Burnout in physiotherapy

Ky Wynne’s editorial reveals that burnout in physiotherapy is driving early career attrition and impacting patient care. Ky agreed to answer some questions here.

Your editorial considers burnout in the physiotherapy profession. Burnout is increasingly discussed in physiotherapy – what does it actually look like in day-to-day clinical practice?

Burnout is not always recognisable, especially initially. It is a syndrome characterised by three domains: emotional exhaustion, depersonalisation and low professional accomplishment.

Burnout can be viewed as a continuum, where risk factors and work demands exceed an individual’s capacity and lead to emotional exhaustion – an early indication of burnout. 

Signs of burnout can include fatigue, reduced empathy for patients, withdrawal from social situations and interrupted sleep.

Workers may no longer have a desire or the ability to invest energy into normal workday situations, which is observable through reduced work engagement and satisfaction, reduced motivation, decreased work performance and negative work attitudes (eg, cynicism or depersonalisation). 

This can also manifest as physical health changes and poor mental health.

 As burnout progresses, physical symptoms, attitudes towards work and professional accomplishment may all be affected.

However, everyone’s experience of burnout is different.

Your editorial highlights early career attrition – why are so many physiotherapists leaving within the first five to 10 years?

The attrition rates in physiotherapy are multifactorial and it is important to note that burnout is only one contributing factor.

Qualitative data shows that many physiotherapists struggle with complex industry factors like a lack of clearly defined career pathways or financial progression, high workloads and inadequate training and support, causing them to consider leaving the industry.

What are the key workplace factors that contribute most strongly to burnout in physiotherapists?

Ky Wynne.

There are numerous factors that influence burnout risk, some modifiable and others less so. 

When evaluating workplace factors, people should consider things like a lack of support, poor workplace relationships, inadequate renumeration, ethical or moral conflicts between values, poorly defined roles and lack of progression opportunities. 

There is no ‘one factor’ and the contribution of factors will vary depending on the workplace and individual involved.

There’s often a focus on resilience and self-care – are we placing too much responsibility on individuals rather than systems?

Traditionally, workplaces and education programs focused heavily on ‘individual factors’ contributing to burnout in physiotherapy.

While these are important, they form only one part of a larger picture. 

More recently, factors such as organisational culture and influences related to one’s workplace have been shown to significantly impact employee engagement and job satisfaction and to contribute to burnout in employees. 

Therefore, if we are to truly manage burnout holistically, simply categorising it as an ‘individual problem’ may fail to address all factors influencing burnout.

What practical changes can clinics and organisations make right now to better support their physiotherapy workforce?

As discussed in the editorial, there isn’t a ‘silver bullet’ for managers or workplaces to implement. 

Due to the multitude of factors, a tailored approach is important. Workplaces should aim to foster a positive work culture.

Consideration of factors like business values and workplace relationships can influence this culture. 

Factors like empowering employees to work with autonomy and to their strengths, along with providing adequate flexibility and career progression pathways, should be incorporated where possible. 

Supporting personal and professional development, including resilience training, leadership interventions and positive psychology interventions, can be beneficial. 

Additionally, simple strategies like recognising staff performance can have a big impact.

Looking ahead, what broader reforms are needed across the profession to create more sustainable and fulfilling physiotherapy careers?

It is great that questions like this are being posed and a broader discussion had about how we can mitigate burnout risk at multiple levels. 

System-level priorities and interventions could include reforming existing models of care and renumeration structures.

Education and training can continue to be strengthened at university level and within the workplace. 

There are positive interventions currently happening in many physiotherapy university programs, which need to be continued and progressed into the workplace where possible. 

Creating clearly defined career pathways and structures is another important area for ongoing workshopping. 

Finally, managers and business owners should place a strong emphasis on cultivating positive workplace culture.

>> Ky Wynne APAM is a Melbourne-based physiotherapist, exercise scientist and director of Athlete’s Edge Physiotherapy. He teaches within the physiotherapy program at RMIT University and contributes through research, presenting and industry education, alongside advocating for clinician burnout and wellbeing.

Low back pain prevention and management research highlights

A new review reveals what five years of research tells us about preventing and managing low back pain. One of the researchers, Associate Professor Bruno Tirotti Saragiotto, agreed to answer some questions about the review.

Low back pain remains the leading cause of disability worldwide. Why does care still so often fail to align with best evidence?

