Podcast Episode #26 The Biopsychosocial 40 Years Later


Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston. And I’m Eric Purvis. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence informed practitioner. Let’s dig into this episode.

As somebody who just turned 47 years old, I can’t quite remember things that happened 40 years ago, but the biopsychosocial model of pain has been around for about 40 years now. And it’s very important for us to take a look at anything like this and understand what changes have taken place in 40 years. And how have we improved?

Eric Purves 0:57
And this is a this is actually a really kind of Hot Topic, really the the bio, psychosocial, social model and, you know, is it like, how do you apply it in practice, you know, and there’s a lot of arguments back and forth about like, you know, it’s on a predictable model, right? It’s not like a mathematical model. It’s, it’s a conceptual framework and the authors of this paper, this paper is called the biopsychosocial, social model of pain. 40 years on time for reappraisal, it’s in a relatively recent journal of pain. And, yeah, it’s good because I think it it challenges or brings into discussion, a lot of the points that you hear, especially those of us that spend time reading the debates on social media, and a lot of problems people see in the bio, psycho social. And I what I feel is that in, in my experience, my understanding is, the bio psycho social model is itself not much of a problem, because it just it seems, has been around right for over 40 years, in the pain world longer. I think it first was talked about 1947 or 1977, I think, by George angle, and then, you know, loeser or loeser, have you printed him and Waddell had it? You know, and, you know, fears after that. But the facility is still around, I think there’s there’s still a lot of value. But the biggest problem seems to be is how was it used in clinic? Or how was it researched? And then that’s what we’ll talk about today is in this, this research paper, or this discussion paper, they talk about how when people use the terms biopsychosocial oftentimes, the studies are just looking at one aspect of it. They’re not well defining other like, well define the psychosocial or what is social? Or what is conservative psychological. And, you know, in the bio, like when we’re looking at bio, what, like what’s included in that. So there seems to be lots of a gray area there. And I think that’s probably when people are critiquing the model. And I think they do have reason to critique it. It’s because more often of how the model is applied, rather than the muscle word to use the conceptual, conceptual framework of what the model is supposed to represent, which is this full person care.

Jamie Johnston 3:14
Yeah, and one of the things that really stood out, as I read through it is how much they touched on multidisciplinary care, where they had psychologists that are dealing with the psychological end of it and physios that are maybe handling the bio, and you know, and then the social factors that come into play, and the importance of communication between all parties, when they’re trying to help that person and, and interesting, I’m sure we’ll get into it when we’re looking at the the social aspects of the person returning to work, the importance of communication with the workplace, from the people who are delivering care so that it’s more of a, it’s more of a person centered approach, when you’re trying to help that person get back to their job or get back to those things that they enjoy doing.

Eric Purves 3:59
What I found funny with this, though, when you think about it, you know, you think about medicine, and you think about musculoskeletal care and MSK pain and, and whatnot. And you look at this, this model has been used for pain for 40 years, or it’s been talked about for 40 years. And the reasons that they say here was Waddell and Loeser. They observed that many of their patients with low back pain didn’t improve after corrective surgery. So the pain cannot be attributed to only biological influences. It’s funny though, cuz it makes you think what happened to all the years before that when people didn’t get better? You know, it’s funny how like, it took that long for people to actually start wondering if there’s something else going on. Yeah. And excited. Seems like, that’s like, seems to make sense, but it’s funny to think of how people must have thought about the body and pain.

Jamie Johnston 4:54
Yeah, and really interesting that those two, those two people that you mentioned was with Wadell and Loeser. You I would almost say that they were surgeons.

Because I wouldn’t have thought that that was coming from surgeon because we, I mean, we say it tongue in cheek a little bit and maybe make fun a little bit that we’re like, oh, you’ve, if you’re a scalpel, you just want to cut everything. Yeah, right. So great to see that they that it was surgeons who were looking at, hey, maybe we need to change the way that we’re doing things. And also really interesting that, you know, that happened 40 years ago. And maybe it’s just because you and I haven’t been therapists for 40 years, obviously. But we’ve only really seen it catch on and become more of more of a thing when we’re helping people in the last 10 years. Yeah, I would say model.

