB
Twith
olderadults
suffe
ring
from
chronicpain
inthe
US.
Quantitativedesign
.Cross
sectionaln
ation-wide
phon
esurvey
inUS.PTs
weremem
bers
ofthe
Geriatricsand
Ortho
pedics
sectionof
theAm
erican
Physical
TherapyAssociation
(APTA).n
¼152
PTshadpo
sitiveattitud
estowards
CBT.Mostused
activity
pacing
butrarely
used
cogn
itive
restructuring,
relaxatio
ntechniqu
esandvisual
imageryor
dis-
tractio
n.Themajority
indicatedinterest
inusingCB
Ttechniqu
esin
practice
andexpressedhigh
interest
inlearning
more.Barriers
includ
edlack
ofknow
-ledg
e,tim
e,reimbu
rsem
entconcerns
andpatient
expectation.
Shortph
onesurvey
not
allowingforindividu
alinterpretatio
n.PTson
lyinvolved
inchronicpain
managem
entwith
older
patients.
9/9
Ham
son-Utleyet
al.[50]
Exploretheattitud
esof
PTs(and
ATs)towards
usinggo
alsetting,
imageryandpo
sitive
self-talkwith
injured
athletes
intheUS.
Quantitativedesign
.Cross
sectionalA
ttitu
des
Abou
tImagerysurvey.
PTsfrom
theAP
TAdatabase
listedas
work-
ingin
outpatient
ortho-
pedicrehabilitationin
US.n¼356(PTs)
PTshave
overallp
ositive
attitud
etowards
imagery,po
sitiveself-talkandgo
alsettingin
rehabilitation.
Thosewith
form
altraining
inpsycho
logicalskills
had
morepo
sitiveattitud
esanddesiredfurthertraining
.OverallPTsbelievedthe
aboveskillsto
beeffectivein
rehabilitationwith
regardsto
adherenceand
outcom
es.
Leadingstatem
ents
used
forsurvey.O
nlystud
ied
PTsworking
with
injuredathletes
inou
t-patient
setting.
8/9
Laffe
rtyet
al.[52]
Investigatetheview
sof
PTs(clubandno
n-club
)towards
thepsycho
-logicalaspects
oftheir
practicewith
sports
injuriesin
theUK.
Quantitativedesign
.Mod
ified
versionof
the
AthleticTraining
and
SportPsycho
logy
Questionn
aire
(ATSPQ
)in
theUK.
Certified
PTs
working
with
sports
injuries.n¼87
PTsrepo
rted
usinggo
alsetting,
variety
inexercises,enhancingself-confidence,
encouragingpo
sitiveself-thou
ghts
andeffectivecommun
icationmost.Least
used
techniqu
eswererelaxatio
n,redu
cing
depression
andteaching
emo-
tionalcon
trol
strategies.P
Tsthou
ghtitimpo
rtantto
incorporatesportpsy-
cholog
icaltechniqu
esinto
PTpractice.
Smallsam
pleforqu
antita-
tivestud
y,andon
lylookingat
sports
injuries.
8/9
Arvinen-Barrow
etal.[53]
Exam
inetheview
sof
PTs
with
regardsto
thepsy-
cholog
icalaspectsof
theirpractice,with
insports
injury
clinicsin
theUK.
Quantitativedesign
.Mod
ified
versionof
ATSPQcalledthe
Physiotherapistand
SportPsycho
logy
Questionn
aire
(PSPQ)in
theUK.
CharteredPTs
working
insports
injury
clinics.n¼361
Nearly
allP
Tsacknow
ledg
edthepsycho
logicale
ffectsof
injury,ratingstress
andanxietyas
themostcommon
respon
se,and
consider
itimpo
rtantto
addresstheseaspects.Mostused
interventio
nswerego
alsetting,
variety
inexercisesandencouragingpo
sitiveself-thou
ghts
with
imageryandrelaxatio
nleastused.P
Tsrepo
rted
training
desiresin
goal
setting,
variety
orexercises,
positiveself-thou
ghts,u
nderstanding
motivation,
listening
skillsandincreas-
ingathletes’confidence.M
ostrepo
rted
wantin
gspecifictraining
atpo
st-
graduate
level.
Samplingmetho
dno
twell
repo
rted
andon
lyaddressedPTsworking
with
sports
injuries.
8/9
JevonandJohn
ston
[54]
Exploretheknow
ledg
eandattitud
esof
PTs
towards
psycho
logical
aspectsof
rehabilitation,
working
with
UK
Olympians.
Qualitativedesign
.Sem
i-structured
interviews
with
charteredPTsin
theUK,
who
were
mem
bers
oftheBritish
OlympicAssociation
Steerin
gGroup
.n¼19
PTsrepo
rted
awarenessof
psycho
logicalinterventions
andimpo
rtance
ofaddressing
psycho
logicalaspects.K
nowledg
eandskillswerepredom
inantly
gained
throug
hclinical
practiceandvicario
usexperiences.A
therapeutic
rela-
tionshipwas
describ
edas
impo
rtantandthey
held
positiveattitud
estowards
interventio
nsin
practice.Barriers
includ
edlack
ofform
altraining
andknow
-ledg
e,tim
e,role
clarity
andscop
eof
practice.Allu
sedsomeform
ofgo
alsettinganddescrib
edaspectsof
social
supp
ort,on
lysomedescrib
edrelax-
ationandvisualization.
Onlystud
iedPTsworking
with
Olympicathletes.
19/24
Hem
mings
andPovey,[55]
Surveyed
theperceptio
nsof
PTsin
theUKwith
regardsto
thepsycho
-logicalcon
tent
ofPT
practicewith
sports
injury.
Quantitativedesign
.Mod
ified
versionof
ATSPQ,calledthePSPQ
.PTsfrom
theEngland
EasternRegion
Sports
MedicineDirectory.
n¼90
PTsrepo
rted
theimpo
rtance
ofpsycho
logicalfactorsrelatedto
sportinjury
and
recogn
ized
stress
andanxietyas
common
respon
sesto
injury.P
sycholog
ical
skillsmostused
werevariety
ofexercises,go
alsettingandpo
sitiveself-talk.
Leastused
weresocial
supp
ort,redu
cing
depression
andteaching
emotional
controlstrategies.PTstraining
desireswereaimed
atgo
alsetting,
under-
standing
motivationandvariety
inexercises.They
feltitleastimpo
rtantto
learnabou
tsocial
supp
ort,increasing
self-confidence
ofathleteandteaching
emotionalcon
trol
strategies.
