Physiotherapist or pseudo Psychologist?

I read this paper very recently and it challenged my assumptions hugely about patients with chronic pain, or rather persistent pain as it’s now preferred to be called. My assumption was that patients with persistent pain would naturally have a reduction in their physical activity levels and so suffer some level of physical deconditioning over time in terms of reduced muscle strength and/or increased weight and body fat gains.

Not so it seems, so I posted it out onto the twitter-sphere expressing my surprise and learning experience and it soon got some comments. First was from some about how I shouldn’t assume anything, and yes they’re right, I shouldn’t, but I do, it’s called being human, so shut the hell up, you’re not being helpful.
But more interestingly I got comments from others who tell me physio’s need to recognise and understand that many patients with persistent pain don’t have ANY reduction in their physical activity levels, or ANY loss of their activities, nor suffer from ANY lack of physical conditioning.
They went on to tell me how they see patients with persistent pain who have very high activity levels and have NO movement or functional limitations just pain. Some also went onto tell me that exercise or movement interventions should not be used by physios in these cases.
Well I am really surprised by these comments, firstly because in 15 years as a physio I can not think of a single patient who I have seen in pain who did not have or tell me they have some issue or loss of a movement, or function.
There are of course some who come to see me for advice on injury prevention or strength and conditioning but these tend to be one off consultations, and they certainly don’t have persistant pain.
I am also really surprised that some physios think physiotherapy doesn’t have to include exercise or movement interventions.
This is something I hugely disagree with. Of course exercise and movement interventions should NOT be used in isolation, but movement or exercise therapy is THE foundation treatment we as physiotherapists should use, it’s our primary role, it’s in our bloody job title for christ sake… Physical Therapy.
So I questioned this point further on social media, asking for more opinions on when people thought the role of a physiotherapist stops being a physiotherapist.
As far as I am concered when a patients tells me there are no physical impairments, or no functional limitations, and exercise and movement interventions do not help, then my job as a physiotherapist is done.
I say this because a physiotherapists role is to increase, improve, and restore movement and function of an individual with pain or a disability. This is reflected in the UK chartered society of physiotherapists statement on ‘what is physiotherapy’ here.
Many physiotherapy departments are simply struggling with the work loads they have in just dealing with the patients with physical disability and pain limiting their activities. So is it fair to ask physios to help those WITHOUT movement or physical issues as well? The question also begs that if there are no physical issues for a patient, what the hell does a physiotherapist do in a session with a patient?
When does a physio stop being a physio and start becoming a psychologist?
Now of course many physiotherapists, including myself, are trained in some psychological and other non physical interventions to help patients over come pain and other life changing events. Most physios have techniques to help motivate, encourage and reconceptulise patients pain. But these interventions are never used in isolation, just as any intervention even exercise should not be used in isolation.
Psychological methods are to be used by physiotherapists to help supplement exercise and movement interventions, and visa versa, exercise interventions help supplement psychological interventions.
What gives some physiotherapists the arrogant belief that they are the best healthcare professionals to treat patients with persistent pain using only psychological interventions?
Physiotherapists first need to get their shit together on improving ways to restore and improve movement, physical impairment and disability of those in pain before worrying about helping others who are coping with pain.
Now, before you all go nuts in the comments section, I am acutely aware that there is a very fine line, if there is one at all, between physical and psychological problems and there interventions. I am not implying that physical interventions are not psychological, nor that psychological ones are not physical. The physical and psychological are intimately and inextricably linked!
Nor am I saying that we should ignore or abandon our psychological techniques to help those with physical impairments, or that pschological interventions don’t work or help people with pain as some often try to claim I am suggestting. These are tiresome false dichotomy’s and they piss me off immensely when people try to twist my views like this. So again, shut the hell up, you’re not helping.
Cognitive Behavioural Therapy; Acceptance and Commitment Therapy; Mindfulness; Motivational Interviewing, etc etc… the list is long of different methods many physios, and again I include myself here, can successfully use in their management of patients with pain, but, and this is the ass grabbing, elephant in the room point I want to stress again, they are all used with exercise or movement interventions… TOO GET PATIENTS MOVING MORE!
So physio’s, be physio’s. Focus on our primary role, what our job title states, to get people physically moving more! That’s more comfortably, more efficiently, more often. Of course use psychological methods and interventions, but lets not use them in isolation, and let’s focus on those not coping with life in pain first before we look to help those who are.
As always thanks for reading
PS: Hat tip to Alan Taylor @TaylorAlanJ for the inspiration for this blog!