Eric Purves 5:43
Yeah, yeah. Oh, for sure. And even if I think you know, back to when I first started diving into the stuff and trying to understand it, and think I did my first CE course teaching in 2015. And I remember just kind of bringing these very basic ideas, because I was only still learning to two courses to try to be like, hey, there’s some interesting stuff that’s out there, maybe, you know, like, let’s, let’s talk about this. And then that was kind of the general idea of those early course stakes. Nobody, nobody knew about a psychosocial as then. Yeah. So it’s been around for 30 years. Yeah. And so nobody knew. And I was only had just been I’d heard of it before, but I didn’t really pay attention to it. Like, I didn’t really mean much to me. I was like, oh, yeah, okay, whatever. But it’s interesting to to, to see like those early days. And we know from our experiences, when we searched for spare teaching together in 2018, we started talking about things and bring up the biopsychosocial. And little bit of myth busting in there and some of the science of pain stuff, and how that stuff was completely new. To like, 99% of the people, whereas now, obviously, the last three or four years or two or three years, particularly. It’s everyone’s, yeah, it’s a common term. And people can have a general idea of Oh, biopsychosocial, yep. That’s like treating the whole person like person centered care. You know, what that exactly means? How do you do that in practice is still that’s the difficult thing. But that’s what we call our practice. Not a perfect. Right is to that’s the hard part, but at least people become more aware of it. But yeah, it’s taken 40 years. Yeah. It isn’t our profession where we are in our part of the world. Yeah.

Jamie Johnston 7:21
But then you look at, like the Louis Giffords that we’re doing this ages ago. Right. So like you said, it might be that it’s our profession or part of the world. Because I think Louie was a UK guy. He was yeah, nice, 80s and 90s. So maybe that was more prevalent there than then it was here. We don’t know.

Eric Purves 7:42
And this without going on too much of a tangent, which we might want to and we’ll see what happens here is the is when we look at the stakeholders involved in our profession, at least here in BC, right, we got the association, we’ve got the college, the cmtbc. And we’ve got all the all the schools that and there’s now 10 of them, maybe I think it was probably about 2014 2015 around there. If you tried to teach a Con Ed course, that said, and I said had bio psychosocial and you would not they would not approve it is out of scope. With the argument being that they hadn’t really the idea was they had no idea. They had no idea what it meant. Our own regulatory body had no idea what it meant. And even you know, our association in the schools and stuff still don’t adequately teach that stuff like the association. You know, they have conferences, and they put out content out there, but I don’t ever see anything on there being I think what biopsychosocial Yep. And you know, the it but it however, in Ontario, they put out some really good stuff. You had some great stuff there too. And so if we want to compare ourselves right to to another province has been around for a very long time and Ontario regulated province, is what I meant to say if I didn’t say that, there’s no province has been around for a very long time. So I’m tired back from the gym, my brain still foggy. The they had a conference in 2019, which I was fortunate enough to be at. That was I think it was called like bio psychosocial care or something for RMTS or something. So they actually had a conference those three years ago now. And they’ve had other things subsequently, which have been been kind of trying to bring us this idea to to the professional to the members. So we don’t have that here. And I really wish you know, this is a call to action thing. I wish the schools known I know some schools are great. I’ve talked to some the the people that are clinic directors and stuff of schools here and they are trying to do it but it’s just not widely accepted and just not widely accepted or maybe understood. And so I would suggest anybody that’s curious about what biopsychosocial means this is this is actually a pretty good paper to start at.

