Pain: remember me? Significance of psychosocial factors in affecting motor skill training


I have discussed the idea that cortical reorganisation occurs among many pain states. The greater the chronicity of pain the greater the neuroplastic changes. Exercise; particular motor skill training in particular can assist in the reversal of such maladaptations.

Towards the end of my previous post I made a comment regarding the pyschosocial factors having have a comparable effect on learning like that of that under the influence of pain, novel skill acquisition is reduced.

Physiotherapy is moving to a much more psychosocial focused paradigm. I would like to end my blogging experience by touching on the role of pyschosocial factors within neuroplasticity.

It is well evidenced that the experience of pain is shaped by a whole host of cognitive and behavioural factors and that some factors such as fear, anxiety, beliefs regarding pain, avoidance of movement and mood are shown to be prognostic factors in the development of chronic pain (Linton & Shaw 2011).


Image 1. A modern view of pain perception from a psychological perspective according to Linton (2005)

Out with the old in with the new

The body; a large widespread network of neurones that consists of loops between  the thalamus and cortex and cortex and the limbic system is an entire network, whose spatial distribution and synaptic links are determined initally by genetics but later sculptured by sensory inputs is termed a ‘neuromatrix’. The ongoing cycle of processing and synthesis of nerve impulses through the neuromatrix impart a characteristic pattern known as the neurosignature. The neuromatrix is genetically progammed to perform the specific function of producing the signature pattern. It is distributed throughout many areas of the brain and generates patterns and processes information that travels through it and ultimately produces a pattern reflecting the whole body.

Appreciatively this view is largely different to the previous notion that the pain experience is proportional to peripheral injury or pathology. Previous pain theories; pattern theory and the pain gate theory have paved the way for this neuromatrix concept. 

In persistent pain states there is an associated with overactivity of the pain neuromatrix increased activity is present in a number of cortical areas within the brain; insula, anterior cingulate cortex, prefrontal cortex (Seifort and Maihofner 2009). The amygdala is one key brain area involved in the pain neuromatrix often referred to as the  memory centre of fear. It plays a primary role in the processing of memory, decision making and emotional reactions. negative emotions and pain related memories. Evidence through neuroimaging suggests that the amygdala plays a key part in facilitating the development of chronic pain and the increase in sensitivity of the central nervous system pain pathways ( Simons et al 2012).

What does this mean in practice? The significance of this in practice is the recognition of the brain and in particular the amygdala’s role in pain memory. In particular memories of painful movement. The amygdala’s collaboration with the hippocampus and anterior cingulate cortex can explain the display of antalgic postures, gait and altered motor control in chronic pain patients (Nijs et al 2015). This understanding signifies how a patient who has had a previous painful experience that associate’s pain as being harmful can display maladaptive movement without the presence of nociceptive input.

Getting the best out of  exercise: changing pain memories

Cognition targeted exercise in patients with chronic pain can be effective in changing pain memories in patients with chronic musculoskeletal pain and centeral sensitisation (Nijis et al 2014). Cognition targeted exercise is an approach that focuses on addressing patients perceptions about exercise through thorough questioning and discussion before during and after exercise. It is an approach that is not time contingent like driving plasticity with icreased number of repetition but  symptom contingent (Nijis 2015).

I hope my blog has been purposeful in that when  you are next treating a patient with persistent pain you may question, what affect you are hoping to have and where. This may drive how you treat them and consequently facilitate your outcomes.

Thankyou for taking the time to read.


Linton S and Shaw W. Impacet of Psychosocial Factors in the experience of Pain. Physical Therapy 2011;91:700-711

Nijis J, Meeus M, Cagnie B, Roussel NA, Dolphens M, Van Oosterwijck J. A modern  neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Phys Ther 2014;94(5):730-8

Nijis J, Girbes E, Lundberg M, Malfliet A and Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual Therapy 2015;20:216-22

Seifart F and Maihofner C. Central mechanisms of experimental and chronic neuropathic pain: findings from neuropathic pain: findings from functional imaging studies. Cell Mol Life Sci: CMLS 2009;66:375-90

Simons LE, MoultonEA, Linnman C, Carpino E, Beccera L, Borsook D. The human amygdala and pain:evidence from neuroimaging. Hum Brain Mapp 2012;25:2199


Motor Learning in Musculoskeletal practice

As mentioned in my previous blog a common example of neural adaptation is learning.
In novel motor skill acquisition cortical neuroplastic changes are frequently associated with an advantageous change such as an increase in motor performance. Conversely, in persistent pain neuroplastic changes are often linked with unfavourable behaviour such as a decrease in motor performance.
As altered motor performance is thought to be a factor for the maintenance of pain, motor rehabilitation approaches that aim to re-establish normal motor strategies are an important factor to consider in the treatment of musculoskeletal pain disorders.


Image 1. New theory of Motor Adaptation to pain. (Hodges and Tucker 2011)

Learning from each other.  Collaboration between specialities

Much of the evidence that underpins the basis of neuroplasticity and the potential for re establishing normal motor strategies in musculoskeletal patients is based on evidence in patients with neurological disorders.

Recognising neuroplasticity as a component in patients with musculoskeletal dysfunction may lead to a greater understanding of neural mechanisms that influence musculoskeletal dysfunction. By addressing maladaptive neural organisation through the recognition of neuroplasticity the effectiveness of treatments that target motor behaviour such as movement quality and muscular strength could be improved.(Snodgrass et al 2014)
In stroke the best evidence based inventions that demonstrate a positive effect on neuroplasticity and motor learning are intensive repetitive practice and task specific training (Richards et al 2008, Van vliet 1993 and French et al 2007).
Although there is new found evidence in the role of neuroplasticity within musculoskeletal practice musculoskeletal Physiotherapists continue to be guided by exercise protocols justified through clinical trials (Bystrom et al 2013)

Shaping our practice

Prior to now I had not really considered the relation between pain and altered motor performance in the context of cortical reorganisation. I certainly never contemplated the principles of inducing plasticity when treating my patients.