Smallsam
pleof
PTson
lyworking
insports
medi-
cine
intheEast
ofEngland.
8/9
(continued)
6 C. DRIVER ET AL.
Results
Table 3 summarizes the included articles and results of qualityassessment. Fifteen studies that addressed various aspects associ-ated with the use of psychological interventions in physiotherapypractice were included in this systematic review. Nine studiesfocused on sports injuries, four on chronic pain, one on mentalhealth, and one on neurological rehabilitation. The results dis-played common identifiable themes across all practice settingsproviding valuable insight into the knowledge, behaviors, atti-tudes, and beliefs of PTs towards the use of psychological inter-ventions in practice. Table 4, presents the results of thematicanalysis identifying first, second, and third order themes. The fourfirst order themes included: knowledge and behaviors, attitudesand beliefs, perceived barriers, and training needs.
Knowledge and behaviors
Goal setting was described as regularly used in six studies[47,51–55] and was the primary focus for one study.[57]Motivational strategies such as positive reinforcement, motiv-ational talk/interviewing, and effective communication wereapproaches highlighted by PTs in seven studies,[47,51,52,59–62]with positive reinforcement and praise being the most used strat-egy in one study.[61] Social support was identified as an import-ant component in three studies,[51,52,54] and was the main focusof one study.[62] CBT was formally described in three stud-ies,[49,58,61] however, many other studies described techniquesthat fall under CBT-based strategies including activity pacing, self-talk, and cognitive restructuring.
The response for least used interventions was difficult to quan-tify due to heterogeneity of the studies. Teaching emotional con-trol strategies and reducing depression were reported as leastused in three studies,[52,55,60] whilst cognitive restructuring anddistraction methods were mentioned twice, as being rarelyused.[47,49] Although attitudes towards mental imagery was thefocus of one study,[50] reporting that generally PTs attitudes werepositive, it was conveyed as one of the least used (and leastimportant to know about) interventions by PTs in seven of thestudies reviewed.[47,49–51,53,59,60] Relaxation was highlighted asleast used in six studies,[49,51–53,59,60] yet reported as frequentlyused in two studies.[54,58] Furthermore, encouraging social sup-port whilst regarded as important in some studies,[51,52,54,62]was subsequently identified at least used in one study.[55]
Attitudes and beliefs
The majority of studies indicated that PTs acknowledged the psy-chological effects of disability from injury or associated pain andwere aware of the various responses elicited by cli-ents,[47,50–55,60] with some studies identifying that PTs believedstress and anxiety were the most commonly encounteredresponses.[47,53,55] The importance of PTs being able to addresspsychological aspects and offer support during physiotherapypractice was evident in all studies.
All studies confirmed that PTs were aware of psychologicalinterventions either through formal training, clinical practice orvicarious understanding, and overall, PTs held positive attitudestowards psychological interventions in practice. Furthermore,those who had some level of formal training in psychologicalinterventions held more positive attitudes than those without for-mal training,[49,50] and predominantly those with underpinningknowledge valued the importance of psychological skillshigher.[54] In contrast, Holden et al. [61] found that PTs believedTa
ble3.
Continued
Authors
Stud
yaim
Metho
dology
and
participants
Keyfin
ding
sLimitatio
nsQAScore
Quant/9
Qual/2
4
Franciset
al.[60]
Investigatetheview
sof
AustralianPTstowards
theuseof
psycho
logical
skillsin
sports
injury
rehabilitation.
Quantitativedesign
.Survey
adaptedfrom
Sports
Physiotherapists’V
iews
onPsycho
logical
Strategies
Questionn
aire
(PVP
SQ)PTsworking
insports
medicinein
Melbo
urne,A
ustralia.
n¼57
Psycho
logicalcom
ponentswererecogn
ized
byPTsas
beingimpo
rtantin
rehabilitationof
injury.Lackof
know
ledg
ewas
suspectedto
beabarrieras
manyneutralrespo
nses
wererepo
rted
towards
psycho
logicalinterventions.
PTsfeltthemostimpo
rtantfactor
was
goal
setting,
commun
icationand
motivationandtheleastimpo
rtantwererelaxatio
n,teaching
emotionalcon
-trol
strategies
andimagery.PTsexpressedadesire
tolearnmoreabou
tgo
alsetting,
positivereinforcem
ent,un
derstand
ingintrinsicmotivation,
encourag-
ingself-talkandenhancingself-confidence.
Smallsam
pleof
PTson
lyworking
insports
medi-
cine
inMelbo
urne.
8/9
Ninedek
andKo
lt[59]
Exam
ined
theop
inions
ofAu
stralianPTsregarding
therole
ofpsycho
-logicalstrategiesin
rehabilitationwith
sports
injuries.
Quantitativedesign
.Survey
adaptedfrom
PVPSQ.
PTswho
hadcompleted
orwerecompletinga
postgraduate
course
insports
physiotherapyin
Australia.n
¼150
Mosteffectivestrategies
wererepo
rted
tobe
commun
icationskills,andpo
sitive
reinforcem
ent.PTsvalued
goal
setting,
positiveandsincerecommun
ication
andun
derstand
ingmotivationas
mostimpo
rtantto
learnabou
t.Relaxatio
nandimagerywererepo
rted
asleastimpo
rtantforhelpingathletes.
Sampleconsistedon
lyof
PTswho
hador
were
completingsports
physiotherapycourses
atapo
stgraduate
level.
8/9
Ford
andGordo
n[47]
Stud
iedtheview
sof
Australian,
Canadian
andNew
Zealandsports
PTsregardingthe
impo
rtance
ofpsycho
-logicalaspects
ofrehabilitation.
Quantitativedesign
.Survey
mailedto
sports
PTsin
New
Zealand(n¼65),
Australia
(n¼147)
and
Canada
(n¼45).
n¼257
PTsdescrib
edtheimpo
rtance
ofaddressing
psycho
logicala
spects
ofinjury
and
repo
rted
stress
andanxietyas
common
lyseein
injuredathletes.P
Tswere
positivetowards
theuseof
goalsettingandincreasing
confidence
inathletes
andutilizedthesestrategies.Theyalso
ratedtheseas
mostimpo
rtantto
learnabou
t.Co
gnitive
restructuringandimagerywereratedas
least
impo
rtant.