Jamie Johnston 10:04
Yeah, yeah. Well, and it’s it’s very cool that there was a lot of things in here as I read through that resonated with me because of my, because of my background. And also, because I’m somebody who works at a job in industry where people get hurt. So a lot of this really stood out to me. And it’s funny, one of the guys at work, told me he’s like, why don’t you go to the chief and see if you can come in once a week? And just do what you do with guys here who who need the help, but I think there would be a big conflict of interest. If I did that. If I, you know, if I was working on guys, and WCB was like, well, you’re one of his co workers, you can I think there would be too much of a conflict of interest for me to do that. But it would be very, yeah. Yeah.

Eric Purves 10:48
And that would be really cool, actually. Because that way, you would have the social and the bio, and the psycho all together in the workplace, in with their colleagues and their, their social network. And then yeah, you became the new exercising, which would be bio and Psycho and social would be the whole thing, right, are getting moving. And we’re going to be doing any hands on stuff. I mean, that’d be brilliant idea.

Jamie Johnston 11:12
I think so. And I’d love to just take a portable table and and be able to set up the table in the gym and be able to go through rehab with guys and do some treatment. And like I mean, guys are coming to me all the time anyway. And being like, Hey, this is sore. What should I do? So yeah, it’d be cool to just have like, you know, a day of clinic hours at the fire hall. So that somebody who needs it could come in and, and get what they need. But, but I think the problem is once WCB or something like that was involved, they’d be looking and going, No, you can’t have one of his co workers doing the work, because we’re not going to get an honest feedback about what’s going on with him. I think I think there would be too much of a conflict of interest score. Yeah. Yeah, that would be really cool. Yeah, very cool. Yeah. So just quickly skimming through, of course, we talk about psychological treatments, when we’re talking about the bio psychosocial and quite often, quite often, we’re looking at things like mood disturbance, and high levels of unhelpful thoughts like catastrophization, you know, the person kind of thinking that they’re broken, and lowered self efficacy. So when they talked about it throughout the paper, that’s a lot of the things that they talked about. And that was, were they, in my understanding it anyways, as I read through the paper, that those things were better handled by, say, a psychologist or a mental health expert, to be able to help them through that as part of that multidisciplinary care that we talked about a little bit at the beginning.

Eric Purves 12:36
Yeah, this paper, what I thought was really interesting was they broke down, like they broke it down into that, like a psycho bio social, and looked at the research. Because I think it’s just really important, you know, that the common term, you know, if you’re a hammer, you see nails, right. And if you’re a psychologist, and you’re treating people with that are hurting, of course, you’re going to be viewing them through a psychological lens, of course, your interventions are going to be more on the psychological end of things, right? Just like when we, as massage therapists, were treating people we’re going to we should be aware of the psychological and social stuff. But really, I mean, we’re working primarily on bio things. We’ve meant in touch and exercise, you know, a little bit of education, but most of our more focuses in the bio like so. It’s I liked that they they broke it down into this and talked about, like, what was included in psychological research, and what was included in bio was good in the social stuff. But what I thought was really interesting, though, was like the little quote here says that, you know, there is positive effects is positive outcome seen with the psychological interventions to focus on the things you said thought processes, beliefs, behaviors, this type of thing that says that the size of these effects have generally been found to be a small or moderate, and systematic reviews of randomized controlled trials with chronic pain samples. So with this, I mean, go shows is that, and I think if you look at all the research, they’ve probably I think they quote this all and throughout this paper, is that it doesn’t really seem to matter what you do. When you look at the literature, the outcomes are all relatively small to moderate at best. Yeah. So what that can sound to some people defeat us, to me that sounds Oh, that’s actually sounds pretty good. Because if you’re doing something done, or you’re doing something, you’re seeking care and someone is providing care to you, chances are you’re probably going to feel better than not. So doing something is like this is good. And that lets us know that there’s not like a right or wrong but they do say in here, though, is it’s not necessarily providing a specific treatment. It’s finding the treatment that works for that person. Right. So it’s not like you need this. It’s like what’s going to work for this person, this presentation here today. I like that rather than you step was the person need rather than what are we going to do to the person?