Numerous studies have identified through the use of functional magnetic resonance imaging (fMRI) that during a painful experience there is an increase in activity in specific areas of the brain. These include the primary and secondary somatosensory cortex, insular, anterior cingulate cortex, prefrontal cornices and thalamus. (Peyron et al 2000, Henry 2000, Apkarian et al 2005)

Novel motor skill training in healthy individuals compared to passive assistance or repetitions of general exercise has been shown to improve task performance and provide an increase in representation of the trained muscle in the motor cortex (Karni et al 1995, Pascual-Leone et al 1995, Svensson et al 2003, Hlustik et al 2004).


Image 2. Primary motor cortex homunculous (Wikipedia)

Svensson et al 2003 showed during one week of novel tongue task training an increase in motor representation of the tongue muscle occurred and that there was an increase in cortical excitability of the tongue primary motor cortex. Increased cortical excitability was also demonstrated for the hand primary motor cortex following novel motor training in a study by Koeneke et al 2006.

Furthermore both studies suggest that neuroplastic changes in the motor cortex can occur over a short period. Improvements in motor performance and rapid changes in cortical excitability of the tongue primary motor cortex occurred immediately after just 15 minutes of novel tongue task training.

Based on the evidence that novel motor skill training is associated with rapid changes in cortical excitability and cortical reorganisation this training approach is considered relevant in the treatment of patients with musculoskeletal pain and movement dysfunction.          Image result for bOUDREAU 2010 MOTOR SKILL TRAINING

Figure 3. Cortical maps of the face primary motor cortex. Expansion of the tongue muscle representation following novel task training. (Svensson et al 2003)

Training the activation of a delayed or inhibited muscle through the use of repeated isolated voluntary contraction is an effective clinical approach commonly used in the management of musculoskeletal pain disorders.
Tsao et al, 2010 observed that maladaptive changes in the motor cortex reverted towards that of a healthy individual with task specific exercises in persons with low back pain.
Transcranial Magnetic Stimulation (TMS) revealed that deep abdominal muscle training consisting of voluntary activation of the Transverse Abdominals (TrA) independently from other trunk muscles induced an anterior and medial shift in motor cortical representation of the trained muscle towards that of healthy asymptomatic individuals in persons with low back pain compared to that of walking as a control intervention.
Subjects were positioned in crook lying and were instructed to activate their TrA. Electromyographic activity recorded the contraction once patients could activate with little use from their abdominals, contractions were held for 10 seconds whilst continuing to breath . 3 sets of 10 were performed twice a day.
Those in the control group were required to walk at their own pace for 10 minutes twice a day for 2 weeks.
Although the basis of using this approach is based on the principle of novel motor skill training, further key components in motor skill strategies have emerged that could advance  rehabilitation outcomes.

Skill or Strength

Motor skill training requires great skill and a high level of attention and precision in comparison to the mere contraction of a group of muscles such as strength training. A study by Remple et al 2001, identified that motor skill training coupled with strength training did not promote any greater cortical neuroplastic changes in the motor cortex compared to motor skill training alone. These findings are in keeping with the study by Tsao et al 2010, that showed an increase in reorganisation of the motor cortex following skilled training compared to that of just walking. The observation of improvements in the amplitude and speed of activation of the deep cervical flexor muscles through isolated training of these muscles as opposed to strengthening exercise in patients with neck pain further support the importance of motor skill training over strength training (Jull et al 2009).

Role of pain

Many studies that have examined the effects of acute experimental pain have found that pain can alter the excitability of the motor cortex.
Compared to the rapid changes that are associated with motor skill acquisition, the changes in cortical excitability that occur in association with experimental pain or persistent pain do not necessarily correspond to the muscle groups represented in the motor cortex. For example induced pain at the finger in a study by Koflet et al 1998, revealed an induced increase in excitability of the hand primary motor cortex but at the same time a decrease in excitability of the upper arm muscles. These pain related changes in excitability of the motor cortex may suggest why patients move differently when in pain. The findings would help to explain why maladaptive movements occur but not necessarily at the location of where we would expect.

Incremental gains in task performance have been shown not to occur when pain is present this is thought to be due to the effect that pain has on suppressing the rapid increase in cortical excitability (Boudreau et al 2007).
The belief that pain hinders novel skill acquisition is in keeping with other factors that are well known to hinder learning unfortunately such are commonly found in chronic pain patients. These include increased stress, reduced cognition, reduced quality of sleep and attention deficit.

What is the purpose?

A goal orientated sequential finger tapping task was associated with a significant increase in representation of the trained muscle in the motor cortex compared to a protocol that required mental rehearsal of the finger tapping task and even more so than the random performing of the finger tapping task.
Altering the complexity of the task was noted to further enhance cortical neuroplastic changes. A complex finger tapping task compared to a simple finger tapping task showed additional areas of cortical activation under fMRI (Pascual-Leone et al 1995). These findings suggest that purposful meaningful tasks that require cognitive effort contribute significantly to the extent of cortical neuroplastic changes.

How many repetitions? Quality versus Quantity

Hundreds of repetitions of movement in varying contexts are necessary for inducing cortical change (van Vliet et al 2012). However, it is important to remember that this is not always achievable without the presence of pain. As mentioned earlier pain does not support novel motor skill acquisition. There has been studies that suggest the use of imagery when pain prevents a patient from performing the task. Boudreau et al 2010, suggested that if rapid changes in cortical excitability are apparent following short training sessions (approx 60 within-session task repetitions over the course doc 10-15 minutes) such a high number of repetitions isn’t actually required and therefore the number of task repetitions should be based upon all of the principles discussed through the course of this post in order to improve the performance of a motor task.


