Participants were included if they fulfilled the following criteria: currently registered physical therapist in Australia or completing training to become a registered physical therapist in Australia, currently working or have worked in the past 12 months with patients who experience persistent pain.

The sample of participants was one of convenience from a Physical therapy Pain Day Forum held in Sydney, Australia in December 2019. The Physical therapy Pain Day was organized by local physical therapists with support from the Australian Physical therapy Association. The aim of the day was to provide a forum for discussion on matters specifically related to pain management for physical therapists. There was a variety of guest speakers and presentations. There was no fee to attend the day. Permission was sought from the organizing committee to conduct the data collection as part of the day.

At the beginning of the day, a member of the organizing committee introduced the study to attendees who were given a participant information sheet. It was emphasized that participation was entirely voluntary. Attendees were given the opportunity to ask questions either privately during morning tea or in a public forum after the morning tea break. Those wanting to participate then attended the designated study discussion session. Consent forms were signed, and participants took part in the small group discussions.

To facilitate the participant discussion addressing the research question, the research team developed four open-ended stimulus questions (Table 1) grounded in the study's objectives. The development process involved input from experienced physical therapists and the research team to ensure the questions were comprehensive and aligned with the study's aims. The final questions were designed to elicit detailed and specific responses, encouraging participants to share their perspectives and experiences in a structured manner.

The research team asked the participants to organize themselves into small groups of up to 10 people. Participants were encouraged to join with people that worked in different settings, or who they did not know. To describe the sample, participants completed a brief demographic questionnaire (Appendix A).

Each participant was given a copy of the four questions (Table 1). A scribe was self‑nominated for each group. There were four questions with ten minutes allocated to each question. Each question also contained an additional prompt to focus the conversations. Each group independently discussed each question with the scribe taking notes as the discussion took place. After eight minutes groups were asked to ensure they had provided a response to the specific question. Specific information provided to the group members and the scribes is available in Appendix B There was no audio or video recording of the small group discussion. Audio recording was not undertaken to preserve the informal, collegial nature of the forum and support participant comfort in an open professional setting. Each group used a standardized note-taking template (Appendix B) to capture key discussion points and illustrative quotes. Immediately following the session, notes were cross-checked with participants by the research team to ensure accuracy and consistency.

The researchers were physical therapists and educators with experience in pain management and professional training. No researcher had a prior clinical relationship with participants. Reflexive attention was given to how these professional backgrounds could influence interpretation. Team discussions were used to mitigate potential bias in data generation and analysis.

To address the aims and objectives the data was analyzed using systematic text condensation (STC) for qualitative data.22 Systematic text condensation is appropriate for cross section data which involves inductive coding across different cases and does not quantify data. Questions response forms completed by the scribes were transcribed into word documents and checked by a second researcher.

For the first step and in accordance with systematic text condensation, initially three members of the research team (DK, TG, IS) reviewed and discussed the data to gain first impressions and to make sense of the data (Total Impression). Data from the word documents was then transposed to an excel workbook. The text was separated into individual cells based on discrete, fragmented ideas, relevant to the research questions.

For the second step, two reviewers (DK, TG) independently coded each discrete unit to identify meaning within the data within a decontextualized framework (Condensation). These codes were then reviewed by the research team (DK, TG, IS) with iterative coding and review taking place (Identifying and Sorting Meaning Units).

For the third step we established broad themes with specific subgroups based on the decontextualized codes. These were reviewed by the full research team (DK, TG, SS, IS).

In the fourth step the themes and data were reconceptualized within the context of the research and as they relate to the research questions (Synthesizing). This required iterative review and discussion of the data, themes, and context in relation to the research questions.

We were able to extract the most relevant content and meaning from the data and present cross-case thematic summaries. The final themes and summaries were reviewed and agreed by the research team.

The complexity of persistent pain, including a poor understanding of the underlying causes and therefore the potentially unlimited targets for treatment, was clearly identified as a key factor that impacts the care of patients experiencing persistent pain across all system levels.

Persistent pain has long been considered a complex human condition with no clear pathoanatomical cause and recognition for an approach that considers a non-biomedical perspective.25–28 Physical therapists clearly identified that pain is a complex experience, that is managed in a complex system. While not a novel finding, we felt it was important to highlight and anchor the rest of the results under this overarching theme raised by the participants.