Smallsam
ples
from
Canada
andNew
Zealandandlim
itedto
sports
PTs.
8/9
PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 7
CBT, motivational interviewing and goal setting were moderatelyeffective, yet formal training in these strategies did not increaseperceived effectiveness.
Positive attitudes were identified towards the use of goal set-ting,[47,50] effective communication to increase confidence,[47]positive self-talk, pain tolerance support (coping strategies), men-tal imagery,[50] and activity pacing [56] particularly with regardsto encouraging proactive rehabilitation, adherence to rehabilita-tion, and recovery speed. Social support was also perceived to beeffective for adherence to physical activity programs for schizo-phrenic patients.[62]
Perceived barriers
Barriers affecting the use of psychological interventions in physio-therapy practice were only documented in a few of the includedstudies. Lack of knowledge and understanding from limited formaltraining [49,51,54,58] and lack of practical skills [54,58] werebelieved to be common barriers. Practice and consultation con-straints in the form of time restrictions,[49,51,54,58] cost/reim-bursement issues [49,58] and the perceived need to prioritizephysical care,[51,58] were also frequently described barriers. Otherbarriers included, managing the publics’ expectations of the PTrole,[57,58] role clarity and individual scope of practice,[51,54] andunsure feelings of when or when not to refer a client to apsychologist.[51,58]
Training needs
The discussion of desires for further training in psychological inter-ventions was raised in only some of the included studies. Themost commonly addressed further education needs were effectivegoal setting and communication skills, along with techniques toincrease motivation and client confidence, for example
encouraging positive self-talk and creating variety.[47,53,55,59,60]In the two studies that addressed CBT,[49,58] both raised the issueof wanting CBT training at a postgraduate level.
Discussion
Knowledge and behaviors
A variety of techniques were reported and described by PTs,although sometimes not formally labeled as psychological inter-ventions. Additionally, some studies were focused towards oneintervention in particular whilst others addressed many, and someinvestigated perceptions rather than actual use. For this reason, itwas difficult to quantify and conclude which interventions wereutilized most or least used across the studies. It was apparent thatmany PTs described techniques they employed in practice, butdid not formally label these techniques as psychological interven-tions suggesting there is still much confusion about what PTsbelieve to be actual psychological interventions.
The observed research focus given to examining goal settingin the physiotherapy context is consistent with previous researchin rehabilitation, recognizing it as one of the most widelyaccepted and fundamental interventions for successful physiother-apy practice.[63] Scobbie et al. [63] proposed the development ofa practice framework to implement effective goal setting. Theyoutlined the importance of tailoring the framework to the individ-ual client based on their rehabilitation status, emphasizing the sig-nificance of a systematic method to goal setting in rehabilitationpractice. Two studies in this review [57,61] reported that PTsbelieved goal setting effectiveness may be reduced when clientsare not ready to be actively involved in the process; a further twostudies identified the use of goal setting as a prescription by PTswithout shared ownership with the client,[51,54] which may limiteffectiveness.[63] One study [57] highlighted that PTs believed a
Table 4. Results of thematic analysis of included studies.
1st Order 2nd Order 3rd Order
Knowledge and behaviors Interventions used Goal settingPositive reinforcement, effective communication and motivational talk/interviewingEncouraging positive self-talk and increasing self-confidence (in patient)Creating variety in exercisesEncouraging social supportActivity pacing (CBT)
Interventions identified as least used Mental imageryRelaxation techniquesCognitive restructuring (CBT), distraction methodsTeaching emotional control strategies and reducing depressionEncouraging social support
Attitudes and beliefs Awareness and importance Awareness of the negative impacts of psychological responses to disabilityAware of the benefits of interventions on adherence and rehabilitation outcomesImportance of addressing physical and psychological aspectsIntuitive support rather than structured interventions
Positive attitudes and experiences Positive attitudes towards using in practiceHelps encourage patients to be proactive in rehabilitationAttitudes developed mostly through clinical experience and some trainingTherapeutic relationship integral part of physiotherapy
Perceived Barriers Lack of knowledge and skills Limited formal training (especially at undergraduate level)Lack of understanding of types and appropriateness of interventionsLack of practical skills to confidently implement in practice
Time and money Practice/clinic environment constraints (reimbursement)Consultation limitations (time constraints and client attendance)Perceived need to prioritize physical care due to consultation times
Scope of practice Personal role clarity within individual scope of knowledgePublic perceptions of physiotherapists traditional roleUnsure when to address issues and when to refer
Training needs Training desires and level CBT at postgraduate levelEffective goal setting, communication and motivational techniques for optimal practicePostgraduate training important as clinical experience necessary first
8 C. DRIVER ET AL.
balance between PT lead and patient lead goal setting was essen-tial, but varied dependant on the rehabilitation stage. Accordingly,further education in the most effective methods of goal settingfor PTs through a framework similar to that described by Scobbieet al. [63] may be advantageous.
Motivational interviewing is increasingly being adopted inhealthcare and rehabilitation settings to encourage and motivatebehavior change;[64,65] a concept confirmed by PTs in the morerecent studies in the current review.[61,62] Positive self-talk,[52,53,55] encouraging self-confidence in clients,[51,52,59] andcreating a variety of exercises [52,53,55] were other strategies uti-lized by PTs in the studies reviewed, to encourage participationand engagement in rehabilitation. Such techniques can act toenhance the therapeutic relationship between the health profes-sional and client, adopting a patient-centered approach, promotingengagement, and adherence in physiotherapy programs.[25,66]
Social support and perceived support from peers and PTsthemselves during rehabilitation can have a positive impact onrecovery outcomes and adherence to physiotherapy pro-grams;[26,67,68] a principle perceived important according to PTsworking with patients with schizophrenia in the currentreview.[62] The awareness and willingness of most PTs to offersupport through adopting a therapeutic relationship is evidentthroughout the studies, suggesting that social support is also pre-sented in methods that PTs themselves have not formally identi-fied. This emphasizes the importance of PTs maintaining apositive relationship with their clients, offering support from manyangles and dimensions.