Apkarian AV, Bushnell MC, Treede RD and Zubieta JK. Human brain mechanisms of pain perception and regulation in health and disease. Eur J Pain 2005;9:463-84 doi:10.1016/j.ejpain.2004.11.001

Boudreau S, Farina D and Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy 2010;15:410-414

Bystrom M, Rasmussen-Barr R and Grooten W. Motor control exercises reduces pain and disability in chronic and recurrent low back pain a matter analysis. Spin 2013; 38(6):E350-8

Figure 2. Cortical homonculous available at: last accessed 23/11/15

French B, Thomas LH, Leathley MJ, Sutton CJ, McAdam J and Forster A et al. Repetitive task training for improving functional ability after stroke. Cochrane database Syst Rev 2007 (4):CD006073

Hlustik P, Solodkin A, Noll DC and Small SL. Cortical plasticity during three-week motor skill learning. Journal of Clinical Neurophysiology 2004;21(3):180-91

Henry P, Creac’h C, Caille JM, and Allard M. Functional magnetic resonance imaging analysis of pain related brain activity after acute mechanical stimulation. American Journal of neuroradiology 2000;21:1402-1406

Hodges P and Tucker K. Moving differently in pain: A new theory to explain the adaptation to pain. Pain 2011;152:90-98

Jull GA, Falla D, Vicenzino B and Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy 2009;14(6):696-701

Koeneke S, Lutz K, Herwig U, Ziemann U and Jancke L. Extensive training of elementary finger tapping movements changes the pattern of motor cortex excitability. Experimental Brain Research 2006;174(2):199-209

Karni A, Meyer G, Jezzard P, Adams MM, Turner R and Ungerleider LG. Functional MRI evidence for adult motor cortex plasticity during motor skill learning. Nature 1995;377(6545):155-8

Kofler M, Glocker FX, Leis AA, Seifert C, Wissel J, Kronenberg MF and Fuhr P. Modulation of upper extremity motoneurone excitability following noxious finge tip stimulation in man: a study with transcranial magnetic stimulation. Neurosci Lett 1998;246:97-100

Pascual-Leone A, Nguyet D, Cohen LG, Brasil-Neto JP, Cammarota A, and Hallett M. Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. Journal of Neurophysiology 1995;74(3):1037-45

Peyron R, Laurent B and Garcia-Larrea L. Functional imaging brain responses to pain: a review and meta analysis. Neurophysiol Clin 2000;30:263-88

Remple MS, Bruneau RM, Vandenberg PM, Goertzen C and Kleim JA. Sensitivity of cortical movement representations to motor experience: evidence that skill learning but not strength training induces cortical reorganization. Behavioral Brain Research 2001;123(2):133-41

Richards LG, Stewert KC, Woodbury ML, Sensec C and Cauraugh  JH. Movement dependent stroke recovery: a systematic review and meta-analysis of TMS and fMRI evidence. Neurophy 2008;46:3-11

Snodgrass S Heneghan N, Tsao H, Stanwell P, Rivett D  and Van Vliet P. Recognising neuroplasticity in musculoskeletal rehabilitation: a basis for greater collaboration between musculoskeletal and neurological physiotherapists. Manual Therapy 2014; 19:614-617

Svenson P, Romaniello A, Arendt-Nielson L and Sessle BJ. Plasticity in corticomotor control of the human tongue musculature induced by tongue-task training. Experimental Brain Research 2003;152(1):42-51

Tsao H, Galae M and Hodges P. Driving plasticity in the motor cortex in the current low back pain European Journal of pain 2010

Van Vliet PM, Matyas T and Carey LM. Training principles to enhance learning-based rehabilitation and neuroplasticity. In: Carey LM, editor. Stroke Rehabilitation: insights from neurosciences and imaging. Oxford: University Press: 2012. pp. 115-26. ch. 9








The bigger picture: Pain and Cortical Change

Neuroplasticity has been defined as “the ability of the nervous system to respond to intrinsic and extrinsic stimuli by reorganising its structure, function and connections” (Cramer 2010)

A common example of neural adaptation that all can relate to is learning. Most I am sure have heard the term ‘practice makes perfect’ and some are aware of conditioning paradigms; remember being told the story of Pavlov and his experiment with dogs?

Central sensitisation is another example of adaptation. Allodynia and Hyperalgesia are known to be a symptom of central sensitisation and occur as a consequence of repeated activation of spinal nociceptors. Both symptoms can provide a biological advantage by increasing sensitivity to peripheral inputs. Increased sensitivity can potentially optimise the possibility of tissue healing and assist in preventing further injury. However ongoing sensitisation can pose a problem of its own when its benefit is lost such as in chronic pain.
It is well evidenced that among individuals with chronic pain the mere thought of a task can evoke pain and swelling. Equally, the observing a task  can elicit a painful response and the development of swelling though no action has taken place (Acerra and Mosely, 2005 and Mosely 2004).

Phantom limb pain and neuropathic pain following spinal cord injury were among the first pain states that identified a relation between pain and primary sensory cortex reorganisation. However, a wealth of evidence has since emerged that suggests a similar correlation exists  in patients with chronic musculoskeletal pain.

Mercier and Leonard, 2011 carried out a review that looked at the relation between pain and the motor cortex in patients with phantom limb pain and complex regional pain syndrome. Due to my musculoskeletal bias and purpose of this blog I shall  cover findings around complex regional pain syndrome.The review found that indeed there was evidence of change in motor cortex reorganisation in patients with complex regional pain syndrome.  The size of cortical representation of muscles on the affected side was found to be reduced in comparison to the unaffected side. Intra-cortical inhibition was found to be reduced in the motor cortex again in the unaffected side or bilaterally. Consistent with this reduced inhibition, an fMRI study showed that during a finger tapping exercise there was greater activation within the motor cortex and other areas when the exercise was performed by the affected hand compared to the unaffected. Such findings support that these alterations in motor function may be as a consequence of changes at cortical level and not just peripheral or spinal level.The review highlighted that several other factors may contribute to the reorganisation in the motor cortex other than pain alone as patients with chronic pain often have other sensorimotor defecits that could have an impact of motor-cortex excitability.  Motor  cortex  reorganisation was also thought to be dependent on the chronicity of the pain. The review hypothesised that cortical changes may also vary  dependent on the pain population. This hypothesis was based on studies that observed changes that occur at the level of somatosensory cortices. In patients with phantom limb pain and complex regional  pain the representation of the painful area decreased but increased in patients with low back pain and patients suffering from fibromyalgia. Thus suggesting cortical responses are specific to pathologies. The review posed the question: is it pain that drives plasticity within the motor cortex or, conversely does the motor cortex plasticity contribute to the development of chronic pain? Attempting to cover this may make me diverse somewhat and so I welcome ideas from the reader.