This is an important but complicated question. The evidence for low back pain is clear and consistent but it challenges long-held beliefs that pain is structural in nature and needs to be fixed. 

At the same time, health systems tend to reward quick, procedural care over the more sustainable work of education, lifestyle and behaviour change.

Expectations also need to be addressed. Many patients present seeking a clear diagnosis and a solution and clinicians can feel pressure to provide one. 

People also move through very different care pathways and hear different explanations along the way, which leads to mixed messages and fragmented care. 

This is not a matter of clinicians ignoring evidence. Evidence is complex, patients are complex and systems rarely support change.

That is why this is not a knowledge or dissemination problem – it is an implementation problem. 

More guidelines are not the answer; we should be designing health systems that make evidence-based care the easiest and most natural path forward.

Your review highlights exercise and education as key strategies. What makes these approaches so effective for both prevention and management?

Bruno Saragiotto.

These interventions produce small-to-medium effects on pain and disability, although their value extends beyond effect size. 

They are safe, scalable and consistently beneficial across populations, while targeting the factors that drive ongoing pain and disability rather than simply reducing symptoms in the short term. 

Exercise improves physical capacity, movement confidence and resilience, while consistently reducing the risk of recurrence.

Education complements this by reshaping beliefs, reducing fear and improving self-efficacy. 

When combined, they support self-management and give people a sense of control over their condition, which is important as symptoms are rarely explained by tissue factors alone.

Many patients still receive medications, injections or surgery. What does the latest evidence say about their benefits and risks?

The evidence shows a clear pattern of limited benefit and meaningful risk. 

Most medications provide only small or negligible improvements in pain and many carry well-established harms, particularly with repeated or long-term use. 

Opioids are a clear example, with limited benefit and a high risk of harm. Injections and surgery follow a similar story for most people with low back pain. 

They rarely provide meaningful long-term benefit compared with non-operative care, while exposing patients to complications and high costs. 

There are some situations where invasive treatments are helpful, such as in certain cases of nerve compression. 

However, these cases are relatively uncommon and are the exception. For most people, simple, non-invasive care works just as well and often better.

Psychologically informed care is gaining attention. How does it differ from traditional physiotherapy approaches? 

Psychologically informed care is really about recognising that people are more than their scans or their symptoms. 

This is not a separate type of care delivered by psychologists; it is something physiotherapists can and often do integrate into routine practice. 

Traditional approaches often focus on what might be wrong with the body. 

These approaches step back and ask how someone is understanding their pain, how it affects their confidence and what it has prevented them from doing. 

In practice, this means helping people move again while also addressing fear, worry and unhelpful beliefs about pain. Many people avoid activity because they are scared of damage or making things worse. 

Psychologically informed care helps people feel safe to move, rebuild trust in their body and gradually return to the things that
matter to them. 

This broader focus may be why these approaches tend to produce larger and more sustained improvements.

You highlight important inequities in care. What needs to change to better support underserved populations?

Improving care for underserved populations requires structural and cultural change. 

These groups often face barriers such as cost, limited access, cultural differences and mistrust of healthcare systems. 

They are also more likely to receive care that does not follow the latest high-quality evidence. 

Addressing this means moving away from one-size-fits-all care and instead providing care that is culturally appropriate, shaped by the community and adapted to local needs.

Importantly, this should not be framed only in terms of deficits or barriers but should also recognise and build on the strengths within these communities, including strong social networks, resilience and existing health practices. 

Strengthening community-led and co-designed approaches allows care to be shaped by local knowledge and priorities rather than imposed from the outside.

If clinicians could change just one thing about how they manage low back pain tomorrow, what would have the biggest impact?

The most impactful change would be to consistently prioritise active, person-centred self-management over passive, symptom-focused care. 

This means reassuring patients, encouraging movement early, avoiding unnecessary imaging and medications, and focusing on long-term behaviour change rather than short-term pain relief. 

It is a shift from trying to ‘fix’ the back to supporting the person in managing their condition. 

This change would reduce harm, improve outcomes and bring everyday practice much closer to what the evidence actually supports.

>> Associate Professor Bruno Tirotti Saragiotto is head of the physiotherapy department at the University of Technology Sydney. His research focuses on musculoskeletal pain management, including the use of digital health and artificial intelligence to improve patient care. His work aims to develop scalable, patient-centred models of care that improve outcomes and reduce low-value interventions.