In this review, it was identified by Nielsen et al. [58] andBeissner et al. [49] that PTs felt CBT is relevant and appropriatefor physiotherapy practice and enabled them to encourage clientsto be proactive in their rehabilitation; whilst Holden et al. [61]reported that most PTs surveyed were familiar with CBT and per-ceived it as moderately effective. CBT has been acknowledged asan intervention pivotal to the treatment of lower back pain [22]and CBT-based rehabilitation programs such as the ProgressiveGoal Attainment Program have proven effective in rehabilitatingpatients by identifying psychological risk factors and supportingreturn to work.[17,69] Brunner et al. [22] determined that CBT-based strategies within PT practice for the prevention of lowerback pain, could enable the advancement of active coping strat-egies with patients, and Bryant et al. [70] established that PTstrained in a CBT-based pain coping skills program were able toexhibit a high level of ability during PT sessions. In this review,Scott-Dempster et al. [56] ascertained that PTs using activity pac-ing in chronic pain management needed to adjust their thinkingout of a biomedical model, developing techniques such as reflect-ive listening and experiential learning, and should be utilized aspart of a process rather than a stand-alone treatment.
Cognitive and behavioral change techniques, such as thosementioned (amongst others) can be seen as crucial elementswithin a biopsychosocial model of care and important factors toadopt in order to address the complex nature of disability.Nonetheless, these methods were also described as least used bya few studies, and were not listed as regularly applied in practiceby any study reviewed. This is concerning given the increasingincidence of depression, anxiety, reduced self-efficacy, unsupport-ive coping strategies frustration, and fear avoidance amongstthose living with injury and disability.[1,9,10]
There still remains a limited body of research addressing theappropriateness of CBT within general physiotherapy practice andNielsen et al. [58] outlined that even after training in CBT, PTs felttheir knowledge was still limited. In contrast Holden et al. [61]established that PTs believed training in CBT increased their
confidence, but not perceived effectiveness for rehabilitation.Therefore, research should investigate further the practicality andlogistics of PTs being able to offer this type of intervention andtheir experiences associated with it, as the need for educationregarding the most relevant interventions, and guidance on howto approach behavior change when addressing such issues isapparent. The clinical reasoning model recently proposed byElv�en et al. [71] for PTs, begins to consider this approach; how-ever, further investigation into the effectiveness of such a modeland its applicability within practice is warranted.
This review also highlighted the limited use of mental imageryamongst PTs. Some studies speculate a misunderstanding of thetechnique, and lack of knowledge as the main reasons for theabsence of mental imagery use,[50,51] nevertheless this is not vali-dated in the present studies. Evidence suggests that various formsof mental imagery can have positive effects on adherence torehabilitation,[24,67] re-learning of movements, anxiety, pain lev-els,[23] and coping strategies.[24] Consequently, it may be benefi-cial to address the apparent lack of interest in mental imagerytechniques, to tackle potential barriers and facilitate knowledgeand application in PT practice.
There were notable disparities with regards to reported use ofrelaxation techniques and social support. It is inevitable that prac-tice variations occur, and decision processes of PTs will differwhen deciding which interventions to employ, particularly ifencompassing a patient-centered approach. Accordingly, insightinto the decision processes of PTs when assessing the psycho-logical needs of their patients could prove valuable in evaluatingthe appropriateness, and consequential effectiveness of a chosenintervention.
Attitudes and beliefs
In the studies reviewed, PTs acknowledged the psychologicaleffects associated with rehabilitation. This suggests that the psy-chological impact of disability from injury or disease is evident inclients engaging in physiotherapy, and potentially at a level thatmay affect rehabilitation outcomes. Although most of the studiesinvolved sports injuries, these findings are consistent withresearch regarding other areas of PT practice where it has beenreported that depression, anxiety, and poor self-esteem are com-monly recognized conditions in those living with chronic pain, dis-ability, and cancer.[1,7,72] Additionally, after injuries such as hipfracture, frustration, fear avoidance, and decreased coping strat-egies were evident.[9,10] Psychological support was seen by somePTs in this review as a professional responsibility, and within theboundaries of practice is an essential part of therapy and rehabili-tation.[51,54] PTs also expressed that a therapeutic relationship iscentral to physiotherapy practice, and helped guide the use ofappropriate interventions.[54,56,57,62]
The patient-practitioner relationship has been implicated as akey determinant of adherence to rehabilitation,[2] and researchersadvocate that listening, supporting emotional responses, andencouraging hope are essential components to facilitate effectivepatient-centered practice.[73] Aguilar et al. [74] reported that gain-ing patient trust, understanding individual patient characteristicsand addressing patient-centered care, was considered to be anessential component of PTs professional values. Patients them-selves have also reported the role of PTs as pivotal in improvingrecovery after injury and during cancer treatment, by providingpractical and individualized care and strategies,[10,35] endorsingthe expanding role of PTs.
PTs in the studies reviewed expressed that psychological inter-ventions were beneficial to encourage proactive rehabilitation and
PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 9
adherence to physiotherapy programs. Adherence is a pivotal fac-tor affecting progress and outcomes, and ultimately increasedadherence leads to enhanced rehabilitation both psychologicallyand physically.[4,26,67,75] Much research has investigated theeffects of various types of psychological support during rehabilita-tion specifically with regards to adherence and determinants thatincrease adherence. Levy et al. [68] suggested that in preliminarystages of rehabilitation, education about the injury and its severity(effective communication), task orientated goal setting, andencouraging a positive mindset can help to enhance patientbehavior, setting strong foundations for the recovery process andconsequently increasing adherence. Additionally, Medley andPowell [25] reviewed the use of motivational interviewing afteracquired brain injury, proposing a framework to potentially directclinical practice. Through the incorporation of motivational inter-viewing, Medley and Powell’s [25] model aims to increase self-awareness, intrinsic motivation and consequently, engagement inrehabilitation, and is driven by theories such as self-determinationtheory,[76] stages of change,[77] and self-efficacy.[78] However,there is an identifiable need to test such methods in clinical andindividual settings, and the level of underpinning knowledge inpsychological principles may surpass the current level of know-ledge expected for physiotherapy practice. This notion is endorsedby Holden et al. [61] who reported that training in motivationalinterviewing did not increase confidence or frequency of use inPTs surveyed. Nevertheless, as the attitudes of PTs towards suchapproaches are positive, the opportunity to teach PTs and equipthem with the skills to confidently utilize certain strategies shouldbe taken, to ensure client adherence and optimal outcomes.
