We’ve been here before, we’re going in circles.

There’s a moment in the Lord of the Rings, where Frodo and Sam are walking in the rocky terrain of the Misty Mountains trying to head towards Mordor. Sam speaks about the familiarity of the terrain and Frodo, jaded, responds with, “That’s because we’ve been here before, we’re going in circles” Eventually, it is Golum, whom they form a relationship with, to help the pair out of the mountains.

Why do I raise this in a physiotherapy blogpost? Well, I share a love hate relationship with my beloved physiotherapy. For as long as I’ve known you, (since I was a wee lad) you’ve intrigued me and caught my eye. Since I’ve been a part of you, you’ve challenged me and tried my patience. I believe that physiotherapy has much to offer in terms of rehabilitation and exercise, and it’s move into psychologically informed practice within in pain management (it should be rehabilitation, I’ll get to this later) is definitely an innovative and exciting one.

But (I’m sorry there will be lots of buts in this blog), potentially a treacherous one, much like Frodo and Sam.

Physiotherapy is full steam ahead investigating and investing time into psychologically informed practice, using the evidence base to support it. We’ve begun to adopt methods like exposure based therapy and cognitive restructuring within our rehabilitation and exercise repertoire to address those ever important psychosocial factors contributing to pain related disability. A bold move, which has left some clinicians feeling underprepared, inadequately trained, lacking confidence and competence (Denneny et al., 2019; Synnott et al., 2015).

Actually, Denneny et al’s paper is interesting. I agree that physiotherapists are ideally placed to promote experiential learning through movement and activity focused sessions. But 1) The profession has been doing this for years, perhaps not with the theoretical underpinning or the research base but we’ve been doing it.  Strangely enough, much of what we thought was required for rehabilitation has kinda changed and that social support, empathy, listening and being compassionate are as important. I would go out on a limb and say that motivation, verbal persuasions, positive affirmations are things that physiotherapists would have used throughout its 100+ year history. That’s because these things are inherently human and social.

I agree that physiotherapists have the training and credibility to assess risk vs safety in human movement and can help in reducing disability in persistent pain conditions. But 2) I replaced the words have a key role withcan help in because I believe that other members of the MDT also have a key role and sometimes physiotherapy is not key to reducing disability in persistent pain conditions. Our close sibling, Occupational Therapy (OT) is also perfectly placed to assess risk vs safety in human movement. In fact I would say that OT is probably better in some respects because OTs have a better understanding of function from a contextual perspective.

I agree that physiotherapists provide a bridge between biomedical and psychosocial models of care and that we provide education, advice and reassurance to target unhelpful beliefs and behaviours. Physiotherapists do have excellent knowledge of impairments, which means we can help people make sense of what might be going on in their bodies. But 3)

The bridge between the biomedical and psychosocial models has been (yup you guessed it) a treacherous one. We’re not over the bridge yet, hopefully we don’t do what Indiana Jones did in the temple of doom!

Can Physiotherapy stay level headed?

I agree that physiotherapists do require further training in areas of motivational interviewing and communication skills and to develop an understanding of psychological approaches. Admittedly, Denneny et al’s paper is a wonderful read. The thematic analysis almost helps to build a framework for where physiotherapy should be focusing its attention in terms of foundational training, to grow as a profession and not just within pain management or musculoskeletal practice. But 4) We appear to be in an ongoing phase of embracing pain neuroscience education (PNE). The premise, by engaging clients in deeper learning about the brain and nervous system promotes “retraining” and better self-management. Yet the deep learning can often leave clients confused and upset as the content strongly emphasizes biology and the ever misunderstood explanation that the brain creates pain and that the brain needs to be retrained. This is suggestive of the “fix it” approach that lurks in the trap door of the physiotherapy profession (Stilwell & Harman, 2019).

What’s lurking in Physiotherapy’s Trap Door?

And what of our current psychologically informed methods?

There are several, some I have mentioned in this blog. For the remainder of this blog I want to focus on an approach that has gained most attention, exposure based therapy.

When working with cognitions and inner experiences that contribute to feelings of fear or anxiety there will usually be the use of exposure. This is common within Cognitive-Behavioural Therapy (CBT) or Acceptance and Commitment Therapy (ACT). Exposure therapy has matured with CBT. Intended as a treatment for phobia, exposure therapy is well developed and has been adapted for use within pain management, through the fear avoidance model (Vlaeyen & Linton, 2000).

Common features of living with pain is suffering and distress. Cognitions and inner experiences contribute to these features and are also reflected in a person’s behaviour either as an escape behaviour (fear) or as an avoidance behaviour (anxiety).

If we can reduce negative thoughts and feelings through restructuring then perhaps we can reduce a person’s anxiety or fear and their distress. Of course, it’s never that simple.

Traditionally, exposure therapy is commonly intended to work through a rationale of habituation in an attempt to control the feelings of distress (Kendall et al., 2005). Ease a person’s distress, through restructuring and exposure and the gains or outcome of exposure is expected to be successful.

So, using pain neuroscience education (or pain science education) we intend to update a person’s sense-making by giving them explanations of sensitivity of nerves, tissue healing etc. Undeniably, this is important stuff! It seems logical that if we help a person make sense of what is going on, this should ease their distress and exposure therapy will work better, right?

