Upskilling for cognitive functional therapy competence

Dr JP Caneiro and Professor Peter O'Sullivan consider a pathway to upskilling clinicians to competently and confidently deliver a biopsychosocial intervention. 

Dr JP Caneiro

Best-care guidelines call for clinicians to take a biopsychosocial approach to treating people with musculoskeletal pain (Lin et al 2020).

Although many clinicians recognise this, they often feel under-trained and lack the confidence to implement a biopsychosocial approach in their practices (Holopainen et al 2022, Cowell et al 2018).

The RESTORE back pain trial (Kent et al 2023) demonstrated that clinicians can be trained to competently and confidently deliver a biopsychosocial intervention called cognitive functional therapy (CFT) (Simpson et al 2024).

CFT is a physiotherapist-led, person-centred, biopsychosocial approach that explicitly targets the pain cognitions, emotions and behaviours that are barriers to an individual’s recovery (O’Sullivan et al 2018).

The RESTORE back pain trial

RESTORE was a randomised trial carried out in 20 primary care physiotherapy clinics in Australia. The trial compared CFT and CFT with movement sensor biofeedback to usual care in people with chronic disabling low back pain (LBP).

RESTORE results showed that CFT produced large improvements in disability and pain, which were sustained at 12 months.

CFT also offered large cost savings (approximately $5000 per person over a year) compared to usual care (Kent et al 2023).

Prior to the start of the trial, clinicians needed to be trained and deemed competent to deliver CFT.

Training clinicians to competence

Eighteen physiotherapists across Perth and Sydney who had an interest in biopsychosocial care principles, a minimum of two years of clinical experience and no or minimal previous exposure to CFT were trained to competence over six months (80 hours of direct contact).

The training encompassed three stages and a formal competence assessment.

Credentialed CFT trainers facilitated this process.

Knowledge

In the first month, clinicians attended a two-day workshop and were presented with evidence-based knowledge of the multidimensional nature of LBP, a clinical reasoning framework, the principles of person-centred communication and the foundational principles of CFT.

Clinicians also observed a CFT expert examining and treating a person with LBP.

Skills

In the second month, clinicians attended a two-day skills workshop, which covered patient-centred communication, guided behavioural examination, CFT management and dealing with common barriers.

Videos of real cases were used to contextualise active role-play.    

Clinical mentoring

During months 3 to 5, clinicians were directly mentored while they assessed and treated patients with LBP in a small trainee group setting.

The trainer supported each clinician, providing personalised feedback based on a checklist of competencies.

Consultations were filmed and used for clinician self-reflection.

Over time, the clinicians required less support from the trainer.

In between workshops, clinicians were encouraged to reflect and integrate what they had learnt into practice.

Two clinical manuals (ebooks) were used to assist this process.    

At month 6, clinicians were formally assessed to determine their competence in delivering CFT while independently treating a patient with LBP.

If they   were not deemed competent, they were provided with feedback and encouraged to develop over the subsequent month.

The clinician's journey to competence

Professor Peter O'Sullivan

Clinicians described a rewarding process of experiential learning that challenged their beliefs and clinical behaviours.

The knowledge workshop was reported to be highly informative and applicable.

Watching a CFT expert manage a real case provided a practical road map for how person-centred care can be delivered.

Practising the skills of communication, guided behavioural examination, clinical reasoning and delivering CFT through active role-play with peers was an eye-opener for many of the trainees.

Working through how they would perform each of the skills promoted reflection and highlighted areas for improvement.

This has been described as a point where clinicians realise they need guidance on how to implement these skills in clinical practice (Holopainen et al 2022).

Clinicians reported that while direct mentoring was at times challenging, receiving personalised feedback when delivering care to real patients was essential to their learning and to changing their clinical behaviours (Simpson et al 2024).

It enabled  clinicians to self-reflect, fostering a shift in their pain beliefs and practice while building their confidence to gradually incorporate CFT into daily practice.