Camille et al, 2015 investigated whether there was a difference in motor cortical organisation among those with knee osteoarthritis (OA). The study  aimed to ascertain whether there was an association between cortical organisation and accuracy of a motor task.  11 participants who had moderate to severe OA and 7 asymptomatic individuals whom served as the control group were required to perform 3 visually guided, variable force, force matching motor tasks involving isolated muscle contractions of the knee (quadriceps), ankle (tibialis anterior), and hand (finger/thumb flexors). fMRI data was used to map the location of peak activation in the motor cortex during the three tasks. The results showed that there were differences in the organisation of the motor cortex during the performance of the knee and ankle motor tasks in those participants with knee OA. The differences in organisation was also related to the quality of performance of the knee motor task in this group too.

The differences in organisation presented as an anterior shift of the knee representation and a switching of the relative anterior-posterior arrangement of the knee and ankle representations in those with OA. The range of shift in the motor cortex representation was related to poorer performance and was specific to the knee. Organisation of the ankle and hand representations did not differ.
The greater the anterior location of the site of peak motor cortex activation during the knee tasks in those with OA in comparison to the site of those without OA signified substantial remodelling of that brain region.
The difference in location was measured and a similar range of remodelling of the motor cortex was also found in a study by Tsao et al, 2011 that looked at the representation of the longissimus erector spinal muscle in the back representation. Such changes in representation of muscles in the motor cortex was also linked with reduced coordination of trunk muscles. (Tsao et al 2008)
A systematic review by Henry et al, 2011 further supports the findings by Tsao et al, 2011 in the reorganisation of the motor cortex in chronic back pain. Schabrun et al, 2015 also confirmed that cortical reorganisation is accountable for clinical features of back pain. A general consensus among the literature is that  the amount of reorganisational change in chronic back pain increases with the chronicity of pain and not the intensity of the pain.

Lastly  a study by Ngomo et al, 2015 whom looked at whether rotator cuff tendinopathy lead to changes in central motor representation of a rotator cuff muscle. 39 participants with unilateral rotator cuff tendinopathy were recruited. The motor representation of infraspinatus was assessed bilaterally. Infraspinatus was chosen as according to Reddy et al, 2000 it is a rotator cuff muscle for which its movement pattern has been shown to be altered during arm elevation among those with rotator cuff tendinopathy. Also it is the only rotator cuff muscle that electromyographic activity can be directly recorded using surface electrodes.
In contrast to findings among other papers I’ve read the results of this study did not reveal any significant differences between the two hemispheres in cortical map location. However similar to other studies the study did show a higher motor threshold indicating a decrease in corticospinal excitability on the side of a rotator cuff tendinopathy. It too proposed that cortical changes is dependent on the duration of the pain. Most  studies that analyse cortical reorganisation  use functional MRI, this study used transcranial magnetic stimulation perhaps that may have implications on the findings.

So what’s next, what do these findings mean to us as clinicians and how does it alter our practice? Part 2 to come…


AcerraN, Mosely G. Dysynchiria: Watching the mirror image of the unaffected limb elicits pain in the affected side. Neurology. 2005;65:751-753

Cramer S. brain Repair after Stroke. New Engl J Med. 2010;362(19):1827-9

Flor H. The modification of corticol reorganisation and chronic pain by sensory feedback. Appl Psychophysiol Biofeedback. 2002; 27:215-227

Henry, D Chiodo A, Yang W. Central Nervous System Reorganizationn a variety of chronic pain States: A review. Phys Med Rehab. 2011;3:1116-1125

Mercier, C, Leonard G. Interactions between pain and the motor cortex: insights from research on phantom limb pain and complex regional pain syndrome. Physiother Can.2011;63(3);305-314

Moseley G and Flor H. Targeting cortical representation in the treatment of Chroninc Pain: A review. Neuro Rehab and Neural Repair. 2012;26(6)646-652

Moseley G. Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology. 2004;(62):1644

Ngomo S, Mercier C, Bouyer L, Savoie A, Roy JS. Alterations in central motor representation increase over time in individuals with rotator cuff tendinopathy. Clinical Neurophysiology. 2015;126:365-371

Schabrun S, Elgueta-Cancino E, Hodges P. Smudging of the Motor Cortex in relation to the severity of low back pain. Spine.2015

Tsao H, Danneels LA, Hodges PW. Issls prize winner: smudging the motor brain in young adults with recurrent low back pain. Spine. 2011;36:1721-7.
Tsao H, Galae M, Hodges P. Reorganisation of the motor cortex in association with postural control deficits in recurrent low back pain. brain 2008;131(pt 8)2161-71

My final post and conclusion

Thank-you for following my blog. Here is my final instalment. Please feel free to post any comments related to any experiences you have had within your practice or training experiences you have felt useful.

Initially, I discussed what is meant by biopyschosocial risk factors and how they are categorised. I then looked at how pain is perceived and how biopsychosocial factors can influence this. This was because based on my clinical experience I found patients that often presented with biopsychosocial factors were harder to treat and seemed to have a slower rate of recovery and occasionally there were times that I was unable to successfully manage their presentation. After gaining an understanding of how pain is perceived and how it can be shaped by an array of biopsychosocial factors I chose to look at what attitudes and beliefs that we as clinicians hold on biopsychosocial risk factors in the view of how this effects patient experience and clinical outcome.

