Our previous three-part series looking at improving patient recovery from work injuries explored how understanding psychosocial factors can improve clinical outcomes. 

This article introduces a practical conversational framework, the ABCDEFW mnemonic, developed as part of the New Zealand Acute Low Back Pain Guide, which can help physiotherapists explore these factors naturally during clinical encounters (Accident Compensation Corporation 2004, Watson & Kendall 2000). 

This approach complements formal screening tools like the Örebro Musculoskeletal Pain Screening Questionnaire and the Tampa Scale of Kinesiophobia, offering a structured yet conversational way to understand your patient’s situation. 

By addressing the seven broad yellow flag categories, physiotherapists can help patients become curious about their circumstances and what may be influencing their recovery. 

As physiotherapists have more of these conversations, they can build their confidence in delivering truly biopsychosocial care. 

Attitudes and beliefs about back pain

Our patients’ beliefs about their condition significantly influence their recovery. 

Key areas to explore include their understanding of pain, expectations about recovery and beliefs about activity. 

Rather than directly questioning their beliefs, try opening with ‘What do you think is happening with your back?’ or ‘How do you see this affecting you over the next few weeks?’ Listen for beliefs like ‘my back is damaged’ or ‘movement will make things worse’.

These can be gently explored and addressed through education about pathways to recovery and, if relevant, basic pain science.

Such discussions help both the patient and the practitioner see what ideas may be contributing to over-protective behaviours. 

If a patient says, ‘I need to rest until the pain goes away’ you might respond with ‘Tell me more about what makes you think that’s the best approach.’ 

Behaviours 

Observing and discussing behaviour provides valuable insight into how patients are managing their condition. 

Notice movement patterns, activity levels and coping strategies. 

You might ask ‘What activities have you found helpful in managing your symptoms?’ or ‘How have you modified your daily routine since the injury?’ 

Within the context of their accident, consider if there is an excessive avoidance of activity, over-protective movement patterns or overreliance on passive treatments. 

These behaviours often reflect underlying fears or beliefs that need addressing. 

For example, if someone is avoiding all bending, you might say ‘I notice you’re being very careful with bending. What concerns you about that movement?’ 

Compensation issues 

The processes, responsibilities and impacts of the compensation system are daunting for many people—the accompanying distress can significantly delay recovery. 

Assessing how patients are personally coping can begin with general questions like ‘How are you finding the workers compensation process?’ or ‘Is there anything about the claim process that’s worrying you?’ 

Listen for signs of frustration with the system or concerns about financial security. 

While we can’t resolve these issues directly, acknowledging them and making appropriate referrals can help. 

For instance, if someone expresses anxiety about paperwork, you might suggest speaking with their case manager or their vocational rehabilitation provider for guidance. 

Diagnosis and treatment

Healthcare can be confusing for people when there is a lack of clarity about a diagnosis, when they have received conflicting opinions or if they sense that there have been insufficient investigations. 

It is important to support their health literacy and their understanding of their condition and what they can do to self-manage. 

This can be explored by asking, ‘Has anyone given you a clear understanding as to which part of you is injured or whether something needs to go through healing? Does this make sense to you or do you feel it doesn’t quite fit your issue?’ 

Understanding your patient’s experience with previous treatments and their expectations of current care provides valuable context.

You might ask, ‘What treatments have you tried before?’ or ‘What do you think would be most helpful for your recovery?’ or ‘What do you think is the best physiotherapy that you need at the moment?’ 

Emotions 

Emotional responses to injury are normal but can become barriers to recovery if not properly addressed. 

Create space for emotional expression with questions such as ‘How has this injury been affecting your mood?’ or ‘What’s been the most challenging part of dealing with this injury?’ Watch for signs of what may be excessive levels of anxiety, depression or frustration that might warrant referral for additional support. 

If someone appears unusually distressed, you might say ‘Many people find that after their injury life is not the same; the loss of working with colleagues and the workers compensation processes can affect their emotional wellbeing. 

Would you like to talk about how you’re feeling?’ Identifying early on whether someone is particularly affected by the accident itself can enhance clinical outcomes. 

This can be explored by asking if the event is playing on the patient’s mind, is affecting their dreams or brings up strong physical or emotional reactions. 