After the training, clinicians reported feeling confident and competent in delivering CFT.

Nonetheless, they still experienced challenges in daily practice.

This reflects the value of continued learning and the importance of a community to support this practice in the future.

There are, however, roadblocks related to the profession (traditional training and professional identity), the clinician (own pain beliefs and lack of confidence) and the work environment (time constraints, lack of peer support and privacy) and additional roadblocks at a system level (pervasive incentives, financial constraints and societal beliefs).

What's next?

Our group has received funding from the Medical Research Future Fund to test the training and implementation of CFT in both public and private care settings in Australia, including rural areas.

The project will be led by Professor Mark Hancock APAM.

We have also been working on the development of an educational platform to enable training at a global scale.

This social enterprise will provide equitable access to education for all, including those in low-income and middle-income countries.

The platform, which we are endeavouring to launch this year, will also have free, evidence-based content to support both clinicians and people living with pain.

>> Visit restorebackpain.com to register your interest.

>> Dr JP Caneiro FACP is a Specialist Sports and Exercise Physiotherapist (as awarded by the Australian College of Physiotherapists in 2013), an APA Pain Physiotherapist, an Adjunct Clinical Senior Research Fellow at Curtin University and a clinical director of Body Logic Physiotherapy in Perth.

>> Professor Peter O’Sullivan FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2005), a John Curtin Distinguished Professor in the School of Allied Health at Curtin University and a clinical director of Body Logic Physiotherapy in Perth.

Upskilling physios in pain management

Dr Joshua Pate outlines the importance of advancing non-pain-specialty clinicians' and students' ability to work confidently with people challenged by pain. 

Dr Joshua Pate

I am excited that the landscape of pain management is advancing.

As we continue to discover more of the complexities of pain, it is becoming increasingly clear that a multidimensional approach to pain is not just beneficial, but necessary.

There is an emerging need to upskill non-pain-specialty clinicians to work confidently with individuals challenged by pain—a topic I had the privilege to present to a full house at the Australian Pain Society conference 2024.

The management of chronic pain often falls short of addressing the multifaceted nature of this experience.

The biopsychosocial (BPS) framework has emerged as a way of thinking more broadly.

It helps to guide clinicians towards a biologically accurate understanding of pain.

However, the integration of this framework into clinical practice is a challenge, particularly for clinicians who may not specialise in pain.

The evidence of a gap between knowledge and practice is substantial.

Pain- specific training and education are pivotal in enhancing the confidence and competence of health professionals working within multidisciplinary teams.

To address this, we must shift our educational focus from teacher-centric models to facilitating a learner-centric journey.

In my presentation, I zoomed in on the experience of the University of Technology Sydney’s (UTS) Master of Physiotherapy course, to initiate conversations about person-centred pain care.

We all tried out the Concept of Pain Inventory for Adults (COPI-Adult), a tool developed to assess the reconceptualisation of pain.

I focused on the UTS-PhySS study, assessing how Master of Physiotherapy students think about pain throughout their two-year degree.

Before I get to that, some relevant context is needed about the course I teach at the UTS.

Academics have witnessed a significant shift in educational research, moving away from teacher-centric models to empowering learners.

The International Association for the Study of Pain’s (IASP) PT Curriculum, which embraces this shift in research, informs the pain curriculum I teach.

Because most of our postgraduate students have undergone a biomedical or pathoanatomical subject in their undergraduate studies, our course is structured to foster a safe environment where students actively engage with the latest evidence, applying it to complex case studies and real- world scenarios.

We carefully designed the syllabus so that each week, students participate in masterclasses and workshops that challenge their preconceptions, and they are encouraged to embrace the uncertainty and complexity of pain.

Similarly, assessment tasks are crafted to practically evaluate knowledge and application, develop behavioural management plans and demonstrate patient education about pain.

The PhySS study aimed to evaluate the concept of pain before and after a 14-week pain science education university subject.