Over recent decades the shift towards the biopsychosocial model features heavily in the literature as a prevailing model in which to consider persistent pain.29–32 The model allows physical therapists an approach to make sense of complexity when patients present with persistent pain.33–35 Our study highlights that it is not just the complexity of the patients and their pain, but also their interactions within the complexity of the broader system they operate in that leads to significant challenges.

Our results indicated that the evidence shift to more psychologically informed physical therapy interventions has not been supported with appropriate training for physical therapists. It was recognized that training courses alone are not sufficient for the clinical application of such interventions and that ongoing mentoring and shadowing of other physical therapists are needed. These results are supported by evidence that recommends a structured training approach to psychologically informed physical therapy underpinned by strong communication skills.36–38 Indeed, there is emphasis on the importance of training in applying psychologically informed physical therapy,39 that does come with its own challenges, particularly where psychology supervision is not readily accessible.40,41 These studies underscore the need for psychologically informed physical therapy training to effectively integrate theoretical skills into practice.

Indeed, there was a perception that pre-registration training programs do not adequately prepare graduate physical therapists to support the management of people experiencing persistent pain, highlighting the need for earlier education in pain science and management. The role of pain science has been described as a potential threshold concept in physical therapy training programs and there is a curriculum available from the IASP that can be successfully implemented in such programs.42,43 Given the complex and multidimensional nature of pain, it is understandable that training programs have faced challenges in incorporating theoretical aspects, such as perceptual, ontological, epistemological, linguistic, and existential dimensions, into physical therapy education. In addition, with the scope of practice continuing to expand and the demands of the curriculum already high, it is difficult to expose students to and train them in evidence-based interventions within the constraints of current programs.43 Practice thresholds need to be achievable and balance the ability to appropriately recognize, triage, and provide initial evidenced based care to people experiencing persistent pain while aligning with post graduate training opportunities and specialist pathways.

Our results indicate that there is a lack of funding and resources that impacts on the delivery of appropriate care for people experiencing persistent pain, and that changes in funding structures need to occur to support the increased consultation times required. The issues identified mirror those in a study conducted in Israel arguing that the time allocated combined with the increased administrative burden was a barrier to effective management.44 While evidence broadly supports multidisciplinary, biopsychosocial interventions for persistent pain, funding models to support the delivery of such interventions to a broad number of people is lacking.1,45

A systems approach enables the identification of solutions by addressing overlapping issues and finding opportunities for convergence, rather than using reductionist methods that focus on isolated solutions for each issue. Because the themes reflected a complex system rather than discrete categories, some conceptual overlap is unavoidable and reflects how participants themselves described interconnected challenges.

There has been a call for greater recognition and application of complexity theory in health care, and rethinking reductionist, linear approaches to addressing health issues in favor of adopting a complex adaptive systems perspective.46 This approach conceptualizes health outcomes as the emergent product of a complex system, comprised of smaller nested systems of interconnected “agents” at various levels of scale (ranging from single cells and body systems, to organisms, to communities, institutions, and government), where the individual is viewed not in isolation but embedded within a broader context, environment, and society.47 Previous literature has proposed the application of systems perspectives to the phenomena of pain,48,49 which may offer an opportunity to better appreciate the complexity of factors contributing to individual experiences of pain, as well as the global burden pain represents and the role of physical therapists as being part of the solution.

Nested systems can be used to understand factors influencing outcomes at various levels, ranging from the individual to society as a whole. Drawing on and adapting Bronfrenbrenner’s Ecological Systems theory,50 we plot the themes of this study at the levels of the individual (i.e., the patient), the “microsystem” (i.e., the patient's immediate environment, the places they go and the people they interact with, including health professionals and services), “exosystem” (i.e., organizations, local governments, broader community, health and educational systems, infrastructure, media/internet), and “macrosystem” (i.e., policy, culture, social norms and perceptions, systemic injustice and oppression) levels (Fig. 1). We have chosen to omit the “mesosystem” level as described by Brofrenbrenner, as it encapsulates the interactions between components of the microsystem and is arguably redundant given that systems theory implies inherent interrelationships between agents within and between all levels of a system.

Fig. 1.

Challenges and barriers identified by Australian Physical therapists when working with patients with pain.

