Is it ok to ask patients if their chronic pain is affecting their mental health?

With #worldmentalhealthday taking place this week (October 10) there is an opportunity to promote the role that #physiotherapists can play in identifying difficulties with #psychologicalwellbeing at an early stage. As most physiotherapists acknowledge, the impact of pain on mood is enormous and can lead to all sorts of difficulties such as isolation and anxiety.

Pain is chronic if it lasts longer than three months. But for many people pain lasts much longer – sometimes throughout their whole lives. The relationship between chronic pain (which is also referred to as persistent, long-term, or ongoing pain) and mental health is well recognised. Some find their pain and how it affects their mental health can lead them to be less active. It can affect their work, leisure, socialising and can lead to mood difficulties like depression and anxiety.

NICE guidance recommends that psychological based interventions are used in the management of pain and the recently issued draft chronic pain guidance also recommends considering psychological treatments. Physiotherapists are well positioned to offer psychologically informed approaches but research suggests many physiotherapists are reluctant to ask clients about their emotional wellbeing for fear of ‘opening up a can of worms’ and being unable to professionally advise them about where to go for help and support. Physiotherapists are one of the few health professionals that can spend around 30 minutes each week for a number of weeks with patients. This gives physiotherapists a valuable opportunity to build a therapeutic relationship with the patient and understand what is important to them and how to make improvements. They can ask them what is worrying them about their pain and then work together to tackle the physical and psychological impact.

The PPA wanted to support physiotherapists to become more confident when working with people living with pain and the impacts that this can have on emotional wellbeing. In collaboration with Frank Keefe, Duke University USA, we created a training course that explored behaviours and provided opportunities to practice techniques that can be used by physiotherapists when working with patients presenting with pain.

We can now announce that a new innovative training package for physiotherapists has been developed in partnership with the #HealthInnovationNetwork (HIN) AHSN South London, St George’s NHS Foundation Trust and Kingston Hospital NHS Foundation Trust hospitals in South London.

It all started about a year ago when I got a call from the Health Innovation Network project team inviting the PPA to partner with them. I found out that around the same time the PPA were running our training with Frank Keefe, the HIN project team had been running research focus groups with musculoskeletal physiotherapists at St George’s and Kingston hospitals. Their findings echoed ours; low confidence in discussing emotional wellbeing, concerns about ‘opening a can of worms’, but also a gap in skills because of limited training around the link between pain and mental health or training on mental health in general. Physiotherapists were enthusiastic about a possible course on delivering psychologically informed physiotherapy but highlighted the need for ongoing supervision and mentoring after training to embed the learning into daily clinical practice. For the last year, the PPA has been working collaboratively with the four partner organisations and our two brilliant patient representatives who are living with persistent pain, and last week we launched our evidence based Therapeutic Interactions and Person-centred care Skills (TIPS) training package.

The course content is grounded in behaviour change theory and underpinned by aspects of contextualised cognitive and behavioural approaches. The TIPS training draws on theory from Cognitive Behavioural Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness. It includes strategies that are widely used in pain management settings, that some physiotherapists may already be familiar with, but may not feel confident using in clinical practice. The course involves eight weeks of experiential learning followed by eight weeks of supervision. Our pilot sites are St Georges and Kingston musculoskeletal physiotherapy teams.

In our profession we hear the term ‘parity of esteem’ quite a lot which means ‘tackling physical and mental health issues with the same energy and priority’. Physiotherapy is a profession that people assume focusses on offering physical treatments, like manual therapies, as well as exercises. Yet we know from engagement with physiotherapists that although many people they work with will not have (or reach criteria for) a mental health diagnosis, they will be experiencing an impact upon their psychological health because of their pain and how it affects their life. Now, more than ever with the pandemic, we need to recognise the contribution that physiotherapists can make to reduce the impact of pain on emotional wellbeing. We have high hopes our TIPS training will deliver the outcomes to support this, for both the physiotherapist and the people who live with pain day-in-day-out. We welcome the opportunity to share our learning to a wider range of healthcare professionals once the course is evaluated next year. Our warm thanks go to the Q Improvement Lab/Health Foundation for funding this work.

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