Perceived barriers
Lack of knowledge and skills from limited formal training in psy-chological interventions contributed to PTs perceived barriers.Scott-Dempster et al. [56] and Lloyd et al. [57] noted that althoughPTs interviewed reported being experienced in activity pacing andgoal setting respectively, they struggled to explicitly define theirmethods or a theoretical foundation for their knowledge. PTsexpressed that some skills evolved over time, but the focus andapplication of such strategies changed with experience.[57] This issubstantiated in previous research, where it is evident that a vastarray of practice variations exists in the literature with confusionstill apparent amongst PTs. This suggests that a lack of knowledgeand understanding of how, and when to implement psychologicalinterventions may be hindering practice outcomes.[27]
In this review, PTs perceived need to prioritize physical carewas expressed as a barrier. This concept has also been consideredby Mudge et al. [73] in an auto-ethnographical study of physio-therapy practice, highlighting that traditionally the role of PTs wasto address the biomechanical perspective first. Accordingly, astime constraints can inhibit implementation of psychological inter-ventions in practice, the consequential need to prioritize the phys-ical component of rehabilitation, coincides as a barrier resulting inthe potential neglect of a biopsychosocial approach to care.Mudge et al. [73] further described how PTs may still resist theadoption of a biopsychosocial approach, due to the traditionalperceptions of physiotherapy practice, and feel a lack of role clar-ity may inhibit progression away from a biomedical model. This issupported further in the current review where PTs reported bar-riers were associated with role clarity and scope of practice,[51,54]publics’ expectations of PTs,[57,58] and a lack of clarity of whenreferral to a psychologist would be appropriate.[51,58]
The overlapping of roles from physical therapist to psycho-logical therapist may be confusing for both patient and PT.
Although PTs are increasingly accepting this concept even if notfully acknowledged, conflicts may arise about the appropriate con-text and nature of this role.[54] In this review, Barlow et al. [79]indicated that PTs working with clients suffering from chronicpain as a result of physical injury encountered difficulties, and feltconfused, frustrated and unskilled when it came to treating theirclients from a biopsychosocial perspective. Additional researchcorroborates this viewpoint, reporting that rehabilitation staffdealing with elderly patients with orthopedic conditions, believedthey did not have the skills to manage psychological risk factorsidentified in patients and felt they had limited access to psycholo-gists or adequate referral schemes.[9] PTs working in palliativecare similarly described encountering difficulties when dealingwith emotional responses of patients when trying to adapt to lim-ited functionality.[34]
There appears to only be a small body of literature investigat-ing the barriers inhibiting the incorporation of psychological inter-ventions in physiotherapy practice. With considerable evidencepresenting the benefits of psychological interventions as part of abiopsychosocial model of care, it is paramount for further researchto explore potential barriers, in all areas of physiotherapy practice.This would enable a deeper understanding of how such barrierscan be addressed, and what action is necessary to facilitate theuse of appropriate psychological interventions in physiotherapypractice.
Training needs
PTs have described the value of continually updating their know-ledge to ensure professional practice,[74] yet the current reviewsuggests that psychological skills are not being taught at a levelthat is making an impact in the physiotherapy setting. Forexample, goal setting strategies used by PTs in the reviewed stud-ies were largely reported as PT driven and collaboration withpatients proved challenging. Therefore, education aimed towardseffective goal setting using frameworks such as Scobbie et al’s.[63] may be beneficial. Ford and Gordon [80] advocated thatthose working in rehabilitation should be trained to encourageactive participation, aiming to increase patient adherence throughmotivation, education, and realistic goal setting.
In a review of sport psychology education for those working ininjury rehabilitation, Heaney et al. [81] concluded that psycho-logical intervention training could be implemented effectively inboth undergraduate and postgraduate degree programs.However, it was also highlighted that due to the large body ofprofessionals already practicing without such experience, the needto facilitate training for qualified professionals particularly is para-mount. This was evident in the current review where further train-ing in CBT was regarded as important specifically at apostgraduate level, as the need for clinical experience beforetraining in such interventions was perceived as beneficial.[58]
The Ottawa Charter for Health Promotion [82] established thatin order to accomplish reorientation of health services, a focus onprofessional education and training was essential to modify theperceptions of those involved in healthcare, transferring the focusto a whole person approach. The ongoing progression towards abiopsychosocial perspective incorporating psychological interven-tions in rehabilitation is prompting the evaluation of trainingreceived by health professionals involved.[83] Heaney et al. [84]established that the psychological content of physiotherapy pro-grams in UK universities was inconsistent and varied, however, itwas noted that this consisted predominantly of psychologicaleffects of disability, and behavior change. Although the PTs in thecurrent review did not specify behavior change as a training
10 C. DRIVER ET AL.
desire specifically, techniques described that aim to increasemotivation, enhance self-confidence, and encourage participationare all crucial components of behavior change models.Accordingly, the need for behavior change training in physiother-apy practice is vital, in order to support patients as they adapt tonew levels of functionality, and the incorporation of behavioralchange approaches with traditional physiotherapy practice hasbeen shown to result in improved rehabilitation outcomes.[71]
Limitations and future directions
Although a systematic search strategy was applied, it is acknowl-edged that appropriate studies may have unintentionally beenoverlooked, and as unpublished papers were not included, thismay affect conclusions drawn. The heterogeneity of the includedstudies presents issues with regards to generalisability, as theemphasis of psychological interventions differed between thestudies. Nonetheless, the information extracted provides valuableinsight and can be utilized to formulate further research ques-tions. The individual studies have their own limitations that havebeen outlined in Table 3.
The reviewed studies present an international perspective ofthe knowledge, behaviors, attitudes and beliefs of PTs towardsthe use of psychological interventions in multiple practice set-tings. Although the included studies predominantly involved PTsworking with sports injuries and chronic pain (due to the lack ofliterature considering other specialities), common themes wereobvious, across all practice settings. Nonetheless, in light of cur-rent research emphasizing the importance of physiotherapy acrossa range of settings including oncology, HIV/AIDS, palliative care,neurological rehabilitation, and complex mental health; futureresearch should investigate PTs perceptions towards the use ofpsychological interventions across a range of areas, from a cross-sectional perspective. Such information could provide insight in towhether PTs are accepting the role of offering a biopsychosocialmodel of care, incorporating psychological strategies.
