Self-efficacy in physiotherapy: a guide for the treatment session

For professionals · as of October 2026 · about 8 minutes' reading, 12 with the in-depth sections · all DOIs individually verified

1. Why it pays to look at self-efficacy

Self-efficacy is a person's belief that they can carry out a particular behaviour, even under difficult conditions [1]. In persistent pain, it is among the characteristics that best predict the course. A primary care cohort compared 20 psychological characteristics. In the combined model, four remained as predictors of disability at six months, among them pain self-efficacy [2].

Self-efficacy can be assessed in every session with little effort and addressed in a targeted way. This sets it apart from many other prognostic factors such as age, symptom duration or imaging. Treatments that build on movement and confidence change it measurably. For Cognitive Functional Therapy in chronic low back pain, a meta-analysis found an increase in pain self-efficacy, with high certainty of evidence [3].

In depth: what the studies show and what they do not

Association with outcomes. A meta-analysis of 86 samples with 15,616 people with chronic pain found negative associations between self-efficacy and disability, emotional distress and pain intensity [4]. The associations persisted in prospective studies that controlled for the baseline value of the respective outcome. Heterogeneity was considerable. The content of the scale moderated the association with disability, as did age, pain duration and the type of measurement (self-report or performance test). A systematic review of 27 longitudinal studies in chronic musculoskeletal pain reached similar results, although the included studies were of low quality [5].

Mediation. A meta-analysis of 12 mediation studies with 2,961 people with back or neck pain found that self-efficacy mediates part of the effect of pain on disability (standardised β 0.23; 95% CI 0.10–0.34) [6]. Psychological distress (β 0.10) and fear (β 0.08) mediated smaller shares. For catastrophising, no mediating effect was confirmed. In the RESTORE trial of Cognitive Functional Therapy, early changes in self-efficacy, fear, catastrophising and pain intensity together explained up to 61 per cent of the effect on disability [7].

Limitations. Most of the data are observational. Mediation analyses rest on assumptions about temporal and causal order that the study design secures only in part. Whether a targeted increase in self-efficacy alone improves the course has not been shown directly. The RESTORE analysis estimated the four mediators jointly. It does not show which share is due to self-efficacy alone [7].

2. What is assessed: confidence in a specific task

Bandura distinguishes two expectations [1]. The efficacy expectation concerns whether a person can carry out a behaviour. The outcome expectation concerns whether this behaviour leads to the desired result. A patient may be convinced that walking is good for her back and still lack the confidence to walk every day. The two expectations then call for different approaches.

Self-efficacy is task-specific. So ask about a concrete activity under concrete conditions. The question "How sure are you that you will walk for 15 minutes three times this week, even on a day with more pain?" tells you more than "Do you feel confident about exercise?"

In depth: Bandura's model

Bandura describes three dimensions of efficacy expectations [1]. Level (magnitude) indicates the level of difficulty up to which a person feels confident about a task. Strength indicates how firmly this expectation holds against contradicting experiences. Generality indicates how far it carries over to other situations.

He names four sources of information [1]:

Mastery experience. The strongest source. Successes strengthen the expectation. Repeated failures weaken it, especially early in the process.
Vicarious experience. Seeing others manage a task without adverse consequences.
Verbal persuasion. Encouragement from others. Its effect is weaker and lasts only if the person's own experience confirms it.
Physiological and emotional states. How a person interprets arousal, palpitations or pain influences their judgement of their own capability.

The implication for treatment: a success that the person attributes to their own actions has a stronger effect than a success they attribute to the therapist or to an aid.

3. How to assess self-efficacy

3.1 One question, 0 to 10

In everyday practice, a single question about the activity you are currently working on is often enough: "On a scale from 0 to 10, how sure are you that you can …?" Record the answer together with the activity. At the next session you can then see whether confidence for the same task has changed. Brief Action Planning (section 4) also works with this question [8].

The Patient-Specific Functional Scale (PSFS) is a suitable starting point [9]. In it, the person names activities they find difficult and rates how well they can carry them out. The confidence question can follow on directly from these activities.

3.2 For persistent pain: PSEQ

The Pain Self-Efficacy Questionnaire (PSEQ) asks in ten items how confident the person is that they can carry out certain activities despite the pain [10]. Each item is scored from 0 to 6, and the total ranges from 0 to 60. Higher scores indicate more confidence. A German version has been validated as the FESS [11].

Change: In chronic low back pain, the minimal important change was 5.5 points. It differed depending on the baseline score [12].
Short forms: The PSEQ-2 asks about confidence in working and in leading a normal life despite pain [13]. In low back pain, the PSEQ-4 was as responsive as the long form and can replace it in routine practice [12].
Reference values: Normative data by age, sex and pain site are available from a sample of 6,124 people attending a pain centre [14].

