Perceptions of Cognitive Behavioural Therapy in Physiotherapy for Chronic Low Back Pain: An Explanatory Grounded Theory

Chronic Low Back Pain (CLBP) is one of the most common and recurrent musculoskeletal problems to cause patients to access healthcare services. The bio-psychosocial model emphasises that psychological, behavioural and social factors contribute to the development and persistence of CLBP. Cognitive behavioural therapy (CBT) is one psychological pain management strategy that can be applied in the context of physiotherapy treatment for CLBP. It aims not only to reduce pain but also to address the cognitive and behavioural aspects of the pain and quality of life. The proposed study was preceded by a mixed methods systematic review that found that CBT has a beneficial effect for CLBP patients when compared to waiting list or other treatments. CBT is an emerging area of interest in physiotherapy and there is a need to understand how best to apply it in clinical practice. An in-depth qualitative study is needed to explore the use of CBT in the physiotherapy management of CLBP to improve understanding of possible reasons for variation in its effectiveness. The study used a qualitative approach applying methods and analysis from constructivist grounded theory. Data were collected from CLBP patients, physiotherapists and mangers of physiotherapy services in the community musculoskeletal based services commissioned to provide outpatient physiotherapy services to patients in Yorkshire, between May 2016 and March 2017. Data were collected from 26 participants (11 patients, 13 physiotherapists, and 2 managers) through 28 interviews. The study findings provided a first explanatory theory that helped in explaining and understanding how, when and why some physiotherapists make a decision to apply CBT for CLBP patients, whereas others do not. Findings suggested that physiotherapists’ decision making to use CBT for CLBP was influenced by many factors including, training in CBT, professional experience as a physiotherapist and after delivering CBT, knowledge and skills, confidence as well as patients’ characteristics, and observed positive outcomes of treatment. The findings of this study improve the understanding of possible reasons contributing to the variation in the effectiveness of CBT applied in the physiotherapy context for CLBP that have been recognised across different studies and populations. This has implications for education and may inform practice and research related to the use of CBT for CLBP in physiotherapy.