This review highlights the demand for knowledge regardingeffective application of psychological interventions in physiother-apy practice. This could direct future research to a gain deeperunderstanding of how to successfully address barriers to imple-mentation and initiate specifically designed, evidence-based pro-fessional development training programs for practicing PTs. Thismay contribute to enabling PTs to confidently utilize psychologicalinterventions during practice. In the long term, such initiativescould improve adherence, rehabilitation outcomes, and quality oflife in all those affected by disability from injury or disease, whilstpotentially reducing chronic conditions, risk of re-injury, and dayslost at work. This could impact substantially on helping to reducethe burden on healthcare systems. Furthermore, it would seemvaluable to address from a settings perspective how clinics, hospi-tals, and practices could provide mechanisms to support PTs toconfidently incorporate psychological interventions as part of abiopsychosocial model of care into everyday practice, without thebarriers outlined in the current review, such as practice and con-sultation limitations. If a biopsychosocial approach is to beembraced, practice guidelines need to provide incentives toencourage all PTs to participate in and adhere to evidence-basedrecommendations.[27]
Conclusion
The aim of this systematic review was to identify the knowledge,behaviors, attitudes, and beliefs of PTs towards the use of psycho-logical interventions in physiotherapy practice. Attitudes and
beliefs were overall positive towards the use of psychologicalinterventions in practice across all areas. A variety of techniquesincluding goal setting, CBT, creating variety in exercises, positive,and motivational talk, social support, and mental imagery weredescribed by PTs as interventions used in practice. Nonetheless,substantial barriers preventing incorporation of such techniquesare still apparent, including the need for supplementary trainingin specific psychological interventions such as goal setting, CBT,effective communication, motivational, and behavior changestrategies.
Disclosure statement
The authors report no declarations of interest.
References
[1] World Health Organization. World report on disability.Geneva: UN World Health Organization; 2011.
[2] Wright BJ, Galtieri NJ, Fell M. Non-adherence to prescribedhome rehabilitation exercises for musculoskeletal injuries:the role of the patient-practitioner relationship. J RehabilMed. 2014;46:153–158.
[3] Tracey J. Inside the clinic: health professionals’ role in theirclients’ psychological rehabilitation. J Sport Rehabil.2008;17:413–431.
[4] Brewer BW. The role of psychological factors in sport injuryrehabilitation outcomes. Int Rev Sport Exerc Psychol.2010;3:40–61.
[5] Brewer BW, Andersen MB, Van Raalte JL. Psychologicalaspects of sport injury rehabilitation: toward a biopsychoso-cial approach. In: Mostofsky DL, Zaich- kowsky LD, editors.Medical and psychological aspects of sport and exercise.Morgantown, WV: Fitness Information Technology; 2002.P.41–54.
[6] Ojala T, H€akkinen A, Karppinen J, et al. Chronic pain affectsthe whole person-a phenomenological study. DisabilRehabil. 2015;37:363–371.
[7] National pain stategy. Pain Australia: working to preventand manage pain. nps 2010 [cited 2015 Mar 15]. Availablefrom: http://www.painaustralia.org.au/images/pain_austra-lia/NPS/National%20Pain%20Strategy%202011.pdf.
[8] Nijs J, Roussel N, Paul van Wilgen C, et al. Thinking beyondmuscles and joints: therapists’ and patients’ attitudes andbeliefs regarding chronic musculoskeletal pain are key toapplying effective treatment. Man Ther. 2013;18:96–102.
[9] Proctor R, Wade R, Woodward Y, et al. The impact of psy-chological factors in recovery following surgery for hip frac-ture. Disabil Rehabil. 2008;30:716–722.
[10] Sleney J, Christie N, Earthy S, et al. Improving recovery-learning from patients’ experiences after injury: a qualita-tive study. Injury. 2014;45:312–319.
[11] Sullivan MJL, Feuerstein M, Gatchel R, et al. Integrating psy-chosocial and behavioral interventions to achieve optimalrehabilitation outcomes. J Occup Rehabil. 2005;15:475–489.
[12] Australian Physiotherapy Association. 2015. What is physio-therapy? [Cited 2015 Mar 15]. Available from: http://www.physiotherapy.asn.au/APAWCM/Physio_and_You/physio/APAWCM/Physio_and_You/physio.aspx?hkey¼25ad06f0-e004-47e5-b894-e0ede69e0fff%3E.
[13] American Physical Therapy Association. 2014. Who arephysical therapists? [Cited 2015 Mar 15]. Available from:http://www.apta.org/AboutPTs/%3E.
PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 11
[14] Chartered Society of Physiotherapy. 2013. What is physio-therapy? [Cited 2015 Mar 15]. Available from: http://www.csp.org.uk/your-health/what-physiotherapy%3E.
[15] MacLachlan M, Mannan H. The world report on disabilityand its implications for rehabilitation psychology. RehabilPsychol. 2014;59:117–124.
[16] Koch S. Achieving holistic health for the individual throughperson-centered collaborative care supported by informat-ics. Healthc Inform Res. 2013;19:3–8.
[17] Sullivan MJL, Adams H. Psychosocial treatment techniquesto augment the impact of physiotherapy interventions forlow back pain. Physiother Can. 2010;62:180–189.
[18] Scherzer CB, Brewer BW, Cornelius AE, et al. Psychologicalskills and adherence to rehabilitation after reconstructionof the anterior cruciate ligament. J Sport Rehabil. 2001;10:165–172.
[19] Skolasky RL, Riley LH, Maggard AM, et al. Functional recov-ery in lumbar spine surgery: a controlled trial of healthbehavior change counseling to improve outcomes.Contemp Clin Trials. 2013;36:207–217.
[20] Te Wierike SCM, Van Der Sluis A, Van Den Akker-Scheek I,et al. Psychosocial factors influencing the recovery of ath-letes with anterior cruciate ligament injury: a systematicreview. Scand J Med Sci Sports. 2013;23:527–540.
[21] Scobbie L, Wyke S, Dixon D. Identifying and applying psy-chological theory to setting and achieving rehabilitationgoals. Clin Rehabil. 2009;23:321–333.
[22] Brunner E, De Herdt A, Minguet P, et al. Can cognitivebehavioral therapy based strategies be integrated intophysiotherapy for the prevention of chronic low back pain?A systematic review. Disabil Rehabil. 2013;35:1–10.