A study by Kidd et al 2011 conducted a qualitative study evaluating what is important to patients in their encounter with their Physiotherapist. Generated from the data were 5 categories of characteristics related to patient centred physiotherapy: the ability to communicate; confidence; knowledge and professionalism; an understanding of people and an ability to relate; and transparency of progress and outcome. These categories appeared to occur in isolation, but formed a picture of patient-centred physiotherapy from the patient’s perspective.

Pinto et al 2012 conducted a literature review that aimed to ascertain which communication factors facilitate patient – therapist relationship during the patient therapist encounter. The results suggest that patient-centred interaction styles that are related to providing emotional support and allowing patient involvement in the consultation process enhances therapeutic alliance however the strength of these results were weakened by the fact that was no meta analysis. Disappointingly the review’s inclusion criteria caused there to be a limited number of studies that investigated the interaction of patients with physiotherapists although the settings that were included involved clinicians and patients within primary care and tertiary hospital facilities: areas where patients’ needs are likely to be similar to the ones seeking treatment in physiotherapy settings. Therefore it could be assumed that the findings that are related to communication factors are transferable within rehabilitation.

A paper by Fairburn and Cooper 2011 that looked at therapist competence, quality and training in psychotherapy recognised that there is a considerable demand for training in psychological treatments but highlights the difficulty in obtaining appropriate training. A variety of training methods were evaluated and even in those who have relevant background knowledge the paper scrutinises the effectiveness of training methods undertook.

Ackerman and Hilsenroth (2003) similarly conducted a literature review exploring what impact therapist characteristics and techniques have on therapeutic alliance. No physiotherapists were included the review looked solely within psychology and included psychologists, senior nursing staff and advanced assistants. Characteristics that commonly emerged were similar to the other studies that I have mentioned previously. Techniques that were thought to be influential were skilled techniques not taught within physiotherapy unless I assume post graduate.

As physiotherapists are continuously facing the challenge of practicing in an increasingly competitive marketplace understanding the needs of patients is even more paramount. As per our own personal standards as well as our governing body and employers organisational standards treating patients as equals, with respect and dignity, listening and including them in decision making processes is something that should be done routinely. My conclusion is that patients with biopsychosocial factors should be no differently treated however if their barriers to recovery are too great then a multidisciplinary approach may be most appropriate. I believe the process of this blog has taught me more about how pain can be perceived and what influence biopsychosocial factors could have in the development of chronic pain and / or poorer compliance. Initially I thought it was all about what treatment I could or should be learning in order to best treat them but know I feel it is more about r,recognising factors well and addressing them as I am able to and if I were to think about specific training such as cognitive behavioural therapy that is said to be a useful modality I perhaps would engage in training that focus’ more on communication and psychological understanding first.

Ackerman J, Hilsenroth M. A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review. 2003; 23: 1-33

Kidd M, Bond M, Bell M. Patients’ perspectives of patient centredness as important in musculoskeletal physiotherapy interactions: a qualitative study. Physiotherapy. 2011; 27: 7: 154-162

Pinto R, FErreira M, Oliveira V, Franco M, Adams R, Maher C and Ferreira P. Patient-centred communication is associated with positive therapeutic alliance: a systematic review. Journal of Physiotherapy. 2012; 58: 77-87

Street R, Makoul, Arora N, Epstein R. How does communication heal? Pathways linking clinician – patient communication to health outcomes. Patient education and Counselling. 2009; 74: 3: 295-301





To approach with an approach or to approach our approach? Tackling the biopsychosocial presentation

So I recognise I have diverged somewhat from what I originally set out to explore. Initially, I set out to determine whether or not I managed patients who presented with biopsychosocial factors ‘correctly’. I wanted to explore what treatment approaches were most effective based on the current evidence.
After my most recent blog I begun to change my way of thinking. I thought it is all being well exploring what the most appropriate treatment approach is but if our views tend to be more biomedical orientated and as clinicians we do not recognise biopyschosocial factors well nor discuss and approach these factors with our patients then surely attempting to utilise a particular treatment approach may have little effect.
I then considered whether the beliefs and attitudes we take towards the biopyschosocial presentation of pain could have a detrimental effect on our patients, their clinical experience and consequently overall outcome.

A systematic review by Darlow et al (2012) set out to explore the association between healthcare professionals attitudes and beliefs and patient related factors in patients with low back pain. They hypothesised there would be an association between health care professionals attitudes and beliefs and patient attitudes and beliefs, patient clinical management and patient outcome.
The results showed a strong relationship between the attitudes and beliefs of patients with low back pain and the attitudes and beliefs of the health care professional that they were consulted by.
The review found the greater the perceived pathology and biomedical focus the more likely the recommendation not to work. This was found mostly among physiotherapists and general practitioners. Also, the higher the fear avoidance beliefs the more sick leave prescription and onward referral to specialist care there was.
Among general practitioners the higher the fear avoidance beliefs the less likely guidelines to physical and occupational therapy were followed.
Physiotherapists that held views that were more biomedically focused viewed activities as more harmful and advised patients to limit their activity. There was also an association between the education that was given to patients. Those with higher biomedical beliefs than those with a more biopsychosocial view gave less instruction and advice to patients. Sample sizes for these studies among practicing therapists in the musculoskeletal outpatient setting were small though.
Rheumatologists that tended to have high fear avoidance belief scores significantly increased the risk of patients also having a high score. Restrictive work and activity recommendations were also made more so by rheumatologists that held higher fear avoidance beliefs.

The study included studies of both qualitative and quantitive data. An extensive literature search was conducted of controlled trials. Studies were scrutinised, if deemed low quality based on if they fulfilled less than 50% of the criteria they were disregarded. The majority of the studies were cross sectional designs, two that were mostly relevant to physiotherapy were both semi structured interviews although the sample size and methodology was good the flexibility of the interview could flaw the results. The authors did consider the rigour of the studies that they identified, this increasing the reviews reliability. The authors used two reliable forms of assessing the strength of the evidence, the AHCPR and the GRADE rating. Attempts to reduce the sources of bias was made; a hypothesises was set from the start, two reviewers independently completed each stage of the review process and a range of reviewers collaborated from a number of institutions, countries, and backgrounds with different research interests and experience. The results of each of the studies were clearly displayed among the type of assessment methods. Assessment methods were in keeping with previous studies such as the Pain, Attitudes and Beliefs Scale (PABS).