  1. Totally agree! My question regarding the paper you sited would be, “How active were these people beforehand?” If a couch potato develops chronic LBP, his/her activity level may not change much at all. If an avid runner or cyclist develops LBP, his/her activity level will most likely greatly change until he/she is able to resolve/decrease that pain. At any rate, I totally agree that PT’s should be PT’s and not try to branch out into other realms of medicine they’re not fully qualified to treat and would not get reimbursed for here in the U.S. Love your blatant honesty with writing and your philosophy – keep it up!! Ann LaboskyP.T. since 1984 🙂
    Date: Fri, 19 Feb 2016 23:34:18 +0000 To: [email protected]

  2. Hi Adam, ironically this post of yours showed up in my e-mail following a discussion I just had in my online DPT course regarding the role of physical therapists in screening and intervention for referrals in the presence of depression and other mental health disorders. I agree and as I said in my post, it is the job of the physical therapist to be alert and aware of mental health disorders and all the stuff that comes along with that (medications and side effects) and the impact that it has on progress and advancement of our patients. However, when I feel that their progress is impeded (mostly the c/o pain) due to some MHD, I refer to the primary care doctor. Physical therapists need to stay focused on the tasks that we are specialized in functional restoration and movement disorders and if pain is due to an emotional or psychological error and not to an injury or mechanical problem than our job is done and the professionals in that field (MH) should take over.
    Love reading your blog,
    Thanks for always saying it best!

  3. Physiotherapist or pseudo psychologist
    I’m writing in response to the aforementioned blog. It’s incredulous that a person with so many followers on twitter fails to appreciate the nexus between movement and cognition. It is my conjecture that this blog is myopic and impishly written and I would posit that this nilhistic view fails to appreciate the intertwined relationship between treating movement and the person.
    This piece is based purely on an empirical model and simply because the author has not experienced this cohort of patient, I do not think it should afford him a position where he feels it is acceptable to indoctrinate his opinion in such a pithy manner. There are many examples in literature and in clinical practice where, reassuring a patient and educating them re harmful or unhelpful beliefs have helped to reduce their pain levels without any movement or physical intervention!!! I usually refer to it as “talking a tendon down” eg 6/10 pain to a 3/10 (poor example I know).
    Certainly if you are an undergraduate or a newly qualified physio then wise advice is proffered to be cognizant of the nuances of movement, but to take a didactic position that ‘we physios should” concentrate on movement is diametrically opposed to what an expert clinician represents.
    There is a cornucopia of reasons why this clinical commentary is abstruse, however, it has raised a level of introspection into my own practice which is advantageous, and therefore in contradiction to this piece I posit that while having a comprehensive understanding of how movement can affect pain / function be it chronic or acute, the expert clinician should inculcate “pseudo psychology” (be it CBT, mindfulness etc) with an unerring sense of segue into their practice and not only focus on movement nuances alone.