[23] Cupal DD, Brewer BW. Effects of relaxation and guidedimagery on knee strength, reinjury anxiety, and pain follow-ing anterior cruciate ligament reconstruction. RehabilPsychol. 2001;46:28–43.
[24] Driediger M, Hall C, Callow N. Imagery use by injured ath-letes: a qualitative analysis. J Sports Sci. 2006;24:261–271.
[25] Medley AR, Powell T. Motivational interviewing to promoteself-awareness and engagement in rehabilitation followingacquired brain injury: a conceptual review. NeuropsycholRehabil. 2010;20:481–508.
[26] Mitchell I, Evans L, Rees T, et al. Stressors, social support,and tests of the buffering hypothesis: effects on psycho-logical responses of injured athletes. Br J Health Psychol.2014;19:486–508.
[27] Foster NE, Delitto A. Embedding psychosocial perspectiveswithin clinical management of low back pain: integration ofpsychosocially informed management principles into phys-ical therapist practice-challenges and opportunities.Physical Ther. 2011;91:790–803.
[28] Stubbs B, Soundy A, Probst M, et al. Addressing the dispar-ity in physical health provision for people with schizophre-nia: an important role for physiotherapists. Physiotherapy(UK). 2014;100:185–186.
[29] Rosenbaum S, Tiedemann A, Stanton R, et al. Implementingevidence-based physical activity interventions for peoplewith mental illness: an Australian perspective. AustralasPsychiatry. 2016;24:49–54.
[30] Stubbs B, Soundy A, Probst M, et al. Understanding therole of physiotherapists in schizophrenia: an internationalperspective from members of the InternationalOrganization of Physical Therapists in Mental Health(IOPTMH). J Ment Health. 2014;23:125–129.
[31] Holley J, Crone D, Tyson P, et al. The effects of physical activ-ity on psychological well-being for those with schizophrenia:a systematic review. Br J Clin Psychol. 2011;50:84–105.
[32] Braun S, Beurskens A, Kleynen M, et al. Rehabilitation withmental practice has similar effects on mobility as rehabilita-tion with relaxation in people with Parkinson’s disease: amulticentre randomised trial. J Physiother. 2011;57:27–34.
[33] Stretton C, Mudge S, Kayes NM, et al. Activity coaching toimprove walking is liked by rehabilitation patientsbut physiotherapists have concerns: a qualitative study.J Physiother. 2013;59:199–206.
[34] Taylor HN, Bryan K. Palliative cancer patients in the acute hos-pital setting – physiotherapists attitudes and beliefs towardsthis patient group. Prog Palliat Care. 2014;22:334–341.
[35] Pidlyskyj K, Roddam H, Rawlinson G, et al. Exploring aspectsof physiotherapy care valued by breast cancer patients.Physiotherapy (UK). 2014;100:156–161.
[36] Pullen S, Gilman K, Hunt K, et al. Physical therapy as anadjunct treatment for people living with HIV/AIDS: an alliedhealth perspective. J Allied Health. 2014;43:e11–e17.
[37] Bancroft MI. Physiotherapy in cancer rehabilitation: a theor-etical approach. Physiotherapy. 2003;89:729–733.
[38] Synnott A, O'Keeffe M, Bunzli S, et al. Physiotherapists maystigmatise or feel unprepared to treat people with lowback pain and psychosocial factors that influence recovery:a systematic review. J Physiother. 2015;61:68–76.
[39] Alexanders J, Anderson A, Henderson S. Musculoskeletalphysiotherapists’ use of psychological interventions: a sys-tematic review of therapists’ perceptions and practice.Physiotherapy. 2015;101:95–102.
[40] Moher D, Liberati A, Tetzlaff J, et al. Preferred reportingitems for systematic reviews and meta-analyses: thePRISMA statement. BMJ (Online). 2009;339:332–336.
[41] Law M, Stewart D, Pollock N, et al. Guidelines for criticalreview form – Quantitative studies. Hamilton, Canada:McMaster University Occupational Therapy Evidence BasedPractice Research Group; 1998.
[42] Letts L, Wilkins S, Law M, et al Guidelines for critical reviewform – Qualitative studies Vol. 2. Hamilton, Canada:McMaster University Occupational Therapy Evidence BasedPractice Research Group; 2007.
[43] Steel DM, Gray MA. Baby boomers’ use and perception ofrecommended assistive technology: a systematic review.Disabil Rehabil Assist Technol. 2009;4:129–136.
[44] Shields N, Synnot AJ, Barr M. Perceived barriers and facilita-tors to physical activity for children with disability: a sys-tematic review. Br J Sports Med. 2012;46:989–997.
[45] Anaf S, Sheppard LA. Physiotherapy as a clinical service inemergency departments: a narrative review. Physiotherapy.2007;93:243–252.
[46] Braun V, Clarke V. Using thematic analysis in psychology.Qual Res Psychol. 2006;3:77–101.
[47] Ford IW, Gordon S. Perspectives of sport physiotherapists onthe frequency and significance of psychological factors inprofessional practice: implications for curriculum design inprofessional training. Aust J Sci Med Sport. 1997;29:34–40.
[48] Heaney C. Physiotherapists’ perceptions of sport psych-ology intervention in professional soccer. Int J Sport ExercPsychol. 2006;4:73–86.
[49] Beissner K, Henderson CR, Jr Papaleontiou M, et al. Physicaltherapists’ use of cognitive-behavioral therapy for olderadults with chronic pain: a nationwide survey. Phys Ther.2009;89:456–469.
12 C. DRIVER ET AL.
[50] Hamson-Utley JJ, Martin S, Walters J. Athletic trainers’ andphysical therapists’ perceptions of the effectiveness of psy-chological skills within sport injury rehabilitation programs.J Athl Train. 2008;43:258–264.
[51] Arvinen-Barrow M, Penny G, Hemmings B, et al. UK char-tered physiotherapists’ personal experiences in using psy-chological interventions with injured athletes: aninterpretative phenomenological analysis. Psychol SportExerc. 2010;11:58–66.
[52] Lafferty ME, Kenyon R, Wright CJ. Club-based and non-club-based physiotherapists’ views on the psychologicalcontent of their practice when treating sports injuries. ResSports Med. 2008;16:295–306.
[53] Arvinen-Barrow M, Hemmings B, Weigand D, et al. Views ofchartered physiotherapists on the psychological content oftheir practice: a follow-up survey in the UK. J Sport Rehabil.2007;16:111–121.