The review highlights the negative effect that biomedical beliefs and attitudes that clinicians hold have on patient care. However, physiotherapists often recommend activity and exercise often justified by using a tissue based biomedical explanation. It appears the two schemas are still often seen as as being separate from each other. General Practitioners recognise the importance of psychological factors but seem to lack the time and training to incorporate it into practice. Thinking back to my second post where I looked at how the interpretation of pain can be shaped by a whole host of factors I touched on what influence the beliefs and attitudes that we have towards pain can have on the development of chronicity and disability and what effect how well our expectations of pain are managed can have on clinical outcome. As discussed in that post the literature suggests the better our expectations are managed the higher the likelihood of a better clinical outcome. Therefore it is not surprising that if expectations are poorly managed this can lead to pain catastrophising leading to poorer recovery and worse clinical outcome.

Looking at all of these points in this post, would it be fair to say that there is a likelihood of practitioners adding to the chronicity of pain in patients presenting with biopyschosocial factors.


Darlow B, Fullen B, Dean S, Hurley D, Baxter G, Dowell A. (2011) The Assosciton between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review. European Journal of Pain. 16 (2012) 3-17

Understanding the biopsychosocial orientation of pain and it’s incorporation into the clinical reasoning process.

Previously we explored what influence psychosocial factors can have on patients’ pain experience. Initially I believed it was all about how the patient presented, that influenced our clinical outcome, however I now aim to explore what influence clinicians’ beliefs on pain can have on their practice. But first what do clinicians believe pain is all about?

A systematic review by Parsons et al (2007) that explored the influence of patients’ and primary care practitioners’ beliefs and expectations on the process of care for chronic musculoskeletal pain found four common themes; Beliefs about pain, expectations of treatment, trust and patient education.
Within the review there seemed to be conflict in patients’ and general practitioners beliefs and causation of pain. Patients’ beliefs seemed to be focused around their subjective experience in comparison to the beliefs of general practitioners which seemed to be more biomedical orientated. The reviewed papers suggest that this biomedical approach may be due to their lack of training and awareness in how to manage patients with musculoskeletal pain.

In 2009, Overmeer et al found that physiotherapists held similar views on the cause of pain to those of the general practitioners in the review by Parsons et al (2007).
Overmeer et al (2009) evaluated the views of forty-two randomly selected physiotherapists on the cause of pain by the use of the Pain Attitudes and Beliefs scale for Physical Therapists (PABS-PT). The PABS-PT consisted of two factors one measuring the biomedical orientation and the other the orientation of biopsychosocial treatment.
Prior to attending a severn day educational program the results of the physiotherapists PABS -PT scores suggested that they held beliefs that were more biomedical focused. Compared to after the educational program results favoured a more biopsychosocial orientation towards pain. Despite the study showing a change in beliefs following the educational program the results could be flawed as the physiotherapists attending the course applied voluntarily and were already interested in and had knowledge about and already with some degree begun to adopt a biopsychosocial approach before the course.
What I found interesting in this study was that the majority of participating physiotherapists had over ten years experience. I would have expected them to have had a greater understanding of the biopsychosocial orientation of pain. However, clinical practice changes all the time despite despite the fundamentals staying the same and concepts move forward. We don’t know if the practitioners specialised and if so what in and how long for. The fact that participants signed up voluntarily could suggest they were keen to improve their current knowledge. Also most of the therapists worked mainly in private practice perhaps they adopt a more biomedical approach. Is there less biopyschosocial presenting clientele within private practice than within the National Health Service?

Similarly, a study by Latimer et al in 2004 that measured the attitudes and beliefs of third and fourth year physiotherapy students on adults suffering chronic low back pain, found that following a specialised educational program, attitudes and views changed.
Six hundred and eighteen, third and fourth year undergraduate physiotherapy students completed the Health Care Providers’ Pain and Impairment Relationship (HC-PAIRS) scale. Believed by Rainville et al (1995) to be a highly reliable form of assessment with internal consistency when used to measure the attitudes and beliefs of health care providers to chronic back pain.
Three hundred and five students went on to complete a further scale after a 4 week, 16 hour teaching module.
Although therapy students’ attitudes and beliefs were measured through the HC PAIRS scale, unlike the study by Latimer et al (2000) the orientation of their beliefs was difficult to tell. The short term effects of the teaching module was evaluated through assessing students’ beliefs immediately after the teaching module. Long term effects of the module were evaluated a year on when year three students were in their final year. The HC-PAIRS scores of students not exposed to teaching i.e those that completed the scale but did not go on to attend the teaching module and the year four students that received no specialist training were found to be similar to those obtained by Rainville et al (1995) for a group of community health care providers, that included physiotherapists, occupational therapists, physicians, nurses, and psychologists. Rainville et al (1995) compared the views of community health care providers to a group of pain clinic providers. Community health care providers had a significantly higher mean HC-PAIRS score than those working in specialist pain clinics. This suggesting that like the physiotherapy students, health care providers agree more with the notion that chronic low back pain justifies disability and the limiting of activities.

Smart and Doody (2007) assessed the clinical reasoning processes of severn experienced physiotherapists. The study concluded that all severn of the physiotherapists demonstrated extensive and diverse psychosocial oriented reasoning. their clinical reasoning took into account patients’ cognitions, emotions, behaviours, attitudes andcoping strategies as well as sociological factors. In the same sequence, each physiotherapist viewed three separate videotaped patient – therapist interviews describing three different pain presentations. Their thought processes regarding the nature of the patients’ pain presentation were asked to be verbalised. As each physiotherapist viewed each of the case studies, the principle researcher, a senior physiotherapist conducted a semi-structured recorded interview. At set intervals the researcher paused the video recordings at which point open ended questions were asked to prompt each physiotherapist to verbalise their thoughts. Each of the interviews were transcribed. The transcripts were then coded and their inter and intra coder reliability was checked which was found to be excellent and good retrospectively according to Daly and Bourke, (2000). As all therapists had a minimum of ten tears experience in musculosketal physiotherapy and had engaged in formal postgraduate education this study highlights the difference between inexperienced practitioners knowledge on the understanding and integration of the biopyschosocial pain presentation compared to those who are more experienced and knowledgable. Jensen et al (2000) and Edwards et al (2004) also support better psychosocial orientated reasoning among experienced physiotherapists in their studies that evaluated the clinical reasoning process of experienced clinicians.

