"Every patient teaches you something new": experiences of physiotherapists delivering cognitive functional therapy

Key points

1. 01Physiotherapists described four themes: sharing patient transformational change, refining new competencies, navigating patient complexity, and balancing care with trial processes.
2. 02Each patient encounter was seen as a learning opportunity, deepening skills in person-centred communication and collaborative goal-setting.
3. 03Complex patients with high disability, comorbidities, or diverse cultural backgrounds stretched physiotherapists beyond their perceived scope of practice.
4. 04Ongoing access to a trainer and trial psychologist was valued for managing difficult cases, though not all physiotherapists felt they needed it.
5. 05Biofeedback movement sensors were seen by most as interrupting clinical flow, consistent with trial results showing sensors did not add value.

How it was conducted

Design

Cross-sectional qualitative study using reflexive thematic analysis, nested within the RESTORE RCT

Participants

15 physiotherapists (7 female) who delivered CFT in the RESTORE RCT across Perth and Sydney, Australia; 3-25 years clinical experience

Data collection

Semi-structured interviews conducted 6-12 months after commencing CFT delivery in the trial; duration 52-220 min, mean 89 min

Analysis

Reflexive thematic analysis (Braun and Clarke) with iterative coding and team-based theme refinement

CFT training

Physiotherapists completed 80+ hours of competency-based training with experiential learning before trial commencement

What they found

• 15 of 15 eligible physiotherapists participated (3 of 18 original trainees withdrew before the delivery phase due to maternity leave, carer responsibilities, or ceasing physiotherapy practice).
• Mean Roland Morris Disability Questionnaire score for RESTORE trial patients was 13.5 (SD 5.2), indicating high disability.
• 93% of CFT-only and 88% of CFT plus biofeedback group patients were classified as medium-high risk of poor outcome on the Keele STarT MSK screening tool.
• Four themes were constructed: sharing the journey of transformational change, refining new competencies, navigating patient complexity, and balancing patient care with trial-related processes.
• Most physiotherapists reported high reward from witnessing patient transformational change and re-engagement with valued activities.
• One physiotherapist reported ongoing discomfort addressing emotional and psychosocial factors throughout the trial.

Limitations

• All physiotherapists were recruited from private practices in Australian urban settings, limiting transferability to rural, regional, or public healthcare contexts.
• Physiotherapists self-selected into the RESTORE trial and had a prior interest in biopsychosocial approaches, which may not represent typical physiotherapy practice.
• The study does not include patient perspectives, so the reported transformations are filtered through therapist accounts only.
• Interviews were conducted by a physiotherapist known to participants from a prior training study, which may have introduced social desirability bias.

Why it matters

For patients

Patients with chronic disabling low back pain may benefit most from a physiotherapist who approaches their care collaboratively and has ongoing mentoring support, as therapist skill in CFT continues to develop through real clinical experience.

For clinicians

Physiotherapists transitioning to biopsychosocial practice need more than initial competency training, they benefit from ongoing experiential learning, peer support, and access to multidisciplinary colleagues for complex cases.

For readers

This study shows that even well-trained physiotherapists delivering an evidence-based intervention continue to refine their skills on the job, and that trial design factors like sensor use and administrative burden can detract from care quality.