    • Thank you for your clearly passionate, in depth, thesaurus inducing comments. I will be honest and say I had too do much google word searching to fully understand what you are trying to say.
      First of all I do NOT fail to appreciate the ‘nexus’ between movement and cognition, I am unsure how you have come to this conclusion from this blog?
      As I clearly state there is a fine line if any at all between physical and psychological interventions. The premise of this blog is based on information I have gained from other physios who tell me they work with people with NO movement or functional issues, and that movement and exercise treatments are not used, and use ONLY psychological interventions! This as I have made perfectly clear is NOT physiotherapy in my opinion.
      Again as I clearly state I don’t dismiss or discredit other psychological techniques that reassure or reduce pain and encourage movement in a pithy or any other manner! I use them ALL the time with a wide spectrum of patients with movement and functional impairments, they are very helpful, but I use them with exercises and movement therapy, not in isolation. This blog is highlighting that using psychological interventions in isolation is not for physiotherapists, just as we dont use exercise or manual therapy this way, why do some physios think psychological interventions are different.
      You are using false dichotomies as I suspected and mentioned some would, and I will reiterate again this is really bloody annoying and tedious.

  4. Totally agree ?
    The biopsychosoical model has 3 part within it and the first part is “biological” which mean don’t ignore “physical” aspects !

  5. I have persistent back pain but have been more active now than ever. I am running 45-50 miles per week (most I’ve ever run) and my pain persists. Just to play devil’s advocate. I’m also a PT that believes we shouldn’t treat people with persistent pain who have no physical or movement deficits.

  6. I commonly see people with no physical limitations and pain as their primary complaint. They will say “I do everything, I just hurt.” The only physical impairments to be identified require using a magnifying glass, unreliable and invalid measures.
    Many are still working and going about their day as best they can. Many are not. Many are self limiting themselves because of pain. They typically are manual laborers working 60 or hours per week 5-6 days per week, have some psychosocial or a fibromyalgia diagnosis.
    I will still use movement as the primary intervention with education. My question is when these are not providing the patient with the results they desire, how effective is a referral to a psychologist or psychiatrist? I hear many people say this is important and necessary but are the outcomes that good?

    • Thats a good question Johnny, too which I would say I dont know but on ward referral should be at least offered.
      The other difficult question is how and when do we stop/withdraw our help if movement and activity interventions combined with psychological ones seem to be ineffective?

  7. Nice piece Adam. First, thanks for using the term persistent pain. We prefer it.
    Physios have a tough job and many are at the sharp end of pain self-management. I think they have to also have some CBT skills, as many people they see will have some yellow flags. Fear of activity (in case it increases our pain) and others I mention in the Pain Cycle.
    Pacing our daily activities is also a tough one for us.
    I will owe much of my recovery to Vicki Harding who was the Physio on my PMP. She showed me how to become more active without fear of increasing my pain.
    To all Physios, I think you are doing a fabulous job of work with the limited time have these days with patients.

    • Thanks Pete, and its great to hear your story, and as you say physios are in a great position to help people with persistent pain and encourage and restore levels of function, fitness and activity, and when a global holistic approach is taken amazing things can be achieved!

  8. It’s very difficult to distinguish between clients that come to see a physio with minimal symptoms with ( large psychological overlay ) and the opposite! Hence the dichotomy.

  9. Adam, observing from the context of my medical speciality area, which is Pain Medicine, may I suggest that, almost by default, health professionals of all persuasions are taking on board a hugely important role in pain education, both of themselves, their colleagues, and their patients. In my opinion, their discourse with patients needs to go far beyond that of a monolog centred upon the intricacies of pain science. Should physiotherapists be willing to embrace the concept of a truly dialogic discourse, here are some tips that might be useful:

    • Thank you for the link to a most useful article! I have written on my own blog, my thoughts on Professor Moseley and the neuroscience of pain and how I believe that it is not enough to understand that the ‘meaning’ people attach to their pain affects their experience of it. In order to change pain we have to examine the ‘meaning’ of it particularly with pain that has gone on for a long time. We have to re-frame pain!

      • Louise, how does one go about re-framing pain? Did you mean to say “we have to re-frame the narrative”?