Family 

Living with a family member experiencing pain is difficult. 

Family dynamics can either support or hinder recovery. 

Explore this area with questions such as ‘How has your family been managing since your injury?’ or ‘What support do you have at home?’ 

Listen for signs of family stress or of over-protective family members who are unrealistically concerned about reinjury. 

In these situations, you might need to empower the patient to help their family regain confidence in the patient’s ability to be active. 

If someone mentions that their partner is doing everything for them, you might explore whether this is helping their recovery or not. 

Work 

Work factors often significantly influence recovery outcomes. 

Discuss the work environment with questions like ‘How supportive has your workplace and management team been since your injury?’ or ‘What aspects of your job are you most concerned about returning to?’ 

Pay attention to signs of workplace conflict, fear of return to work, expectations of the employer or concerns about job security.

These issues might need to be addressed through workplace visits or collaboration with return-to-work coordinators. 

If someone expresses anxiety about their supervisor’s expectations, you might suggest a case conference to clarify the return-to-work plan.

Using the framework effectively 

The ABCDEFW framework works best when used flexibly, weaving questions naturally into your clinical conversations rather than working through it like a checklist of yellow flags. 

Not every area needs to be explored in every session. Start with the most relevant aspects based on your observations and your patient’s presentation. 

The framework complements rather than replaces formal screening tools. Use it to guide your conversations and deepen your understanding of the psychosocial factors influencing your patient’s recovery. 

Like all parts of our work, the more we practise these skills, the more confidence we have in using them. 

Conclusion 

The ABCDEFW framework provides a practical structure for exploring psychosocial factors in clinical practice. 

By incorporating these conversation areas naturally into your assessments and treatments, you can build a more complete picture of your patient’s situation, tailor management and facilitate a smooth return to work. 

This approach, combined with formal screening tools and the strategies discussed in the previous series, enables physiotherapists to deliver truly patient-centred care that addresses both physical and psychosocial aspects of recovery. 

Sliding doors: chef’s neck injury 

John, a 46-year-old chef, sustained a hyperextension neck injury after hitting his chin on a bench while ducking under a shelf. 

While he was initially diagnosed with a muscle problem by his GP, investigations revealed a disc bulge on John’s CT scan, significantly increasing his anxiety about the injury. 

Sliding door scenario 1

John received physiotherapy with hands-on treatment and exercises. Despite the physiotherapist’s reassurance that disc bulges are common and often asymptomatic, John developed excessive worry about his spine condition. 

This was compounded by concerns about letting his team down, career impact and financial stability as the primary breadwinner. Six weeks post-injury, John’s physical symptoms have only mildly improved while his anxiety has significantly increased. 

His scan results are fuelling catastrophic thinking and complicating his recovery. 

Sliding door scenario 2

The physiotherapist utilised the Örebro Musculoskeletal Pain Screening Questionnaire, identifying John’s anxiety, depressive feelings and unhelpful beliefs about his injury. 

Using the ABCDEFW framework, the physiotherapist explored John’s emotional state through curious questioning. 

Treatment included comprehensive pain education about the limited correlation between imaging findings and symptoms, with John’s wife included in education sessions to address her overprotective behaviours. 

The physiotherapist communicated their findings to the GP, encouraging psychological support and a graduated returnto- work plan. 

After providing a modified duties certificate, the physiotherapist liaised with the hotel’s occupational health team, who implemented workplace adjustments and offered employee assistance program counselling during work hours. 

A graduated return-to-work plan maintained John’s leadership role while reducing physical demands through task delegation and a focus on menu planning and team management. 

Outcome 

Six weeks post-intervention, John’s neck pain significantly improved, his anxiety decreased and he was confidently managing his modified workload with a clear plan for a return to full duties. 

Click here for references. 

Des O’Shaughnessy MACP (he/him) is an APA Titled Pain Physiotherapist. 

During his 25 years as a physiotherapist, Des has worked with people with a wide range of pain and movement conditions, including those whose recovery hasn’t gone to plan. 

He balances different treatment ideas of exercises, manual therapies, education and building self-management skills so that people can regain and maintain the important things in their life. 

Significant contributions were made to this article by members of the physiotherapy advisory group It Pays to Care.