Well, not exactly. As I have previously mentioned PNE is tarnished by cartesian philosophy. There is also little support for habituation being a process of change in exposure therapy.

Studies have shown that people don’t have to experience distress reduction in session or between sessions for exposure to be effective (Baker et al., 2010; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014; Prenoveau, Craske, Liao, & Ornitz, 2013).

Remember Frodo, feeling jaded about being here before? Perhaps I shouldn’t be so cynical but my concern is that physiotherapy has only begun to explore psychological approaches. There are large shifts happening in psychology practice. I think we should be appraising the psychological research better and having deeper conversations with our psychology colleagues. Perhaps we could look to our sibling OT and share models, knowledge and frameworks.

You mentioned shifts in psychology, tell me more?

Inhibitory learning

Ok, let’s look at some more recent advances in exposure therapy. The inhibitory learning model proposes that fear learning is not extinguished when people participate in exposure. That habituation is not needed. Instead, what happens is that people develop new learning with what they fear, with the intention of them increasing their fear tolerance rather than fear reduction (Craske et al, 2014).

One such way described by Craske et al (2014) is the method of expectancy violation. Expectancy violation intends to promote new learning by the impact and degree of a mismatch between what the person expects and what they experience. So, does a person’s perceived level of expectation match the actual level of experience. The bigger the violation the better the learning.

Interestingly, Craske et al (2014) identified that providing early education may well reduce the effectiveness of expectancy violation as an exposure based approach.  So do we need to be giving PNE if we are trying to violate someone’s expectations of a task? It depends. What seems to be important with respect to expectancy violation is the timing of your education.  So you may not want to use PNE at the start of pain management input.

Psychological Flexibility

Psychological flexibility aims to help people learn how to pursue a values-based life with the ability to feel and think with openness, to attend voluntarily to individual experiences of the present moment and to move life in directions that are important to the individual all in the presence of difficult thoughts, feelings, bodily sensations (Hayes., 2019).

Psychological flexibility is the philosophy that underpins Acceptance and Commitment Therapy (ACT). Rather than trying to address the thoughts, feelings or bodily sensations through education or updating sense-making, ACT asks if the individual is willing to experience thoughts, feelings and bodily sensations and building relationship with techniques to increase workable methods towards what matters most to the person. So instead of trying to “fix” the underlying thoughts, feelings, physical sensations or behaviour related to pain, ACT focuses on what is “functional” for the person in a given context to help them move towards meaningful life goals.

In essence, ACT helps the person to decide when, where and how much they adjust life to accommodate pain. If you think about it, this intends to put people back in the driving seat. So if, for example, avoiding isn’t getting in the way of moving towards what matters to the individual then that’s kind of ok. By over-emphasising the focus on the thoughts, feelings, physical sensations and behaviour we risk pathologizing them, making the assumption they are bad. In some situations fear is good as is anxiety. ACT considers if these things are serving a purpose that’s supporting the life direction underpinned by the value.

Is there anything I can do now?

Well sure there is. Probably most importantly is using reflection so much more in our own practice. Trying to catch ourselves from inadvertently falling into the Cartesian philosophy trap and imparting our new found tool (or knowledge) onto our clients with the assumption that they should be “all better now.”

I guess what I am saying is for physiotherapy to stop jumping onto bandwagons, thinking that the new awesome technique will be the thing that will solve the problems for people. There’s potentially some hypocrisy in there, cause here I am writing a blog about ACT. I’m also a huge proponent of its philosophy and methods, so I guess you can all throw your arms up and say, “pffft, what a hypocrite! I should have opted for Netflix instead.”

I’m asking physiotherapy to take a step back, consider what underlies your intentions with the person you are working with. Ask yourself:


With what I intend to do, does that reflect a fixing profession or a helping profession?


Thanks for having a read.






Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010). Does Habituation Matter, Emotional Processing THeory and Exposure THerapy for Acrophobia. Behaviour Research and Therapy,48(11), 1139–1143. https://doi.org/10.1038/jid.2014.371

Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.

Denneny, D., Frijdal (nee Klapper), A., Bianchi-Berthouze, N., Greenwood, J., McLoughlin, R., Petersen, K., … de C Williams, A. C. (2019). The application of Psychologically Informed Practice: Observations of experienced physiotherapists working with people with chronic pain. Physiotherapy. https://doi.org/10.1016/j.physio.2019.01.014

Hayes, S. C. (2019). A Liberated Mind: How to pivot toward what matters. New York: Avery.

Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12(1), 136–148. https://doi.org/10.1016/S1077-7229(05)80048-3

Prenoveau, J. M., Craske, M. G., Liao, B., & Ornitz, E. M. (2013). Human fear conditioning and extinction: Timing is everything…or is it? Biological Psychology, 92(1), 59–68. https://doi.org/10.1016/j.biopsycho.2012.02.005

Stilwell, P., & Harman, K. (2019). An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences. https://doi.org/10.1007/s11097-019-09624-7

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016

Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85(3), 317–332. https://doi.org/10.1016/S0304-3959(99)00242-0

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