We assessed COPI-Adult scores of two cohorts of graduate-entry physiotherapy students, providing valuable insights into the effectiveness of pain science education.

We found that COPI-Adult total scores increased, indicating a better alignment with contemporary pain science.

Interestingly, it is possible that our educational efforts are not necessarily about ‘unlearning’, but rather about growing and expanding our understanding of pain.

As we now examine the longer-term data, it appears that the concept of pain continues to change with clinical placements and practical experience.

Upskilling non-pain-specialty clinicians is not just about imparting knowledge to a new generation of physiotherapists: it is about transforming perspectives and practices.

By embracing the biopsychosocial approach to pain, and fostering a learner-centric educational environment, we can equip physiotherapists with the tools and confidence to provide person-centred, effective pain management.

As we continue to bridge the gap between knowledge and practice, we pave the way for a future where pain is better understood and managed with the depth and breadth it demands.

The big question posed in our session was simple yet challenging: ‘We need to be person-centred, but how do we actually do that?’

Our symposium provided time to reflect upon this first step towards bridging the knowledge-practice gap.

There were so many questions that a 45-minute Q&A was not enough time, the conversation must continue!

>> Dr Joshua Pate is a senior lecturer in physiotherapy at the University of Technology Sydney, with expertise in paediatric concepts of pain. Simultaneously working at Westmead Hospital Pain Management Centre and as a physiotherapist with children sparked his interest in the field. Joshua can be contacted via joshua.pate@uts.edu.au

Treating children with chronic pain

PhD candidate Jen Norton writes about upskilling paediatric health professionals to confidently work with children experiencing chronic pain. 

Jen Norton

I recently had the pleasure of presenting with my colleagues Dr JP Caneiro FACP and Dr Joshua Pate at the Australian Pain Society’s 44th Annual Scientific Meeting.

Under the umbrella of ‘Upskilling non-pain-specialty clinicians to confidently work with people challenged by pain’, we presented three different perspectives from our research and professional fields.

My focus is on upskilling ‘non-pain-specialist’ health professionals working with children experiencing chronic pain.

We know that chronic pain is prevalent and burdensome in children and adolescents (King et al 2011, Swain et al 2014) and that it has an impact on school, leisure, social connections, development and family relationships (Brown et al 2023, Bruce et al 2017, Jordan et al 2017).

It affects the family unit as well as the child and results in increased use of healthcare (Roth-Isigkeit et al 2005).

Best practice or ‘gold standard’ treatment for children with chronic pain is interdisciplinary or multidisciplinary and includes pain science education, which is based on the biopsychosocial model (Fisher et al 2022, Harrison et al 2019).

As a paediatric physiotherapist practising in the community across a range of paediatric speciality areas, I have to confess that working with children experiencing chronic pain and their families can be challenging.

There is just something tricky about chronic pain.

In fact, in a recent online survey (soon to be published), we asked health professionals (and the audience in Darwin at the Australian Pain Society conference) what emotions they experienced when working with children experiencing chronic pain.

Ninety-eight per cent of people reported that they feel uncertain at least some of the time.

These clinician experiences may reflect how healthcare is delivered to and received by children experiencing chronic pain and their families.

Evidence shows us that biopsychosocially informed care is delivered suboptimally in this area and that paediatric barriers are different from those of adults experiencing chronic pain (Holopainen   et al 2020, Hurley-Wallace et al 2019, Ng et al 2021, Pate et al 2022, Simpson et al 2021).

There is also emerging evidence that children’s experiences with health professionals when receiving healthcare for chronic pain can be poor.

At times, children report feeling dismissed, misunderstood and disbelieved by their health professionals (Dell’Api et al 2007, Joslin et al 2021, Lee et al 2023, Stinson et al 2013).

This begins to paint a picture.

According to our survey, we have health professionals working in this space who are experiencing not only uncertainty but also frustration, sadness and 30 other emotions.

Then we have children who may not be receiving optimal biopsychosocial healthcare for their pain and who may be feeling dismissed and misunderstood by their health professionals.

