Coach2Move: Coaching-Based Physical Therapy Targets Pain-Related Decline in Older Adults

For millions of older adults, chronic pain is rarely just a symptom. It quietly rewrites daily life: the walk to the mailbox gets shorter, the garden goes untended, and a fear of making things worse nudges people toward the couch. What begins as a protective response can spiral into a self-reinforcing trap, because inactivity accelerates the very declines in strength, balance, and confidence that make pain and disability worse. A Perspective published in Frontiers in Pain Research by Ward Heij and Anne Thackeray of the University of Utah argues that physical therapy is uniquely positioned to break this cycle, and that a structured approach called Coach2Move, originally developed in the Netherlands, offers a blueprint for doing so within the framework of Age-Friendly Health Systems.

The biological and behavioral logic of the problem is deceptively simple. Pain during activity is only half the story; anticipated pain can be equally powerful. Previous painful experiences, worry about tissue damage, and uncertainty about safety prompt avoidance, and the short-term relief that avoidance provides reinforces it. Over weeks and months, deconditioning accumulates, daily tasks grow harder, and the threshold of activity that triggers pain drops further. Clinical practice guidelines consistently recommend nonpharmacologic strategies, with physical activity as a core treatment for chronic pain, yet translating that recommendation into consistent practice has proven difficult. The authors stress that recognizing these psychosocial dynamics does not make pain less real or imply that patients should simply push through it. Instead, it demands a clinical approach that considers how pain, beliefs, physical capacity, emotions, social circumstances, and behavior interact.

Coach2Move does not invent new therapeutic principles so much as organize existing ones into a defined clinical process. Developed in the Netherlands for community-dwelling adults aged 70 and older with mobility limitations or inactivity, it rests on six features that distinguish how familiar geriatric physical therapy principles are configured. The process begins with an extended intake that goes beyond the presenting complaint to explore what patients actually want to do and why it matters. Rather than stopping at a goal such as increasing walking distance, the therapist asks where the patient wants to go, what they want to be able to do, and why it matters, while also mapping health conditions, physical capability, and barriers in the social and physical environment.

From there, findings are organized through hypothesis-oriented clinical reasoning. In an older person with knee pain, quadriceps weakness may matter, but so may fear of falling, poor sleep, concern about worsening joint damage, a spouse who discourages activity, or the absence of an accessible place to walk. The therapist considers which factors are modifiable, which are likely to influence activity and participation, and which require referral or coordination with other professionals. Patient and therapist then make decisions together, framing goals around meaningful activity rather than impairment-level change alone. Range of motion and walking tolerance may remain relevant, but they become steps toward shopping independently, tending a garden, returning to church, or caring for a partner, with the patient’s priorities determining which outcomes deserve attention.

The behavioral core of the approach draws on motivational interviewing, a communication strategy designed to explore ambivalence and elicit the patient’s own reasons for change. The authors point out that ambivalence is common and rational: an older adult can genuinely value independence while also fearing that increased activity will worsen pain. The therapist does not resolve that tension by arguing for exercise, but instead listens for both sides, provides information with permission, and helps the patient consider a safe and personally acceptable next step. Treatment then emphasizes self-efficacy and self-management, with progress monitored and discussed, setbacks anticipated, and activities practiced in the settings where they must ultimately be sustained. Family members, friends, caregivers, and community resources can be enlisted, and the explicit intent is to reduce dependence on the therapist over time.

Notably, treatment intensity is stratified rather than uniform. Coach2Move does not assume that more visits produce better outcomes; the number and focus of sessions are matched to condition severity, multicomplexity, and psychosocial needs, with a shared expectation established early that gains must continue outside formal care. The authors are candid that the contribution lies in systematic integration rather than the novelty of any single component. Evidence for motivational interviewing alone in older adults remains limited, and their own systematic review found very low-certainty evidence for individual motivational strategies, while interventions combining several strategies showed a tendency toward greater effectiveness. The approach combines motivational interviewing, tailoring, shared decision-making, use of social context, and monitoring and feedback within one structured clinical process.