When we consider the key findings from our study we see that the themes extend across all levels of the system. Funding, for example, impacts the individual through their financial means, the microsystem through the payment options and funding provided to the health care provider, the exosystem through the insurance and compensation schemes, and the macrosystem, through cultural expectations and health care policy effected through state and federal budgets. Change and interventions are required throughout all levels of the system and cannot be viewed only in isolation.

Likewise, while clinical skills and education are the responsibility of the individual, they are influenced by the workplace and its emphasis on providing employee education. University training within the exosystem must also align with professional accreditation requirements, with funding made available to support this training.

When considering solutions to these challenges, enablers that extend across systems should be considered. For example, the Australian Physical therapy Association is an entity that has the ability to impact the individual through the training they offer to patients (e.g., seminars, website) and clinicians (e.g., professional development, grants), but can also lobby governments for targeted funding for health and telehealth schemes to increase access for patients and increased funding for extended consultation times for people experiencing persistent pain. For instance, the Australian government's National Strategic Action Plan for pain management has allocated early funding to train health professionals and develop an education strategy to improve access to consistent, up-to-date information and programs for managing persistent pain.51

While individual clinicians may typically orient towards individual and microsystem-level solutions (e.g., within the direct therapeutic context or through professional development and networking), there have been recent calls for physical therapists to adopt a “transformational view,” and consider how society might be changed to address broader social determinants of health. McGrath and colleagues52 state, “ignoring systematic problems reinforces the status quo…physical therapists should engage in transformational change by attempting to alter the system they perceive to be unjust.” Changes and interventions that span all levels of the system, from individual to macro-systems are required to ensure interventions are effective and appropriately address the complexity of pain and the challenges that exist in managing it.

It is important to recognize the limitations of this study. First, the data was collected prior to the COVID-19 pandemic and given the significant impact of COVID-19 on the health system and society, it is likely that these perspectives may not fully reflect the current experiences of Australian physical therapists. The pandemic shifted care delivery, increasing telehealth options, many which have become permanent, addressing the backlog of surgical rehabilitation, and having to integrate long COVID care into their practice, all exacerbating access and availability.53

Next, while not strictly a limitation, the inherent bias of the pragmatic approach should be acknowledged. This cohort represents an almost exclusively metropolitan subset of physical therapists and given that data collection occurred at the physical therapy specific Pain Day 2019, it could be assumed that most if not all have a high degree of interest in the area of persistent pain. In addition, coverage data should be interpreted with caution, as it reflects the proportion of written text by the scribe and not necessarily the entirety of the conversations across the groups. We acknowledge that this approach may limit narrative depth; however, the use of structured templates, multiple scribes, and comparative review helped mitigate the risk of scribe bias and loss of meaning. Our results should not be considered representative of the entire physical therapy profession. Future research in this area should include experiences of physical therapists who reside in rural and remote areas that experience inequitable health burden, and those who work across a variety of settings and clinical interest areas. Given this is a study focusing on the experiences of physical therapists, it is not surprising that many of the suggestions to improve practice involved advocacy, leadership, and promotion of the role of physical therapists in pain management.

Last is the potential bias stemming from the authors' positionality as physical therapists who specialize in pain management and hold academic roles in the field. Their deep involvement in the profession and subject matter may have influenced the development of the research questions, interpretation of the data, and analysis. While their expertise provides valuable insight, it may also predispose them to certain assumptions about pain management that could shape the data collection process, potentially affecting the objectivity of their interpretation. This positionality may also influence how they interpret the participants' responses, given the shared professional background and language, possibly leading to a biased confirmation of pre-existing beliefs or frameworks about pain management in physical therapy. It is important to acknowledge that their shared professional experiences with the participants could shape the dynamics of the group discussions, as participants may have felt encouraged to align their perspectives with the predominant professional discourse.

Ultimately, the findings of this study reinforce the sentiments of broader research that systems-informed approaches to tackling the issue of persistent pain are vital. The insights provided by physical therapists in this study offer nuanced and contextualized perspectives on the realities of working directly with people experiencing persistent pain in the Australian context, and afforded the opportunity for generative, bottom-up suggestions for how barriers and challenges might be addressed at various system levels. Future research should embrace a complex systems perspective to best address the problem of persistent pain and seek novel opportunities to improve outcomes. As Kuhn highlights, “complexity fosters reflection and thoughtfulness…. complexity in this way does not offer research recipes, ‘tried and true’, but rather a space for thinking otherwise”.