Can You Handle the Truth?

June 8, 2011 by   Print
Filed under Physiotherapy Blog

Hardly a day goes by where physiotherapists don’t see an article related to the importance of addressing psychosocial issues in the management of musculoskeletal pain disorders.

The model that has been fairly well established in pain clinics and tertiary care settings which typically involve multidisciplinary pain management input from a variety of clinical specialities.  Too frequently, the practical reality is that by the time patients access these services they have become chronic and developed a spectrum of disability behaviours and are usually unemployed.  These confounding variables increase the rehabilitation challenge and reduce the possibility of a successful outcome.

Epidemiological studies suggest that individuals out of work for more than six months have less than a 50% chance of ever returning to full time work.  I must confess I find this statistic somewhat surprising and it doesn’t correlate with my clinical experience.  Interestingly the structure of state benefit schemes does appear to influence the period of disability.

Here in Ireland individuals remain on full pay for six months following which time their case is either transferred to a case management company (in the case of private sector employees) or in the public sector the disability assessment board are involved in assessing fitness to work.  From this point half normal pay rates are immediately instituted.  I have been impressed with how frequently patient’s attitudes and beliefs about their level of disability change as the six month mark approaches.  I do not think that they are specifically malingers or exaggerating their symptoms but simply that weighing up the balances (either consciously or sub-consciously) has allowed them to reach a decision to return to work with an acceptable level of discomfort. Interestingly other countries have shortened this period of disability support (eg Scandinavia) and statistical analysis has shown a similar pattern of absenteeism mirroring the period of full-pay social welfare support.

These are important factors to recognise as they are classed as ‘unmodifiable variables’ to which we clinicians have no direct control.  As such it is important to recognise them as potential confounders to treatment progress, if for no other reason than to maintain physiotherapist’s sanity.  It can be very taxing to work diligently on a systematic rehab programme and wonder why you are not seeing the effects of intervention, or the patient appears somewhat less enthusiastic about a rapid return of recovery (and return to work) despite your best efforts.  This can easily lead to a breakdown in therapist/patient communication.  That being said, in 22 years I have never had a patient specifically express that their intention is to stay out for the full period of allowable disability on full pay.  Usually this information usually needs to be gleaned by “under the radar” techniques and an intelligent line of questioning.

As the title of today’s post implies, as clinicians we must always consider the reasons why we ask questions, but also to consider that if we ask certain questions are we prepared to engage in a meaningful way with the answers that we get?  Given what we know of psychosocial factors and their influence in pain, then the onus is on the therapist to identify relevant risk factors, which would include some of the following:

Psychosocial Risk Factors

  1. Beliefs and attitudes about pain.
  2. Fear avoidance behaviour.
  3. Catastrophizing.
  4. Anxiety and phobia.
  5. Distorted beliefs.
  6. Conflicting information.
  7. Perception of disability.
  8. Depression.
  9. Fear of pain.

Over the years as this debate gathered momentum there has been a recurring discussion about professional boundaries and what are appropriate and inappropriate psychosocial factors to address.  The clinical reality is that most of the common psychosocial issues contributing to musculoskeletal pain fall within the scope of practice of the treating clinician regardless of what their discipline.

Repeat: that most of the common psychosocial issues contributing to musculoskeletal pain fall within the scope of practice of the treating clinician regardless of what their discipline.

Only cases with overt mental health disease are outside the scope of practice of physiotherapy.  This places demands upon the therapist in terms of how they frame their questions.  How they interpret the answers they are given and how they analyse the information if it is not clear from the communication.  Simply delivering a pain questionnaire and transferring care to a group management programme is an abdication of responsibility in my opinion.  So with the immortal words of Jack Nicholson if you ask the pertinent questions ‘can you handle the truth?’ Are you equipped with the skills to challenge distorted belief systems, to address lifestyle and behavioural issues, to identify fear avoidance behaviour and replace these dysfunctions with an alternative better strategy?

It certainly won’t make for an easy life or even be met with rapturous enthusiasm but it still doesn’t mean we can ignore.


Enjoy the clinical challenge.



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2 Responses to “Can You Handle the Truth?”
  1. TIM CRUSE DREW says:

    you’re damn right I ordered a code RED !!!
    You controversial beast you!
    Keep up the good work

    • Tim
      we must keep probing…

      Has the chemical / hormonal / endocrine / physiological assault resolved after that 87KM run?- or will you never be the same again? For readers who like “extreme” check out what this is all about @

      Well done you.


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