Psychologically informed practice for management of low back pain: future directions in practice and research

In this perspective article, a number of conclusions and recommendations are offered based on the articles in this special issue of PTJ. In this special issue, a new approach to physical therapy, termed "psychologically informed practice," is offered as a "middle way" between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness. This new approach uses the "flags" framework, with psychologically informed practice requiring routine and specific consideration of "yellow flags" and "blue flags" (depending on clinical setting) for determining risk of poor outcome and identifying the potential for treatment modification-but with cognizance of the overall environment or context in which the clinician must operate. This context includes professional culture, health care policy, and insurance reimbursement (potential "black flags"). The primary goal of this approach is to prevent the development of unnecessary pain-associated activity limitations. The approach is based on the identification of normal psychological processes that affect the perception of pain and the response to it as an expected and normal part of the musculoskeletal pain experience and that are potentially modifiable. The potential for linking risk identification with targeted treatment has been discussed, this article focuses on the potential implications for training and implementation, drawing on experience in developing training programs in which the trainees have welcomed this new approach, viewing it as a helpful extension of their basic professional training. Indeed, this new approach can be viewed as evolutionary rather than revolutionary, in that it builds upon the established professional expertise of physical therapists, but incorporates systematic attention to the psychosocial factors that are associated with outcome of treatment.