      • Yes, I guess it is the narrative of pain that must be changed. I have just written another post in which I discuss re-framing pain again, in which I talk about changing the ‘meaning’ of pain. My writings are based on experience rather than empirical data so are up for debate and vulnerable to criticism!

      • Louise, thanks for sharing your thoughts and experiences. For your interest, Milton Cohen and I have just submitted a chapter for a book that is in preparation – Human Meanings of Pain. Our chapter is titled: “The challenge of validating the experience of chronic pain: the importance of intersubjectivity and reframing”. If you are interested, I will post the abstract on your blog.

  10. Adam- Great blog. I’m new to your blogs, articles, etc and I find your approach pretty damn entertaining, on the mark, and informative. I’ve been a therapist for 32 years and in a nutshell in all comes down to exercise. Plain and simple. Listen to the patient , figure it out as best you can, pick a direction, change it up if needed and if you don’t know then tell the patient you don’t know. Is there some psychology involved? Of course!!! We’re working with human beings for god’s sake! It’s probably 90% psych. But if you listen more than you talk, and we keep with the focus on good quality movement, maybe switching up the patients exercise routine if they have one, or encouraging one if they don’t you may just find that things improve. But what the heck do I know, I’ve just gotten started with this therapy thing.

    • Thanks for you kind comments Craig… 32 years hey… Wow congrats!
      As you say physio is all about movement and a lot of psychology, but as I try to put across in this blog is its not ALL about psychology for us as physios… Thats for the psychologists.
      Cheers and best of luck with the remaining X years

  11. I’m yet to find a persistent pain patient with zero functional restriction. in fact, I struggle to remember a patient in pain at all without a physical limitation. Which is the cause and which is the effect is a different argument.
    It’s well evidenced that any single intervention is less useful than a combination approach, both from within physio alone but also inclusion of other professions in an mdt. Why can’t movement and exercise be used as a psychological intervention to challenge beliefs, modify behaviour, reassure and motivate?
    The line between physical and mental health is impossible to discern, as are the physical, neurophysiological and mental effects of our interventions. I would challenge the presumption that any technique fits into just one of those categories alone.
    Pseudo psychology sounds derogatory and probably isn’t fair to the good work that some physios can do with CBT and the like. We should be widening our declarative knowledge, perhaps the name Physiotherapists is holding us back!
    What’s a nexus? 🙂

    • Thanks for some great comments Dan and totally agree. I have never seen a patient without physical or psychosocial issues together, so when I was told that physios do see those without physical issues I was surprised and hence wrote this blog!
      I wasn’t trying to be derogatory in using the term pseudo psychologist rather wanting to ask physios to recognise that Physio is there main role, address both physical and psychological issues is essential not either one in isolation
      And a nexus I thought was a brand of mobile phone until I looked it up… I don’t understand fancy words… Just a dumb Physio/personal trainer me!!! :0)

      • Even if you would find a patient without any form of issue manifesting from their pain, would it not still make sense to try to find a way to decrease their pain for the same activity level? Add something, remove something, see if it would be possible to create a more pain-free life? Or a more Active life with equal pain? And not just consider them as a non-physio candidate because they have no physical limitations from their pain.

  12. While I applaud you for your willingness to commit skin to the game in wrestling some of these issues down to the mat, on this I might part ways a bit. Physio, like other disciplines, has come to be separate from others, not because separate is better, but I suspect for the comfort of its members in clinging to a common narrative. Physio has never been inclined to accept holism; its reductionist roots in science tend to make blending a psychosocial philosophy nearly impossible. This is to the detriment of the public who might benefit from a profession that can feel much more comfortable in the combined aspects of physical and psychological, especially in managing (chronic) pain. The separation is artificial after all since none of us operate in a healthy way by compartmentalising to such a degree. So, yes, physios should be much better versed in counselling and cognitive psychology and should be capable of seeing this as a way forward, an opportunity for evolution.
    Thanks for being a s$%t disturber!!

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