Physiotherapists’ delivery of cognitive functional therapy in clinical practice: perceived facilitators and barriers from a socioecological perspective

Cognitive functional therapy (CFT) is a person-centred biopsychosocial intervention for chronic low back pain, with large sustained clinical and economic benefits. This study explored the experiences of physiotherapists delivering CFT in their usual clinical practice after being trained to competency for the RESTORE clinical trial. A qualitative study design was used. Fifteen primary care physiotherapists were interviewed (seven female, clinical experience 3–25 years). An inductive-deductive content analysis was used, including the Theoretical Domains Framework and socioecological model. Facilitators and barriers were identified within and between individual, micro (clinical interface), meso (health service), and macro (health system) levels. Physiotherapists reported feeling competent and skilled delivering CFT. At the microsystem, this was influenced by time and their evolving professional identity. At the mesosystem, social support within the clinical community and positive patient outcomes facilitated CFT, while disunity in pain management across the health system and inadequate remuneration were barriers. Societal beliefs about pain, shifts in professional identity, and funding models influenced delivery at the macrosystem. This study highlights multilevel facilitators and barriers that physiotherapists perceive when implementing CFT. Targeting these may help to optimise the implementation of this promising intervention, thereby contributing to better patient outcomes. Ensuring that physiotherapists are trained to competency in cognitive functional therapy (CFT) empowers clinicians with the necessary skills and confidence to effectively treat a broad range of musculoskeletal pain patients in usual clinical practice.Building communities of practice that facilitate peer review and reflection builds skills and prevents drift from the competencies of delivering CFT.Creating clinical environments that support both privacy for sensitive patient disclosures alongside connectivity and opportunities for self-management is crucial for delivering person-centred care.Addressing challenges with current funding models is essential for improving access to biopsychosocial interventions like CFT.Patient triage and outcome-based funding models that incentivise high-value care could help ensure more equitable, timely, and cost-effective physiotherapy services. Ensuring that physiotherapists are trained to competency in cognitive functional therapy (CFT) empowers clinicians with the necessary skills and confidence to effectively treat a broad range of musculoskeletal pain patients in usual clinical practice. Building communities of practice that facilitate peer review and reflection builds skills and prevents drift from the competencies of delivering CFT. Creating clinical environments that support both privacy for sensitive patient disclosures alongside connectivity and opportunities for self-management is crucial for delivering person-centred care. Addressing challenges with current funding models is essential for improving access to biopsychosocial interventions like CFT. Patient triage and outcome-based funding models that incentivise high-value care could help ensure more equitable, timely, and cost-effective physiotherapy services.