“Physiotherapy and beyond: how Contextual Factors Influence Pain and Rehabilitation Outcomes?”

Autori

Francesco Bonanno (Università degli Studi di Messina, Messina, Italia)

Leonardi Giulia (Department of Physical and Rehabilitation Medicine, University Hospital “G. Martino”, Messina, Italia)

Garofalo Alfio (Università degli Studi di Messina, Messina, Italia)

Di Dio Antonio (Università degli Studi di Messina, Messina, Italia)

Sposito Francesca (Università degli Studi di Messina, Messina, Italia)

Saraceno Silvia (Università degli Studi di Messina, Messina, Italia)

Cucinotta Carmen (Università degli Studi di Messina, Messina, Italia)

Cavallaro Filippo (Università degli Studi di Messina, Messina, Italia)

Alito Angelo (Department of Physical and Rehabilitation Medicine, University Hospital “G. Martino”, Messina, Italia)

Background and aims

Contextual factors (CFs) are increasingly recognized as integral components in the modulation of pain perception and the potentiation of both pharmacological and non-pharmacological treatment effects. These factors exert bidirectional influences on both patients and healthcare providers, originating from prior experiences and the interpersonal dynamics established during clinical encounters. CFs encompass multiple domains, including patient-specific characteristics, treatment attributes, the therapeutic alliance, and the broader clinical environment. Their influence may manifest as either placebo-induced analgesia or nocebo-induced hyperalgesia, thereby significantly shaping clinical outcomes. In light of the multifactorial nature of pain and its management, this narrative review synthesizes current evidence regarding the role of CFs within rehabilitation settings, with a focus on their mechanisms of action and their impact on pain perception and therapeutic efficacy.

Methods

The authors searched PubMed for English articles published within the last ten years using the keywords:   “pain”, “acute pain”, “chronic pain”, “musculoskeletal pain”, “neuropathic pain”, “psychogenic pain”, “contextual factors”, “placebo effect”, “healthcare setting”, “verbal communication”, “non-verbal communication”, “patient-physiotherapist relationship”, and “physiotherapy”.

Results

The selected articles consistently highlight the significant influence of CFs on pain management. Notably, nocebo effects in musculoskeletal pain can be mitigated by creating a supportive therapeutic environment, personalizing treatment, managing patient expectations, and fostering effective communication between the patient and physiotherapist. Furthermore, accurately interpreting patients’ non-verbal pain cues is essential for optimizing clinical outcomes. Equally important is the therapeutic alliance, which—through active listening, bidirectional communication, and mutual understanding grounded in patients’ lived experiences and social contexts—plays a crucial role in enhancing pain relief.

Conclusion

This review underscores the pivotal role of contextual factors (CFs) in the rehabilitation process, influencing both the patient and the physiotherapist throughout the course of care. Patients are the main beneficiaries of improvements in these areas, so these should be systematically addressed and incorporated into the core training programmes of rehabilitation professionals to foster a better understanding of their impact on clinical outcomes. Increasing awareness of the impact of CFs on clinical outcomes is essential for fostering more effective, patient-centered care. While the evidence highlights the relevance of CFs in enhancing pain management and overall therapeutic effectiveness, the review is limited by the relatively small number and size of the included studies. An important question remains: to what extent are these factors currently and systematically integrated into everyday clinical practice by physiotherapists?

REFERENCES

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