Jamie Johnston 15:04
Yeah. Interesting as we go through like, there’s a couple things that stand out to me is when they’re talking about the psycho psychological treatments, they mentioned how there hasn’t been a lot of research about involving the the person’s family, but one place that they did look at. And I would like to know if this was any of Melanie wells research with stuff that she does with kids. But it showed that the more that the parents are involved in, in helping the kids, it can actually have a positive effect on the parent and the parent experience. So when you’re when you’re teaching, how do they say they’re teaching kids and adolescents, about different strategies that they could use, whether it’s communication or how they handle things at school, and the more that the parents involved, it can actually have a positive effect on the pain experience that a parent feels? Yeah, unreal. Is that great stuff.

Eric Purves 15:58
And there’s nothing that I thought was really interesting wasn’t like, you’re talking about how, yeah, when the way kids are treated with that, with chronic pain is very different from adults are treated with chronic pain. Because in adults, it’s like the individual is being but is being treated, whereas kids, they involve the whole kind of their social narrative family, which is, I mean, just makes it makes sense. But it’s just funny how you’re like, Oh, you’re no longer a child, you’re now an adult. So therefore, we’re just screw up family. Like, we’re all gonna involve you. Right? That’s not necessarily included. But I guess it does make sense though, because the kids need to be cared for. And so the parents have to be involved in care as an adult, you’re independent, least in our most of our cultures out so we distance ourselves from our family a little bit. Yep.

Jamie Johnston 16:45
Yeah, or different circumstances. I mean, you look at me 47, single, no family in town. So the experience that I would go through if I was experiencing pain is a lot different than, say, somebody who has a family at home that they come home to, right. And if the kids were dealing with something, then the parents dealing with that is going to have more of that connection, feeling between the family and probably better care and all those things, especially if, say, the doctor or the physiotherapist is in really good, or having good communication with the family, about me, and education and all those things, then it’s it’s a more cooperative experience. Yeah, yeah. Oh, yeah.

Eric Purves 17:25
Which would be more biopsychosocial that would actually be a better application of the model, right, involving everything. Yeah.

Jamie Johnston 17:34
So they, I mean, they went into, and they talked about a lot of the biological stuff, and separating that into different categories, about how people are experiencing pain, and you know, whether it’s peripheral or central mechanisms, inflammatory pain, chronic pain, and all those kinds of things. And then talked about the treatments that they can use for those things. And what I found very interesting is that when they started talking about exercise, because exercise, obviously, I’m a big fan of that. But when they talked about the exercise, they were they were talking about usually exercises is driven towards building muscle or loading the joints and doing these other things. Whereas they found or my understanding is they found if you geared the exercise more towards just what they were doing at work, or or their chosen activity, and getting them back to doing that thing, then they had more success.

Eric Purves 18:30
Which makes sense, because it’s that your your task or your goal, your functional desire, whatever it is, it’s tailored towards that specifically. Yeah. Makes sense. Yeah. Well, I thought it was interesting that they it says exercises, you know, it’s considered they consider that bio, but I think it’s almost, I mean, obviously, there’s bio going on there, but I would say, Well, yeah, like, it can’t just be bio because you’re not, you know, there’s going to be psychological and probably social unless you’re like in your garage by yourself. Okay. There’s, there’s not like a social influence ever. There’s a psychological influence, like exercises, if something of value something you enjoy doing that it’s not just gonna be bio, so I think that was fine when they said it’s exercise is considered a bio intervention. We’re like, well, it’s I think it probably includes the whole bio psychosocial.