Contract or relax abdomen during Pilates

Researchers from Brazil conducted a randomised trial of 152 people with non‑specific chronic low back pain. Their findings indicated that relaxing the core during Pilates may improve outcomes for patients with chronic low back pain. Researchers Luciana Lunkes and Ney Meziat Filho agreed to answer some questions about their trial.

Your study challenges a core principle of Pilates. Why has abdominal contraction been so strongly emphasised in the past?

Abdominal contraction has traditionally been emphasised in Pilates because it reflects an original principle of the method, known as ‘centring’, which refers to initiating movement from the body’s centre, often called the powerhouse. 

Core exercise training and motor control training reinforced the idea that people with chronic low back pain should focus on abdominal contractions during exercises. 

This concept aligns with biomechanical models suggesting that increased activation of deep trunk muscles, such as the transversus abdominis and multifidus, enhances spinal stabilisation. 

Over time, this idea became central to both Pilates practice and rehabilitation approaches.

What were the key differences between the ‘relaxed’ and ‘contracted’ approaches in your trial and how did participants respond to them?

Luciana Lunkes.

Both groups performed the same Pilates exercise program, with identical frequency and duration over a 12-week period. 

The key difference was the instruction provided during exercise execution.

In the control group, participants received guidance on the specific activation of the core muscle group (including abdominals, pelvic floor, diaphragm and deep spinal muscles), with continuous verbal reinforcement from the physiotherapist. 

In the experimental group, participants were instructed to keep their abdomen relaxed and perform the exercises in a smooth way, focusing on breathing and movement, without any guidance to activate the core muscles.

Participants in both groups adhered well to the program and improved over time. 

However, the relaxed group showed slightly greater improvement in disability.

You found slightly better disability outcomes with a relaxed abdomen. How clinically meaningful is this difference?

The between-group difference in disability favoured the relaxed approach and was achieved without any additional cost, effort or risk. 

From a clinical perspective, this is meaningful because Pilates is already recommended for people with non-specific chronic low back pain and is known to improve pain and disability. 

Our findings suggest that these additional benefits can be achieved with the instruction to keep the abdomen relaxed during the exercises.

In practice, if a simpler and less demanding strategy produces similar or slightly better outcomes, it may be preferable. 

Therefore, clinicians should consider feasibility, patient comfort and the potential to avoid reinforcing unnecessary muscle guarding.

Do these findings suggest that core activation is unnecessary or just that it may not be as important as previously thought? 

Our findings suggest that prompting individuals to activate the abdominal muscles is unnecessary. 

Trunk muscle activation appears to occur naturally in a demand-dependent manner rather than being dependent on verbal cues during exercise. 

Conversely, prompting relaxation of the abdominal muscles may help reduce excessive muscle guarding and protective behaviours during movement.

How do your results fit with current understanding of pain science and the role of muscle guarding in chronic low back pain?

Ney Filho.

Our results are consistent with current evidence suggesting that people with chronic low back pain use increased trunk muscle activation while walking and during functional activities compared with asymptomatic people. 

This increased muscle activation is associated with cognitive and emotional factors such as higher levels of pain catastrophising.

Even considering only the biomechanical perspective, there is growing evidence against the idea of abdominal bracing during exercises. 

For example, abdominal bracing reduces impact attenuation during a drop landing task in healthy adults.

What should physiotherapists take away from this? Should they change how they prescribe Pilates or other exercise programs?

Physiotherapists should know that prompting patients with chronic low back pain to contract their abdominal muscles during exercises may not be the best strategy. 

The advice to keep the abdominal muscles relaxed can slightly decrease disability in the context of Pilates exercises but we believe that these findings may also be applicable to any other exercise approaches used in the management of chronic low back pain.

>> Luciana Lunkes is a musculoskeletal physiotherapist with a doctorate in sciences from the Federal University of Lavras and postdoctoral training in rehabilitation sciences from the Augusto Motta University Centre in Brazil. Luciana works as a professor and researcher at University Centre of Lavras and Augusto Motta University Centre.

>> Ney Meziat Filho is a musculoskeletal physiotherapist and professor of postgraduate programs in rehabilitation sciences at Augusto Motta University Centre. From 2024 to 2025, Ney was a visiting professor at the School of Rehabilitation Science, McMaster University in Canada.