What a difficult situation to navigate for all involved.

My research aims to bridge the gap between the health professional who may feel uncertain or challenged and the child’s experience of healthcare.

How do we improve pain outcomes for children and their families and at the same time improve the pain journey experience for both children and their health professionals?

The first part of the process involved surveying health professionals to ensure that the research is clinically relevant.

We asked about their experiences in providing healthcare to children for chronic pain, perceived barriers and facilitators, strength and development areas and future training preferences and needs.

We found that barriers and facilitators varied and often overlapped when working with this group—for example, parent involvement was described as a barrier and as a facilitator in almost equal proportions.

Health professionals’ perception of their confidence and identified development areas also varied widely across a range of areas and sometimes overlapped.

For example, health professionals viewed themselves equally as a confidence factor and as needing to develop in this space.

Seventy-five per cent of respondents reported that they were moderately to extremely interested in further training.

The second component is collating the perceptions and experiences of children and their families to  ensure that the research is consumer-driven.

We are conducting a qualitative evidence synthesis to conceptualise what factors children and their parents perceive to have an impact on therapeutic relationships when receiving healthcare for chronic pain.

Our lived experience co- authors on this project include a young person who has experienced chronic pain and their parent.

They are contributing to project conceptualisation, synthesis, interpretation and dissemination.

The third element will be observing how all these factors present within a clinical setting to inform future training opportunities.

As with JP Caneiro’s work in the adult space, simply increasing knowledge may not be enough to change how we practise and treat within the clinic.

By observing clinical encounters, we plan to explore additional factors (such as non-verbal behaviours) that may be affecting the quality and delivery of healthcare.

The aim, in bringing these pieces of the puzzle together, is not only to improve delivery of care but also to equip health professionals with the necessary tools to provide confident and effective healthcare for children experiencing pain.

Jen Norton APAM is a senior paediatric physiotherapist and a PhD candidate in the Graduate School of Health at the University of Technology Sydney. Her current research interests include paediatric chronic pain, with a particular focus on upskilling health professionals working with children and families experiencing chronic pain in the community setting. Her clinical experience includes paediatric private practice, working with children in schools and running group interventions focused on participation and achievement. To contact Jen, email Jennifer.Norton@student.uts.edu.au

Horse for courses

Professor Louise Sharpe investigates mindfulness and cognitive behaviour therapy for pain management in people with rheumatoid arthritis. 

Professor Louise Sharpe

For decades, the prevailing model for understanding chronic pain has been the biopsychosocial model.

Psychological treatments have long been used to help people cope better with chronic pain; hundreds of trials have demonstrated better pain outcomes for people who complete psychological treatments than for those who do not.

Two effective psychological approaches are cognitive behaviour therapy (CBT) and mindfulness- based interventions.

CBT provides education about the nature of pain, encourages an optimistic but realistic attitude towards pain and spurs people on to resume activity in a gradual and paced manner.

Mindfulness urges people not to respond to their thoughts or feelings but rather to observe them without judgement.

This changes the relationship that people have with their thoughts, feelings and sensations, leading to less anxiety and depression.

Through prior research, both of these treatments have been found to be effective.

However, there are limitations: the effect sizes are small, face-to-face therapies are difficult to access and there is considerable room for improvement in both outcomes and access to treatment.

To compare the efficacy of CBT and mindfulness in treating chronic pain, four head-to-head trials were conducted.

All four trials found that when delivered face to face (mainly in groups), both CBT and mindfulness were effective compared to control groups. 

For the primary outcomes, they were equally effective.

While there were some small variations between studies, there was little to indicate that either treatment was significantly more effective than the other.

In order to evaluate the limits of mindfulness and CBT in alleviating the symptoms of chronic pain, we completed a trial with 269 people with rheumatoid arthritis (RA).

In the trial, we asked two important questions:

1. Can we administer these treatments online, thereby increasing access to the interventions?
2. Do some people benefit more from CBT and others more from mindfulness?