With the understanding that there seems to a gap in the knowledge of the biopsychosocial understanding of pain and it’s incorporation into the clinical reasoning process particularly among less experienced clinicians. In the next post I hope to look at how this influences our practice does it affect clinical outcome?


Daly L, Bourke G Interpretation and uses of medical statistics. Oxford: Blackwell Science 2000

Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM (2004) Clinical reasoning strategies in physical therapy. Physical Therapy. 84 312-335

Jensen G, Gwyer G, Shephard K, Hack L, (2000) Expert practice in physical therapy. Physical Therapy. 80 28-52

Latimer J, Maher C, Refshauge K (2004) The Attitudes and Beliefs of Physiotherapy Students to Chronic Back Pain. Clinical Journal of Pain. 20 (1) 45-50

Overmeer, T, Boersma K, Main C, Linton S (2009) Do Physical Therapists change their beliefs, attitudes, knowledge,mskills and behaviour after a biopsychosocially orientated university course? Journal of Evaluation in Clinical Practice. 15 724-732

Parsons S, Harding g, Breen A, Foster N, Pincus T, Vogel S, Underwood M (2007) The influence of Patients’ and Primary Care Practitioners’ Beliefs and Expectations About Chronic Musculoskeletal Pain on the Process of Care. Clinical Journal of Pain. 23 91-98

Rainville J, Bagnall D, Phalen L. (1995) Health care providers’ attitudes and beliefs about functional impairments and chronic back pain. Clinical Journal of Pain. 11 287–295.

Smart K, Doody C (2006) The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Manual Therapy. 12 40-49


Pain. A view not so ordinary


As literature suggests there is more to pain, than what was previously thought of as merely a basic physiological reaction to a noxious stimulus. How pain is viewed, is shaped by a whole host of factors.

A function of pain is to demand attention and motivate behaviour to deal with an injury. (Eccleston & Crumbez 1999).

If pain is considered a threat, the greater the threat the more attention is given. Attention to pain may then be linked to fear and anxiety and the necessity to take action.
Vigilance, a term referring to an abnormal focus on possible signs of pain or injury (Leeuw et al 2007), provides an understanding of why a seemingly small injury can result in serious pain. This process highlights the close link between emotional and cognitive processes and attention.
Cognitive processes are used to interpret the information received. The cognitive process is closely linked with emotional processes as how we perceive a noxious stimulus is shaped by our past experiences. This would explain how it is difficult to “think about something else ” when pain is present and in contrast how when attempts to suppress pain are made the experience of pain can be heightened. Cognitive processes rationalise why sometimes an insignificant stimulus such as light touch can be experienced as severe pain or a serious injury as little or no pain.

We all posses some form of opinion on what pain is and what it would feel like to feel ‘pain’. The beliefs we hold about pain are useful as they can serve as a catalyst in the interpretation of stimuli. Accelerating the process our brain undertakes in making sense of the vast amount of stimuli that our brain needs to interpret, thus becoming a sort of automatic interpretation process. However, this natural tendency can lead to detrimental responses.
Main et al (2010) & Leeuw et al (2008) found there are a number of attitudes and beliefs related to the development of persistent pain and disability in patients with low back pain.These include the idea that “hurt is harm” that if it hurts then something serious is wrong and that “rest is the best cure” pain is a signal to rest and therefore any provoking activity should be avoided.
Buitenhuis et al (2008) supports such correlation between beliefs and pain persistence, their study found that there was a link between causal beliefs and prognostic value in patients experiencing neck pain post whiplash.

Normally when we feel pain we have some idea of its cause how it should be managed and how long we should expect before it is better. How our expectations are managed have also been proven to be good predictors of outcome by a number of studies both in patients with low back pain and neck pain.
We each make sense of incoming information differently. However, for a number of reasons some people fall into a cognitive trap where not intentionally but through error, their misinterpretation of actual or probable future events becomes reality (Linton, 2005 and Barlow 2004).
Pain catastrophising is an example of such a process. Typically catastrophic thoughts are assumptions. “The pain I have, if it continues will cause me not to walk again.”. Therefore, it is not surprising that pain catastrophising is associated with a variety of barriers that hinder recovery, thus making treatment more difficult and the chance of developing persistent pain and disability higher. In keeping with previous research into the development of chronic pain Buitenhuis et al (2008) also found that the severity of neck disability post whiplash event was related to pain catastrophising, however to what extent was unclear. Severeijns et al (2001) too concludes that pain catastrophising significantly contributes to pain related disability.

Anxiety, worry, and depression are all common emotional reactions to pain. It is well known within the literature, that emotions are powerful drivers of behaviour. Therefore, how these emotions are regulated by a person will impact on their experience of pain.
Fear, although short in duration is an emotion that prepares us for “fight or flight” a form of anxiety, that plays a huge part in our thought processes and behaviour.According to Salkovskasis and Warwick (2001) anxiety disorders are typically more prevalent in people with persistent pain than in those who aren’t.
Depression defined by Bair et al (2003) as a psychological problem characterised by negative mood, hopelessness, and despair is a common emotional state that has a powerful effect on the pain experience. There are a number of studies, that have found that patients who have depression pre treatment have poorer rehabilitation outcomes and that the incidence of developing chronic pain is a lot higher. Most research that I have found is in patients experiencing low back pain.

So… what does this all mean to us as clinicians? In my subsequent post this is something I hope to answer.

