The application of psychology-informed physical therapy (PIPT) and cognitive behavioural therapy (CBT) as tools to address a range of clinical problems can enhance patient outcomes and improve quality of life.

What are PIPT and CBT?

PIPT is a biopsychosocial approach to physical therapy rehabilitation with an emphasis on using cognitive-behavioural therapy (CBT) in helping patients manage their pain.

CBT is a form of psychotherapy that focuses on how a client's thoughts, feelings, beliefs and attitudes affect their feelings and behaviours.

PIPT for elite athletes

PIPT is essential in physical therapy, particularly in treating the student-athlete population, according to Sports Physiotherapist Kusal Goonewardena.

Mr Goonewardena, who works with Olympic and national level athletes at the University of Melbourne, said periods of stress impact on his clients and caused physical symptoms.

"We work with these athletes throughout the year, and interestingly during the months of June and November, their injuries and pain can be more heightened.

"This is due to the exam and assessment periods. So, stress can play a big part in our athletes' physical performance.

"As physiotherapists, we have to be mindful how much stress can play a part in physical injury."

"We need to identify whether stress is playing a part in their lives."

If stress is identified, it's important to make the client aware of its impact on their physical health as awareness is the first step towards recovery, explained Mr Goonewardena.

Post-partum and PIPT

PIPT is also vital in treatment during the post-partum period, as stress can impact mothers.

Mr Goonewardena said a young mother with a four-month-old baby presented with back pain that responded to treatment, but only temporarily.

"We noticed that her pain was heightened when her baby cried.

"So, her back pain was secondary to a stress response.

"She was getting upset that the baby was upset, which was presenting as low back pain in her body.

"Once she had identified that her back pain was a trigger from her baby crying, it helped her to get over that speed hump.

"She was then able to achieve a full recovery.

"About 40 per cent of my clients will have some form of PIPT," said Mr Goonewardena.

PIPT and CBT for persistent pain

Physiotherapist Lissanthea Taylor, a specialist in biopsychosocial care for persistent pain, works within an education-based, psychologically informed care model.

"PIPT is not just useful.  It's essential!

"You must consider the whole person in any health care interaction, and humans are affected psychologically by pain and illness.

"I am yet to meet a person in the clinic that's not at least a bit worried about their pain and their capacity to get better," said Ms Taylor.

Asking clients challenging questions about how they are living and coping, and how they're being affected daily by the experience of their illness is key to using PIPT, explained Ms Taylor.

"There's no difference between an ankle sprain and chronic low back pain. The whole person and their lived experience must be considered in planning a path to recovery.

"PIPT is the only way that people recover from persistent pain conditions and return to living well.

"It's an essential piece of the puzzle, but it's not psychology.

"It's having an awareness of how to talk about the experiences of illness, gain skills in hearing difficult stories and know when to refer to experts that have well-developed skills in psychological therapy and practice."

It is this multidisciplinary approach that ensures PIPT and CBT are being implemented responsibly and not exceeding a physiotherapist's scope of practice, said Ms Taylor.

"By integrating cognitive behavioural techniques with physical therapy, clients can address pain presentation in much more depth. 

"Rather than just addressing the anatomical cause of their pain, clients can address psychological, social and environmental factors of their pain.

"Patients with psychological distress and associated behaviours, such as pain avoidance, are more likely to have poor recovery and would benefit from cognitive-behavioural techniques. 

"Research has shown clinically significant improvement utilising PIPT with knee and low back pain, with mixed results with neck pain," said Ms Taylor.

Sports Physiotherapist Clare Singleton agrees that PIPT is beneficial for those with persistent pain.

"It's important to identify psychological contributors to a patient's pain presentation, preferably in the acute phase, rather than waiting for the patient to develop chronic pain, as it may be too late for treatment to be helpful. 

"One way of identifying these contributors is to use an Orebro Musculoskeletal Pain Screening Questionnaire to uncover potential psychological and social factors."

The evidence gathered from the patient interview, and the physical assessment with the information from the psychological screening is used to integrate PIPT, explained Ms Singleton.

"Client and clinician work together in a collaborative approach and agree on the goals of treatment and responsibilities of each party. 

"When a therapist recognises issues such as catastrophising or fear avoidance, for example, they must be addressed by exploring the patient's beliefs and identifying how they fit within the presentation of the patient's pain.

"Lastly, utilising graded exercise or activity, as a treatment technique can be utilised effectively. 

"In this approach, pain is not used as a determining factor of activity. 

"Moreover, the graded activity involves finding a patient's baseline of activity by having the patient perform the action within pain limits. 

"Activity is then gradually increased from this baseline, utilising a strategy known as pacing," said Ms Singleton.