3.3 For fear of falling: Short FES-I

Fear of falling can be described as low self-efficacy for managing everyday activities without falling [15]. The Short FES-I assesses it with seven items, and the total ranges from 7 to 28 [16]. Higher scores indicate greater concern. The short form is reliable, and its correlation with the 16-item version is 0.97 [16]. Cut-off scores for low, moderate and high concern have been determined for both versions [17].

3.4 For chronic conditions in general: SEMCD-6

The Self-Efficacy to Manage Chronic Disease Scale asks in six items about confidence in managing symptoms and illness in everyday life [18]. It was tested in self-management programmes with participants from five countries. It is responsive to change and is associated with health outcomes [18].

Our internal assessment tool includes PSFS, PSEQ and Short FES-I.

In depth: pitfalls in measurement

Overlap with function. Many items ask about confidence in activities that functional questionnaires also cover. Part of the association between self-efficacy and disability may therefore rest on similar item content. In Jackson's meta-analysis, the strength of the association depended on the content of the scale [4].
Baseline score. The minimal important change of the PSEQ differed between low and high baseline scores [12]. A single threshold for all patients is a simplification.
Change over time in fear of falling. In a cohort of 500 people aged 70 to 90, FES-I scores rose over one year, even without a fall [17]. A rise therefore does not automatically mean a setback in treatment.
Perceived and physiological fall risk. In the same cohort, perceived and physiologically measured risk diverged in 31 per cent of people [19]. A group of 54 people had a low physiological risk but high fear of falling. This went along with depressive symptoms and poorer executive function. A group of 100 people had a high physiological risk but little fear. In this group, the low fear tended to protect against falls, mediated by a positive outlook on life and maintained activity [19]. So measure both: confidence and balance.

4. Strengthening self-efficacy in the session: a step-by-step approach

The following sequence is based on Brief Action Planning [8]. It combines the approaches that most increased self-efficacy and physical activity in intervention studies in healthy adults: action planning, clear instruction and recognition of effort [20], plus feedback on one's own performance and role models [21].

A goal from everyday life. Ask about an activity that matters to the person and is difficult at the moment. The PSFS provides a list for this [9].
A concrete plan. Together, specify what the person will do, how much, when and how often. Ask the person to repeat the plan in their own words [8].
Ask about confidence. "How sure are you, from 0 to 10, that you will carry out this plan?" If the answer is 7 or higher, the plan stands. If it is lower, identify the barriers together and adjust the plan until the answer reaches 7: fewer minutes, fewer days, an easier variant [8]. The 7 is a rule of thumb (see the in-depth section below).
If-then plans. For one or two likely barriers, agree on what the person will do then: "If it rains, then I will walk in the stairwell." Across 94 studies, such plans improved goal attainment compared with a goal intention alone [22].
Create success in the session. Dose an exercise so that the person succeeds. Then ask the person to name what they managed and what made it work. A success that they attribute to their own actions is the strongest source of self-efficacy [1].
Feedback with measurements. Compare today's values with baseline: walking distance, repetitions, test time. In intervention studies, feedback on past performance increased self-efficacy the most [21]. An activity diary between sessions adds to this. In programmes for more physical activity and healthier eating, self-monitoring explained more of the differences in effectiveness than any other technique, especially in combination with goal setting and feedback [23].
Review. Start the next session with the plan. If it was carried out, acknowledge the effort explicitly [20] and agree on the next step. If it was not carried out, ask about the reasons without judgement and adjust the plan. A plan that does not work shows where the barrier lies.

Role models. Group training or meeting people in a similar situation provides vicarious experience [21]. The more closely the other person's situation resembles one's own, the stronger the effect of the example.

Body signals. Before loading, agree which pain is acceptable during the exercise and how the person will recognise that they should reduce the load. One example is the pain-monitoring model in Achilles tendinopathy: patients who continued running and jumping within an agreed pain limit improved as much as a group that paused these activities for six weeks [24]. With such an agreement, the person can interpret a signal on their own.

4.1 An example conversation

Physiotherapist: You'd like to go to the playground with your granddaughter again. What would be a first step for this week?

Patient: Maybe a half-hour walk every day.

Physiotherapist: How sure are you, from 0 to 10, that you can manage that?

Patient: I'd have to say a 4.

Physiotherapist: A 4 is more than a 0. What would need to change for it to be a 7?

Patient: If it were shorter. And not every day.

Physiotherapist: How about Monday, Wednesday and Friday after lunch, 15 minutes each time?

Patient: That's an 8.

Physiotherapist: And if it rains?

Patient: Then I'll walk up and down the stairs in the stairwell three times.

