Physiotherapy, you just don’t understand!

Why is it that people living with pain upon seeing a healthcare professional often report, “ I have been told that it’s all in my head” and that the central focus of pain management programs is towards living well and not what people living with pain commonly report – the desire for pain reduction. Admittedly, those are questions that are challenging to answer particularly if people living with pain have heard similar explanations on multiple occasions. i.e. “It’s a complex interaction of….”, “your nervous system becomes sensitized……”, “pain does not equal tissue damage…..”, “pain is an opinion on the organism’s state of…..”, “pain is a sensory and emotional…..” In addition, it is also challenging when the aim of pain management programs is to provide strategies to manage the impact of pain. Understandably, this can feel unsettling for clinicians when they feel there is little else to offer.

An interesting qualitative research paper by Paap et al., (2021) explored factors that influence participants’ perceptions of the therapeutic alliance with healthcare professionals and how this might affect their participation and commitment to treatment.

A topic that is discussed a lot amongst clinicians and academics, and is central to patient-practitioner engagement, is the therapeutic alliance (or relationship). In the paper, the authors outline the dynamics of the therapeutic alliance summarising it as a complex interaction between patient and practitioner focussing on three domains: level of agreement between participant and healthcare professional, on the goals of the treatment, and on tasks (to pursue the proposed goals), and quality of the bond between participant and healthcare professional (Bordin, 1979). Furthermore, the paper discusses how building, maintaining and repairing the collaboration is important. The concept of repairing refers to the restoration of the therapeutic relationship following potential ‘ruptures’ that may have come as a result of misunderstandings, tensions, and conflicts between participants and healthcare professionals.

A perpetual challenge for healthcare professionals is explaining pain beyond a biomedical perspective which is aligned with Cartesian dualism and reductionism. Simply, pain is an experience, which means that a person must be alive to report it – I often say to my clients, “it is not your ….insert body part….. reporting pain, it is you who reports pain.” Whereas, for a corpse, of which the biomedical model was predicated, pain is never experienced (to my knowledge). So, unless you are alive, you will never report pain. Thus it makes sense to think beyond the confines of biomedical reasoning. Solely examining the tissues only explains part of a pain experience and in many cases (of chronic pain) tissue damage is not a discernible feature (Raja et al., 2020).

As mentioned, clinicians can feel unsettled when there is little else to offer. Consequently, the physiotherapy profession has adopted a biopsychosocial (BPS) model (or framework for those opposed to calling it a model) to reflect a broader professional perspective and to embrace a more humanistic approach to practice. This is particularly pertinent to the subject of chronic pain (Nicholls, 2017).

Despite the adoption of the BPS model by the physiotherapy profession, it has been suggested that it is inadequate due to its misrepresentation (Pincus et al., 2013), is applied in a fragmented manner and perpetuates dualistic and reductionist beliefs (Stilwell & Harman, 2019). I have had many conversations with clinicians about the BPS model in chronic pain and the particular lack of understanding towards the social domain.  Therefore, if clinicians feel unsettled by only really covering the biological part of pain with some understanding of the psychological domain and very little understanding of the social domain, is it surprising that ‘ruptures’ occur within the therapeutic relationship?

Unsurprisingly, this was a central theme identified in Paap et al’s paper. That social and family life, daily activities and work were expressed to be at the center of their concerns in their struggle with living with pain (Figure 1). Furthermore, previous experiences with healthcare professionals practicing from a biomedical paradigm affected participants’ illness representations and their perception of healthcare relationships in general. This was further compounded by a paternalistic approach to healthcare implementation resulting in the participants learning that they played a minor role in their pain management. Consequently, patients report being passive recipients of care represented by messages such as “the doctor knows best” (Delaney, 2018). In support of this view, Sullivan, Hebron, & Vuoskoski, (2019) in their paper, indicated the struggle experienced by healthcare professionals attempting to reconcile the balancing of a paternalistic wish to “sell” their own views as “experts in their field” with the risk of ‘rupturing’ the therapeutic alliance.

Figure 1
Figure.1. Participants’ perceptions affecting engagement in the therapeutic alliance in pain rehabilitation program. Courtesy of Paap et al (2021).

When it comes to communication, it can be argued that physiotherapists are comfortable within a biomedical paradigm (Gardner et al., 2017), as this model fundamentally has underpinned the basis of their education (Nicholls, 2017). Something I have exchanged in many conversations with clinicians is the perpetual challenge of replacing the biomedical model with the BPS model and whether the stance of the healthcare professional in the therapeutic alliance creates an implicit power imbalance. Where clinicians wish to adopt a patient-centered approach they can be conflicted and feel unprepared to help mitigate the risks of miscommunication (or as I like to call it “reading the room”) due to their prior training as identified by Sullivan, Hebron, & Vuoskoski, (2019).

The Paap et al paper is an enlightening read as it highlights some of the persistent challenges that health professionals and patients experience in pain management programs and from the perspective of physiotherapy education. Does this highlight a perpetuating message of ‘physiotherapy, you just don’t understand.’ 

I feel Sullivan, Hebron, & Vuoskoski highlight this message and also further emphasize the gaps that exist in physiotherapy (and likely other Allied Health Professions) when we participate in a therapeutic alliance dance of establishing rapport, using empathy, maintaining engagement, and being adaptable throughout the duration of our pain management programs. More work to be done!

Thanks for having a read



Bordin, E. S. (1979). THE GENERALIZABILITY OF THE PSYCHOANALYTIC CONCEPT OF THE WORKING ALLIANCE. Psychotherapy: Theory, Research and Practice, 16(3).

Delaney, L. J. (2018). Patient-centred care as an approach to improving health care in Australia. Collegian, 25(1), 119–123.

Gardner, T., Refshauge, K., Smith, L., McAuley, J., H?bscher, M., & Goodall, S. (2017). Physiotherapists beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy, 63, 132–143.

Nicholls, D. A. (2017). The end of physiotherapy. The End of Physiotherapy.

Paap, D., Krops, L. A., Schiphorst Preuper, H. R., Geertzen, J. H. B., Dijkstra, P. U., & Pool, G. (2021). Participants’ unspoken thoughts and feelings negatively influence the therapeutic alliance; a qualitative study in a multidisciplinary pain rehabilitation setting. Disability and Rehabilitation, 0(0), 1–11.

Pincus, T., Kent, P., Bronfort, G., Loisel, P., Pransky, G., & Hartvigsen, J. (2013). Twenty-five years with the biopsychosocial model of low back pain – Is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain. Spine, 38(24), 2118–2123.

Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., … Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.

Stilwell, P., & Harman, K. (2019). An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences.

Sullivan, N., Hebron, C., & Vuoskoski, P. (2019). “Selling” chronic pain: physiotherapists’ lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients. Physiotherapy Theory and Practice, 1–20.


  1. Enjoyed, appreciated this. It serves to remind the profession that it’s education and philosophical basis must modernize before it becomes irrelevant and replaced by an improved model of care.

    Liked by 1 person

    1. Thanks and what a wonderful reflection on your part. Indeed the philosophical basis is certainly a perspective that needs to be explored. I think if we consider the popular philosophers from as far back as Aristotle to Kant, Descartes and David Hume. All (I believe) using a process of Transcendence. Transcendence is reflected in many aspects of physiotherapy practice from paternalism and positivism pervading the professions belief around the ability to cure. From a religious perspective this can mean that we are some kind of divine being. Perhaps we need to be thinking about our profession in an alternative way. Spinoza and Deleuse consider the process of expression as an alternative to transcendence. I intend to explore this in a future blog.
      Thanks again for your comment.


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