People with rheumatoid arthritis (RA) volunteered to take part in a study of two psychological treatments.

Participants were randomly assigned to receive either an online CBT program, an online mindfulness program or a waitlist control—those in the control group would later receive whichever program they preferred.

The results showed that for the primary outcome of pain interference, both mindfulness and CBT were more effective than the waitlist controls.

Both treatments resulted in improvements in pain severity and depression but CBT produced more improvement than mindfulness six months after treatment.

However, only mindfulness produced changes in fears of disease progression.

Mindfulness also showed a greater improvement in functional ability six months after treatment.

Similar to prior research, our study showed that even when CBT and mindfulness are provided online with minimal therapist input, they are both effective treatments for people with RA.

These results also did not strongly favour one approach over another.

We were interested to know whether different people benefited more from one treatment or the other.

The trial revealed that people who were already high in trait mindfulness benefited more from mindfulness than CBT, whereas people in more severe pain benefited less from mindfulness.

It suggested that if people had high levels of pain, they might do just as well with CBT, but if they had low levels of pain, mindfulness was particularly helpful in reducing their fears of disease progression.

This turned out to be important because it was the people who became less fearful over the course of treatment who were able to make changes to improve their functional ability during the follow-up period.

These results can help us to work out who might do best with which approach.

The availability of effective online psychological treatments for people with chronic RA and other chronic pain problems is an important consideration.

One in five people experience persistent pain and there are insufficient resources to provide all of them with face-to-face interventions.

All the same, this is a good news story—the two most common psychological treatments for chronic pain can be effective when completed online with minimal therapist input.

It also seems that those who are high in trait mindfulness but low in pain would be most likely to benefit from online mindfulness, while those high in pain severity appear to benefit more from CBT.

Ultimately, people with chronic pain can make a choice between two effective interventions.

>> Professor Louise Sharpe has nearly 30 years of experience practising and studying her field of clinical psychology, and has more than 300 peer-reviewed publications to her name. Her areas of expertise and research are adjustment to illness, chronic pain, psycho-oncology and the cognitive processes involved in ill health. Louise is a Professor of Clinical Psychology and Pro-Vice Chancellor (Researcher Training) at the University of Sydney.

Interpersonal relationships

Professor Toby Newton-John examines the influence of interpersonal factors on chronic pain. 

Professor Toby Newton-John

By and large, the collective of clinicians and researchers working in the field of chronic pain are comfortable with the biopsychosocial model of pain.

It would be difficult to find a credible physical therapist or academic who strongly disagrees with the proposition that psychosocial factors influence the experience of pain.

However, research and treatment innovations are still heavily focused on the biological and psychological aspects of pain experience—with much less relative attention given to social influences.

In this article, I will argue that this is partly due to the legacy of the operant conditioning paradigm (at least when considering patient-partner social interactions).

However, the role of the dominant medical model, which has only recently begun to be revised, should not be forgotten either.

By adopting a more nuanced understanding of social relationships and systems, we have an opportunity to harness significant capacity in order to improve the lives of many people living with chronic pain.

When it comes to the experience of acute pain, whether experimentally or clinically induced, the evidence strongly points to interpersonal factors being ‘the good’ influence referred to above.

As a general finding, when compared to being alone, the presence of other people helps to ameliorate the negative effects of being in pain (Che et al 2019).

A typical experimental paradigm involves the parent being present during child venipuncture (Azak et al 2022) or having your partner stroke your forearm while a laser-induced pain stimulus is applied (Von Mohr et al 2018). ,

Interestingly, it appears that you do not even need to interact with others in order for the pain buffering effect to occur.

Being alone, but reminded of your social network (via photographs) can be enough to improve your coping with a short-term pain experience (Che et al 2019).

However, when it comes to chronic pain, the evidence suggests that interpersonal factors can be ‘the bad’, and this is predominantly in relation to research on patient– partner interactions.

