Physiotherapists are ‘well suited’ to work with people with severe mental illness (SMI) who are experiencing pain, according to an editorial scheduled for publication in the March edition of the journal Physiotherapy.

The editorial’s first author is Brendon Stubbs, from the Department of Psychological Medicine at the King’s College-based Institute of Psychiatry, Psychology and Neuroscience in London. Dr Stubbs is also based at the Centre for Sport Science and University Sports at the Department of Sport and Human Movement Science, University of Vienna in Austria.

He is one of three authors whose background lies in physiotherapy: the others are Ryan L McGrath and Davy Vancampfort, who are based in Australia and Belgium, respectively.

The authors note that long-term pain is a common issue for people with SMI, an umbrella term that includes diagnoses such as such as schizophrenia, bipolar disorder and major depressive disorder. As many as six in 10 (62 per cent) of people with SMI diagnoses are affected, whereas the comparative figure is one person in four or five (20-25 per cent) among the general population.

‘This complex comorbidity, intertwined with mental health symptoms, amplifies disability, increases healthcare costs, and complicates treatment within traditional, siloed care models,’ Dr Stubbs and her fellow authors write.

‘Physiotherapists, with their expertise in musculoskeletal assessment, movement-based interventions, and patient-centred care, are ideally suited to lead in identifying and managing pain in this population.’

Barriers to improved care

Despite their expertise, physiotherapists are hampered by ‘persistent barriers’, such as ‘diagnostic overshadowing’ – a misattribution of physical symptoms to psychiatric illness – which is particularly common in conditions such as schizophrenia. In these cases, the authors note, ‘elevated pain thresholds can mask serious conditions, delaying intervention’.

Other obstacles include a lack of training in mental health and ‘fragmented healthcare systems’, with many physiotherapists currently being ‘disconnected from multidisciplinary teams’, for example.

The authors refer to a 2024 systematic review, which found that body-based interventions, such as yoga and tai chi, led to large pain reductions, while approaches based on cognitive behaviour therapy (CBT) had a less powerful impact. They note that evidence for interventions on those with schizophrenia remains ‘sparse’.

Training gaps

The need for targeted pain management among people with an SMI – where pain exacerbates psychiatric symptoms and reduces quality of life – is urgent, Dr Stubbs and his colleagues stress.

‘Physiotherapists, with their expertise in musculoskeletal assessment, movement-based interventions, and patient-centred care, are ideally suited to lead in identifying and managing pain in this population’ [Brendon Stubbs et al]

‘Physiotherapists are well-suited to address this need through comprehensive pain assessments using tools like the Brief Pain Inventory and delivering interventions such as exercise, manual therapy, or psychologically informed physiotherapy.

Body-based interventions, which reduce pain interference and disability in SMI, align with physiotherapy’s movement-focused expertise. By integrating physical and psychosocial strategies, physiotherapists can disrupt the pain-mental health cycle, offering holistic care grounded in the biopsychosocial model.’

Limited mental health training is a key challenge, the authors note, pointing to recent research showing that physiotherapy students feel unprepared to address psychological issues like self-harm, reflecting broader training gaps in managing SMI.

‘Physiotherapists often lack confidence in handling SMI patients’ psychological needs, citing insufficient education in psychiatric comorbidities,’ the authors note.

Opportunities for physiotherapy leadership

Physiotherapists could ‘counter’ the knee-jerk tendency to treat pain with opioid medication – an option that raises concerns about creating dependency and mood destabilisation – by offering ‘non-pharmacological alternatives’.

They should promote pain screening regimes using validated tools such as the Brief Pain Inventory and obtain training in SMI-specific pain profiles, such as reduced sensitivity in schizophrenia.

‘Enhanced training in mental health is critical. Physiotherapy curricula should include modules on SMI, focusing on psychosocial risk factors, such as socioeconomic disadvantage and pain catastrophising, and communication strategies.’

Yoga is an effective approach that physiotherapists could adapt with proper training, the authors suggest. ‘Recent research on psychosocial factors in cervical spine pain underscores the importance of addressing psychological distress, suggesting training in CBT-informed approaches could prove useful. Interprofessional education with psychiatrists can foster confidence in delivering such therapies.’

Other recommendations include bringing physiotherapy and psychiatric services together in order to streamline referrals and collaboration and prioritising physiotherapy-led interventions such as graded exercise, which reduce pain and improve mental health. Policy advocacy is needed to obtain funding for these initiatives and expand telehealth physiotherapy and more research is vital, the authors suggest. 

Conclusion: ‘a transformative opportunity’

Dr Stubbs and his co-authors conclude: ‘Physiotherapists have a transformative opportunity to lead pain management in SMI, bridging physical and mental health care. By implementing routine screening, enhancing training, fostering interdisciplinary models, and expanding research, the profession can address diagnostic overshadowing, training gaps, and systemic barriers.

‘The high pain burden, opioid overuse, and care inequities demand urgent action. Physiotherapists must advocate for evidence-based, equitable care to alleviate suffering and enhance quality of life for individuals with SMI.’

To access the full version of the article – titled Closing the mind-body divide: physiotherapists as leaders in pain management in serious mental illness – click

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