The clinical trial evidence, while context-bound, is substantial. After a pilot study, a randomized trial of 130 adults aged 70 or older with mobility problems across 13 Dutch practices found that, at six months, Coach2Move produced greater gains in moderate-intensity activity and reductions in frailty compared with usual physical therapy, with fewer sessions, lower health care costs, and a small gain in quality-adjusted life years. A subsequent cluster-randomized stepped-wedge trial of 292 community-dwelling older adults across 16 practices favored Coach2Move for physical activity, functional mobility, and frailty at six months, with differences largely maintained at 12 months. Sessions again decreased, although the anticipated cost savings did not materialize. The second trial ran during the COVID-19 pandemic, when treatment delivery and community activity were substantially disrupted, which makes the replication encouraging but, as the authors caution, not something to overstate.

The authors are equally careful about the limits of that evidence. Both trials were conducted in the Netherlands and enrolled older adults with mobility problems rather than selecting specifically for chronic pain, so they do not establish Coach2Move as a pain treatment. A process evaluation showed variation in adoption and fidelity despite a multicomponent implementation strategy combining education, peer-assessment meetings, electronic health record changes, and reflection on clinical use. Because coaching can change familiar routines and views of professional expertise, the authors conclude that a manual or one-time workshop is unlikely to be sufficient for implementation. Adapting the approach to the United States required more than translating materials: researchers used Implementation Mapping, engaging physical therapists, patients, social workers with motivational interviewing expertise, and health system partners to target adults aged 50 and older receiving outpatient therapy for chronic musculoskeletal conditions such as low back pain and hip or knee osteoarthritis.

The US adaptation made pain assessment and management more explicit by adding training content on pain-related fear, catastrophic interpretations of pain, beliefs about harm, symptom-related uncertainty, and graded re-engagement in meaningful activity. Pain education is delivered through collaborative conversation rather than a standardized lecture: the therapist explores the patient’s concerns, asks permission to share information, and links explanations to a valued activity. The authors emphasize that individualized pain education must be distinguished from indiscriminate reassurance, because new or changing pain in older adults can signal fracture, infection, malignancy, or other conditions requiring medical evaluation. They also warn that self-management must not shift responsibility onto older adults facing structural barriers such as unaffordable care, unsafe neighborhoods, or limited transportation.

The broader implications reach to how clinicians and health systems measure success. Activity and participation should be treated as primary outcomes rather than expected byproducts of reducing pain, since evidence from other rehabilitation populations shows that gains in physical capacity do not necessarily translate into greater daily activity. Clinicians should separate education from persuasion, understanding what a patient fears before offering advice. The approach aligns most directly with the What Matters and Mobility domains of the geriatric 5Ms framework, while its intake considers how medications, cognition, and multicomplexity affect participation. Key questions remain, including pain-specific effectiveness, equitable implementation across US settings, and the working mechanisms driving improvement. And the authors offer a final caution worth highlighting: coaching should not be presented as universally brief or inexpensive. Fewer visits should be an outcome of appropriate, stratified care, not a target imposed in advance. The central question, they argue, is not only whether physical therapy can reduce pain, but how it can help older adults maintain or resume the activities and roles that pain has begun to restrict.

Subject of Research: A person-centered coaching approach to physical therapy for pain-related functional decline in older adults

Article Title: Coach2Move: a person-centered physical therapy approach to pain-related functional decline in older adults

Article References: Heij, W., & Thackeray, A. (2026). Coach2Move: a person-centered physical therapy approach to pain-related functional decline in older adults. Frontiers in Pain Research, 7, Article 1979758. https://doi.org/10.3389/fpain.2026.1979758

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1979758

Keywords: Coach2Move, geriatric pain, physical therapy, motivational interviewing, person-centered care, physical activity, self-management, frailty, functional mobility, chronic pain, Age-Friendly Health Systems, implementation science