The idea that a well-intentioned spouse could inadvertently increase the pain-related disability of their patient–partner over time was a revelation in 1976 when Fordyce published his seminal book (Fordyce 1976).

Since then, a substantial number of studies have confirmed the basic premise of the operant conditioning model.

Namely, that patients whose partners are reported to respond to displays of pain behaviour (such as grimacing, guarding, lying down, taking medication, etc.) with so-called ‘solicitous’ responses (such as providing physical assistance, expressing sympathy, taking over chores, etc.) tend to become more disabled by their pain over time (Bernades et al 2017).

The relationship between increased partner solicitousness and increased patient disability has been shown across numerous domains including physical function (Leonard & Cano 2006), opioid medication use (Cunningham et al 2012) and even acceptance of pain itself (McCraken 2005).

As a result of these studies, the idea of the ‘solicitous spouse’ being a barrier to improving patient outcomes was established.

Nevertheless, virtually all of the studies cited as evidence of the operant conditioning model have been cross-sectional in design.

In other words, the link between greater partner solicitousness and greater patient disability has been by association and not causation (as predicted by learning theory).

It may be the case that patients with greater disability have more need of their partner’s attentive responses, rather than the latter resulting in the former.

A recent test of causation here was inconclusive (Bernades et al 2024), so there is further work to be done.

Treatments that have attempted to address the maladaptive pain behaviour–solicitous responding interaction have generally produced disappointing results (Smith et al 2019, Tanka et al 2020).

Consulting the relationships and marital satisfaction literature provides a clue as to why this might be.

Behaviours associated with solicitousness (accurate decoding of a partner communication, appropriate behavioural responding in context, provision of validation of partner experience) are all highly predictive of strong, positive relationship satisfaction (Karney & Bradbury 1995).

Any attempt to interrupt these interactions is not likely to be received well.

Rather than teaching partners how to behave less solicitously, helping partners to find alternative methods of communicating their validation and support—particularly encouraging pain self-management approaches—offers a more valuable point of intervention.

Turning now to the ‘just possible’ of interpersonal relationships, what can we learn from those living well with chronic pain or in recovery?

Can a social structure that draws on community insights make a significant difference in improving the lives of people with chronic pain?

Our Medical Research Future Funded project titled Our Recovery, poses such questions.

This research project involves building and evaluating a social support and learning program for people with chronic pain.

Angie Clerc-Hawke, who has a lived experience of chronic pain and created Our Recovery, a not-for-profit organisation in 2021, co-leads this project.

Through an online portal, participants can engage with reflective practice exercises, utilise evidence-based resources that highlight the insights of those living well, and access trained peer mentors delivering structured group sessions and individual peer support.

We are adapting a framework with high-quality evidence for person-centred outcomes and behaviour change (Twelve Step Framework; Chappel & DuPont 1999), using both consumer-led and participatory research approaches.

The Our Recovery project moves away from a traditional medical model in which the healthcare system is the way people access pain management support, and challenges the notion that clinicians are the sole custodians of knowledge and skill from which people can benefit.

So far, seven pain clinics around the country have agreed to assist with recruiting their patients into a feasibility trial of the Our Recovery model, which will start in 2025.

In summary, while the ‘bio’ and the ‘psycho’ have tended to dominate the research and treatment landscape in chronic pain over recent years, this brief overview argues that a greater focus on the social influences will bring dividends.

>> Thanks to Angie Clerc-Hawke for her valuable contribution to the ‘just possible’ section of this article.

>> Toby Newton-John is currently a Professor of Clinical Psychology and Head of the Graduate School of Health, University of Technology Sydney. Toby has published over 90 peer-reviewed journal articles and book chapters on the psychology of chronic physical illness, predominantly chronic pain, and is a chief investigator on research grants totalling more than $11 million since 2020. He continues to practise as a clinical psychologist in a part-time capacity at Northern Pain Centre, Sydney.

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