Reference List

Bair M, Robinson R, Katon W, Kroenke K Depression and pain comorbidity: A literature review Archives of Internal Medicine. 2003; 163: 10: 2433-2445

Barlow D Anxiety and it’s disorders: The Nature and Treatment of Anxiety and Panic; 2nd edition. New York, NY: Guildford Press 2004

Buitenhuis J, de Jong P, Jaspers J, Groothoff J Catastrophising and Causal beliefs in Whiplash. Spine. 2008; 33: 22: 2427-2433

Eccleston C, Crombez, G Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychological bulletin. 1999; 125: 356-366

Leeuw M, Goosens M, Linton, S The fear avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioural Medicine. 2007; 30: 77-94

Leeuw M, Goosens M, Van Breukelen G Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomised controlled trial Journal of Behavioural Medicine. 2008; 138: 192-207

Linton S, Understanding Pain for Clinical Practice. Edinborough, Scotland, elsevier, 2005

Main C, Foster N, Buchbider R How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice and Research Clinical Rheumatology. 2010; 24: 205-217

Severeijns R, Vlaeyen J, Van den Hout, Weber W Pain Catastrophising Predicts Pain intensity, Disability, and Psychological Distress Independent of the Level of Physical Impairment the Clinical Journal of Pain. 2001; 17: 165-172

Thompson D, Urmston M, Oldham J, Woby S The association between cognitive factors, pain and disability in patients with idiopathic chronic neck pain Disability and Rehabilitation. 2010; 32 (21): 1758-1767

Villemure C, Bushnell M Cognitive modulation of pain: how do attention and emotion influence pain processing. Journal of Pain. 2002; 95: 195-199


Patients often present with yellow flags. Are we as Physiotherapists prejudice towards this type of patient? Do we manage them appropriately?

Over recent months, I have had an influx in patients that present with biopyschosocial factors. Although I feel somewhat confident in recognising such factors, what I continually ask myself is whether or not I manage this type of patient correctly. I also question whether there is any truth in the prejudice belief that I have towards this type of patient based on my past clinical experiences in the development of chronic pain and that patients like these don’t respond particularly well to treatment.
Through the purpose of this blog I aim to determine whether biopyschosocial factors play a role in the development of chronic pain, how we as clinicians assess the likelihood of this occurring in these type of individuals and based on the current literature and available evidence what we should be doing in order to best manage this type of patient.

Teaching grandmother to suck eggs…

As clinicians we use the term ‘flags’ to highlight a concern. Typically flags are split into two main categories clinical flags and psychosocial flags.

Clinical flags are used widely within healthcare. In the musculoskeletal setting, red flags are indicators of possible serious pathology, and highlight the need for further urgent investigation if something serious is suspected (Greenhalgh & Selfe 2006).
Orange flags are also clinical flags and refer to mental health and psychological issues that may be psychiatric in nature, they alert the clinician that there may be the need for onward referral to someone who is expert in that field. Orange flags include major personality disorders, post traumatic stress disorders and clinical depression and should not be confused with mild mental health issues such as anxiety (Main et al 2005).

Previously the term yellow flags was used to describe psychological risk factors and social and environmental risk factors for the development of chronic disability and failure to return to work following the onset of musculoskeletal pain (Kendell et al, 1997).
However, the focus more recently has been further subdividing this term and differentiating between the different factors that can affect recovery. Main and Burton (2000) argued that the term yellow flags should be reserved for more apparent psychological risk factors such as fears and negative beliefs. Social/environmental (workplace) risk factors should be divided into two further categories: blue and black flags.
Blue flags being the perceptions that a person holds regarding their environment/workplace that it is a stressful environment, excessively demanding etc and black flags referring to the more observational characteristics of the workplace, the nature of work, and the insurance and compensation systems and procedures that are in place that manage injuries that occur within the workplace.

That thing called pain…

Pain previously understood purely as a biophysical response to noxious stimulus to protect the body from harm is now more thought of as a biophysical response shaped by a whole host of psychological factors (Engel,1954). In my subsequent post I aim to elaborate on this new found understanding and wish to discuss the link that many studies suggest there is between psychological factors and the chronicity of pain.


Engel, G (1959) “Psychogenic” pain and the pain-prone patient. The American Journal of Medicine 26, (6), 899–918

Greenhalgh, S & Selfe, J. (2006) Red Flags: a guide to identifying serious pathology of the spine. Churchill Livingstone, Edinburgh

Kendall, NA, Linton, SJ, Main, CJ. (1997) Guide to Assessing Psychosocial yellow flags in acute low back pain: Risk factors for Long-Term Disability and Work Loss. New Zealand: Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee. Wellington

Main CJ, Burton AK. Economic and Occupational influences on pain and disability. Pain Management: An Interdisciplinary Approach. Edinburgh, Scotland; Churchill Livingstone: 63-87

Main, C.J., Philips, C.J., & Watson, P.J. (2005) Secondary prevention in healthcare and occupational settings in musculoskeletal conditions (focusing on low back pain) Handbook of complex occupational disability claims: Early risk identification, intervention and prevention. I, Z Schultz & R J Gatchel, (eds) Springer Science & Business Media, New York.


Linton, S & Shaw, W (2011) Impact of Psychological Factors in the Experience of Pain. Physical Therapy, 91, (5), 700-711

Bergamot, S, Boersma, K, Overmeer, T, Linton, S (2011) Pain Catastrophizing, Depressed Mood, and Outcomes in Physical Therapy Treatments. Physical Therapy 91, (5), 754-764

About me….

Four and a half years ago I graduated from Sheffield Hallam University. I quickly gained a Junior position and after completing rotations in all core clinical areas I gained a Senior post within the same Trust. I am now static in Musculoskeletal Outpatients. I have recently returned to clinical practice after having my beautiful daughter whom is 18 months old and wish to continue my journey into the exciting world of Physiotherapy. Something that I am still very passionate about exploring. I admit that it is going to be a tough journey with having a little one, but if you don’t try you won’t succeed…