[54] Jevon SM, Johnston LH. The perceived knowledge and atti-tudes of governing body chartered physiotherapist towardsthe psychological aspects of rehabilitation. Phys Ther Sport.2003;4:74–81.
[55] Hemmings B, Povey L. Views of chartered physiotherapistson the psychological content of their practice: a preliminarystudy in the United Kingdom. Br J Sports Med. 2002;36:61–64.
[56] Scott-Dempster C, Toye F, Truman J, et al. Physiotherapists’experiences of activity pacing with people with chronicmusculoskeletal pain: an interpretative phenomenologicalanalysis. Physiother Theory Pract. 2014;30:319–328.
[57] Lloyd A, Roberts AR, Freeman JA. ‘Finding a balance’ ininvolving patients in goal setting early after stroke: aphysiotherapy perspective. Physiother Res Int. 2014;19:147–157.
[58] Nielsen M, Keefe FJ, Bennell K, et al. Physical therapist-delivered cognitive-behavioral therapy: a qualitative studyof physical therapists perceptions and experiences. PhysTher. 2014;94:197–209.
[59] Ninedek A, Kolt GS. Sport physiotherapists’ perceptionsof psychological strategies in sport injury rehabilitation.J Sport Rehabil. 2000;9:191–206.
[60] Francis SR, Andersen MB, Maley P. Physiotherapists’ andmale professional athletes’ views on psychological skills forrehabilitation. J Sci Med Sport. 2000;3:17–29.
[61] Holden J, Davidson M, O'Halloran P. Motivational strategiesfor returning patients with low back pain to usual activities:a survey of physiotherapists working in Australia. Man Ther.2015;20:842–849.
[62] Soundy A, Freeman P, Stubbs B, et al. The value of socialsupport to encourage people with schizophrenia to engagein physical activity: an international insight from specialistmental health physiotherapists. J Ment Health. 2014;23:256–260.
[63] Scobbie L, Dixon D, Wyke S. Goal setting and action plan-ning in the rehabilitation setting: development of a theor-etically informed practice framework. Clin Rehabil.2011;25:468–482.
[64] Elwyn G, Dehlendorf C, Epstein RM, et al. Shared decisionmaking and motivational interviewing: achieving patient-centered care across the spectrum of health care problems.Ann Fam Med. 2014;12:270–275.
[65] Lal S, Korner-Bitensky N. Motivational interviewing: a novelintervention for translating rehabilitation research intopractice. Disabil Rehabil. 2013;35:919–923.
[66] Mertens VC, Goossens MEJB, Verbunt JA, et al. Effects ofnurse-led motivational interviewing of patients with chronicmusculoskeletal pain in preparation of rehabilitation treat-ment (PREPARE) on societal participation, attendance level,and cost-effectiveness: study protocol for a randomizedcontrolled trial. Trials. 2013;14:90.
[67] Levy AR, Polman RCJ, Nicholls AR, et al. Sport injuryrehabilitation adherence: perspectives of recreational ath-letes. Int J Sport Exerc Psychol. 2009;7:212–229.
[68] Levy AR, Polman RCJ, Clough PJ. Adherence to sport injuryrehabilitation programs: an integrated psycho-socialapproach. Scand J Med Sci Sports. 2008;18:798–809.
[69] Raftery MN, Murphy AW, O'Shea E, et al. Effectiveness of acognitive behavioral therapy-based rehabilitation program(progressive goal attainment program) for patients who arework-disabled due to back pain: study protocol for a multi-centre randomized controlled trial. Trials. 2013;14:290.
[70] Bryant C, Lewis P, Bennell KL, et al. Can physical therapistsdeliver a pain coping skills program? an examination oftraining processes and outcomes. Phys Ther.2014;94:1443–1454.
[71] Elv�en M, Hochw€alder J, Dean E, et al. A clinical reasoningmodel focused on clients’ behavior change with referenceto physiotherapists: its multiphase development and valid-ation. Physiother Theory Pract. 2015;31:231–243.
[72] Cardoso G, Graca J, Klut C, et al. Depression and anxietysymptoms following cancer diagnosis: a cross-sectionalstudy. Psychol Health Med. 2016;21:562–570.
[73] Mudge S, Stretton C, Kayes N. Are physiotherapists com-fortable with person-centred practice? an autoethnographicinsight. Disabil Rehabil. 2014;36:457–463.
[74] Aguilar A, Stupans I, Scutter S, et al. Exploring the profes-sional values of Australian physiotherapists. Physiother ResInt. 2013;18:27–36.
[75] Pizzari T, Taylor NF, McBurney H, et al. Adherence torehabilitation after anterior cruciate ligament reconstructivesurgery: implications for outcome. J Sport Rehabil.2005;14:201–214.
[76] Deci EL, Ryan RM. Intrinsic motivation and self-determin-ation in human behavior. New York: Plenum; 1985.
[77] Prochaska J, DiClemente C. The transtheoretical approach:crossing traditional boundaries of therapy. Chicago: DowJones/Irwin; 1984.
[78] Bandura A. Social learning theory. Englewood Cliffs:Prentice-Hall; 1977.
[79] Barlow S, Stevens J. Australian physiotherapists and theirengagement with people with chronic pain: Do theiremotional responses affect practice? J MultidisciplinaryHealthcare. 2014;7:231–237.
[80] Ford IW, Gordon S. Perspectives of sport trainers and ath-letic therapists on the psychological content of their prac-tice and training. J Sport Rehabil. 1998;7:79–94.
[81] Heaney CA, Walker NC, Green AJK, et al. Sport psychologyeducation for sport injury rehabilitation professionals: a sys-tematic review. Phys Ther Sport. 2015;16:72–79.
[82] World Health Organization. Ottawa charter for health pro-motion. Health Promot Int. 1986;1:405.
[83] S€oderlund LL, Madson MB, Rubak S, et al. A systematicreview of motivational interviewing training for generalhealth care practitioners. Patient Educ Couns. 2011;84:16–26.
[84] Heaney CA, Green AJK, Rostron CL, et al. A qualitative andquantitative investigation of the psychology content of UKphysiotherapy education. J Phys Ther Educ. 2012;26:48–53.
PSYCHOLOGICAL INTERVENTIONS IN PHYSIOTHERAPY 13