Physiotherapy management of long COVID

Swedish physiotherapist Associate Professor Malin Nygren-Bonnier and Australian physiotherapist Professor Anne Holland wrote an Invited Topical Review about the management of long Covid. Malin answers some questions here.

Your Invited Topical Review recognises a diverse array of treatment options for long COVID. Long COVID is often described as a complex, multisystem condition. What makes it particularly challenging for physiotherapists to manage? 

The condition is highly heterogeneous and fluctuating and could be seen more as an umbrella term. 

Patients may experience symptoms including fatigue, post-exertional malaise (PEM), dyspnoea, autonomic dysfunction, pain and cognitive impairments, which can affect physical functioning, mental health and the ability to work or participate in everyday activities. 

For physiotherapists, this means that traditional rehabilitation models must be adapted. 

Interventions that are beneficial for one phenotype may be ineffective or even harmful for another, particularly when PEM or dysautonomia are present. 

The need to balance rehabilitation with symptom stability, while responding to day-to-day variation, is a key challenge in clinical practice.

Your review highlights PEM as a key issue. How should this change the way clinicians approach exercise prescription?

Physiotherapists are traditionally accustomed to prescribing exercise and promoting physical activity as a cornerstone of rehabilitation. 

Malin Nygren-Bonnier.

However, in patients who experience PEM, this approach must be fundamentally re-evaluated. 

Exercise can trigger a delayed worsening of symptoms, meaning that rather than encouraging patients to do more, we may need to support them in slowing down. 

Recognition of PEM fundamentally changes the rehabilitation approach: fixed or graded exercise progression is not appropriate.

Instead, all activity and exercise must be symptom-contingent, carefully titrated below the individual threshold and adjusted based on delayed symptom responses. 

Monitoring tools such as heart rate, perceived exertion and symptom diaries are essential. 

In patients with moderate to severe PEM, pacing and energy conservation should take precedence over structured exercise, with the primary goal of symptom stabilisation rather than improvements in fitness.

What are the most important components of a physiotherapy assessment for someone presenting with long COVID?

A comprehensive assessment should extend beyond physical capacity testing. 

Key components include systematic screening for PEM, autonomic dysfunction (including orthostatic intolerance), breathing pattern disorder, fatigue and neurological and cognitive symptoms. 

Understanding symptom variability, recovery time after exertion and the impact on daily activities and work is important.

Assessment should be iterative, with early follow-up after initial interventions to identify delayed symptom exacerbation. 

This holistic approach helps guide safe and individualised management.

There’s growing interest in interventions like breathing retraining and pacing. What does the current evidence tell us about their effectiveness?

Evidence for pacing and breathing retraining is emerging but remains limited. 

Pacing-centred approaches, particularly for patients with PEM, are supported by clinical consensus and observational data suggesting reduced symptom exacerbations and improved self-management. 

Breathing retraining shows promise for patients with breathing pattern disorder, with improvements in breathlessness and breathing efficiency reported in small trials and clinical cohorts. 

However, high-quality studies are still needed to establish effectiveness, optimal protocols and patient selection.

How important is multidisciplinary care in long COVID and what role should physiotherapists play within that model?

Multidisciplinary care is essential in long COVID due to its multisystem involvement and complex presentation.

Physiotherapists play a central role in assessing physical function, guiding safe and appropriate physical activity, managing breathing and autonomic symptoms, and supporting self-management strategies. 

Close collaboration with physicians, occupational therapists, psychologists and other healthcare professionals is often required to achieve optimal rehabilitation outcomes. 

Physiotherapists can also identify symptom deterioration or the emergence of new symptoms and support further assessment and referral when appropriate.

Looking ahead, what are the most urgent research priorities to improve physiotherapy management of long COVID?

Key priorities include identifying which patient subgroups benefit from different physiotherapy interventions and how to safely stratify risk, particularly in relation to PEM. 

Future trials must clearly report PEM status, adverse events and symptom trajectories. 

There is also a need for outcome measures that capture symptom fluctuation, daily functioning and work ability. 

Finally, research into implementation, including accessible models of care and digitally supported rehabilitation, is critical to meet the needs of patients with long COVID.

>> Malin Nygren-Bonnier is a physiotherapist and associate professor with a joint position between Karolinska Institutet and Karolinska University Hospital in Stockholm, Sweden. She leads the research group Function and Health in Respiratory and Cardiovascular Conditions and is the principal investigator of the ReCOV project on recovery and rehabilitation after COVID-19.