In depth: what worked in intervention studies and what did not

Two meta-analyses each analysed 27 intervention studies on physical activity in healthy adults that specifically aimed to increase self-efficacy. The mean effect on self-efficacy was small (d = 0.16) [20][21].

Associated with higher self-efficacy: feedback on one's own past performance or on the performance of others, vicarious experience [21], action planning, instruction and reinforcement of effort [20]. Techniques that increased self-efficacy also tended to increase physical activity [20].
Associated with lower self-efficacy: persuasion, graded tasks and barrier identification [21], and in the second analysis relapse prevention and graded tasks [20].

These findings come from moderator analyses across studies. They show which techniques were present in more effective programmes. They do not test any technique on its own. They come from healthy adults. In rehabilitation, graded loading and relapse planning are often indispensable. The data support combining them with action plans and feedback and not relying on them alone.

In a randomised trial with 952 people with heart or lung disease, stroke or arthritis, a self-management course improved exercise, health status, fatigue and disability at six months and reduced days in hospital. Pain, shortness of breath and psychological well-being did not change [25]. Self-efficacy is assumed to be the mechanism of action of such courses [26].

In depth: origin and evidence of the 7/10 rule

The threshold of 7 comes from self-management programmes and is passed on in Brief Action Planning as a rule of thumb [8]. It is supported by an analysis of 1,136 action plans written by 254 participants in an online course. Higher confidence in a plan went along with more frequent completion. Participants who completed more plans improved more in disability, aerobic exercise and self-efficacy [27]. No study has compared different thresholds or tested the adjustment to 7 in a randomised trial.

A primary care study found that people with low general self-efficacy formulated and carried out action plans as often as people with high general self-efficacy [28]. At least 53 per cent of people with a plan reported a matching behaviour change after three weeks [28]. A low baseline score is therefore no reason to do without a plan. It is a reason to start with a small one.

5. The effect of your words

What clinicians say shapes their patients' beliefs for years. In a qualitative study of 23 people with acute or chronic low back pain, health professionals had the strongest influence on these beliefs [29]. Many messages were understood to mean that the back had to be protected. This led to vigilance, worry and feelings of guilt when people did not manage to protect it. Reassurance and advice to stay active strengthened confidence [29].

Describe what the body can do and how it adapts to load.
Avoid images of wear and tear, degeneration or instability.
Describe progress in numbers instead of general praise.
Attribute successes to the person's own actions: "You practised three times, and that is why it is getting easier."

6. For referring physicians

Physiotherapy offers more than exercises. It can measure a person's confidence, strengthen it in a targeted way and document the course. A report can include:

the everyday goals (PSFS) and how they have progressed,
the PSEQ or the Short FES-I at baseline and during treatment, with the minimal important change as the benchmark,
the agreed action plans and how far they were carried out,
measured performance such as walking distance, strength or balance.

You can support treatment with simple means:

Ask the same question in your consultation: "How sure are you, from 0 to 10, that you can manage that?"
Use the same messages as the physiotherapy team, especially about load tolerance. In low back pain, what clinicians say continues to have an effect for years [29].
Assess for depressive symptoms if confidence remains low and the person withdraws. High fear of falling despite a low physiological risk went along with depressive symptoms [19].

7. Where the limits lie

Association without established causation. Most data show that self-efficacy and outcome are associated. How much a targeted increase achieves on its own remains open (section 1).
No blame. Low self-efficacy describes a starting situation and says nothing about character. A plan that is not carried out gets adjusted.
Self-efficacy does not replace diagnostic assessment. Have new, severe or unusual symptoms assessed before you increase the load.
Confidence and safety. High confidence despite a high physiological fall risk can be protective. It still calls for balance training that lowers this risk [19].

The text for patients is the guide Self-efficacy: confidence in what you can do. You can hand it out as accompanying material.

References

All Digital Object Identifiers (DOIs) were checked against the Crossref register. The links in the reference list lead via the DOI service to the publishers' pages, and for the one work without a DOI directly to the journal. Some of these are outside Switzerland and the EU. When you click, your IP address is transmitted to the respective provider. This does not happen on our own site.

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Transparency

Author: Roger Hilfiker
AI assistance: the literature search and the draft text were produced with Claude (Anthropic). The professional review by Roger Hilfiker is still pending.
Created: 3 October 2026
Last updated: 3 October 2026
Sources: the works in the reference list. All DOIs were checked against the Crossref register, and the findings against the abstracts of the works.
How the sources were found: targeted searches of the Crossref, Europe PMC and PubMed databases in October 2026. This was not a systematic search.
Conflicts of interest: our practice offers physiotherapy that uses the approaches described here.
Funding: Physiotherapie Tschopp & Hilfiker, 3902 Glis. The page was produced from the practice's own funds.
Next review: 1 October 2027