Jamie Johnston 19:23
Yeah, yeah. And I think that’s, I’m trying to remember who the presenter was in San Diego this year when he, he stood up and he said, Okay, who wants to go home and do some homework tonight? And then he’s like, Yeah, neither do your patients. So stop giving them homework, stop giving them exercises to do.I forgot what that yeah, that was great. Great, which was brilliant. Because they and I think that’s whereand, you know, I was on a podcast a little while ago with some some of our friends down in the US and when I was talking about therapeutic exercise, and they’re saying it’s not in our scope. I’m like, well, movement is so I think we have to Start also approaching this and being like, well, let’s stop talking, let’s stop calling an exercise. Let’s just call it movement. And let’s just talk about what meaningful movement is for this person. And how do we get them back to that meaningful movement. And that meaningful movement might be a specific task that they do at their job that they can’t do right now. So how do we, how do we change that task? Or how do we make it so they can do that task? So it becomes more meaningful, and they feel more fulfilled? At their job, or whatever the recreation thing? Is that, that they’re trying to get back to doing

Eric Purves 20:32
that’s a weird thing. Hey, still movement is allowed. But exercise, isn’t? We?

Jamie Johnston 20:38
Yeah, well, it’s funny. How do they define exercise? Well, so my understanding of it, because when I was on the podcasters, two folks from the US, and I said, but you guys can do active range of motion and passive range of motion and a treatment under like, Yeah, that’s fine. Like, so why can’t you do movement? They’re like, it’s that we can’t prescribe exercise for them to do at home. I’m like, But what about if your prescription was gonna work in the garden for half an hour? They’re like, yeah, we can do that. I’m like, so just prescribe movement. And, yeah, that’s, what about if it’s get on the ground and play with your kids? Yeah. What if it’s, you know, so let’s, let’s change, let’s change the opinion around those things. And I think a lot of times, we’re also really, really scared that we’re going outside our scope. And we might get disciplined for going outside of our scope. You know, and then as soon as it’s got the word, in this case, as soon as it has the word exercise attached to it, they people automatically say, Oh, well, that’s out of scope. But if we say it’s movement, there’s no reason that can’t be in your scope.

Eric Purves 21:46
Yeah, just move lots. That’s your that’s your prescription. And that’s exercise.

Jamie Johnston 21:51
Yeah, there’s no reason you want to do you know, somebody comes in and they’ve got a shoulder issue, there’s no reason you can’t grab their arm and passively move their shoulder and get it into different ranges, or do some adaptive movements with them, you’re not prescribing an exercise for them to take home, you’re not prescribing something, you’re, you’re just helping them get back to doing the movements that they enjoy or that are meaningful to them. So and to me, it makes more of a psychosocial. Not psychosocial sense. But it makes more sense to me to, to talk about rather than us giving a treatment or delivering a treatment. We’re engaging in treatment with our people. Yeah. Because we’re, we’re engaging and educating and conversing and finding out what’s important to people, rather than us just saying, okay, get on the table, and I’m going to do this to you.

Eric Purves 22:40
Yeah, yeah, sure. Yeah, I 100% agree, that’s such a great point to make, right? You’re engaging with with the treatments, you’re not just doing it, you’re not doing something to them. Now, some of them is great. Like, I mean, I mean, sometimes when I go, if I go for a massage, I often want something done to me, because I don’t necessarily have something wrong that is bugging me. It’s just like, I want to feel good. That’s different. Right? There’s the field, I think, is a seven point distinction to make is that, yeah, you can go and get the table and just someone just like spoil yourself. That’s fantastic. But if it’s like, if it’s something that you’re suffering with, it’s bugging you for a long time. And, you know, that passive approach isn’t working. Yeah, try and engage a bit more with with your clientele.

Jamie Johnston 23:18
Yeah. Like, well, like we’ve talked about so many times before, too, you know, we were fortunate here, because we have so many people that have unlimited benefits that, that maybe they come in once a week, but that’s just an hour break from life that they get, which is good. And there’s no reason you can’t just do a passive relaxation massage. Maybe I shouldn’t say that a relaxation, massages password, because you’re still having an influence. But you know, in those cases, there’s no reason but somebody comes in and they’re like, I’m having a hard time moving my shoulder, or moving my hip or my knee or whatever, then, you know, we want to, we want to engage more with them and figure out how we can get them back to doing the moving that shoulder or so that they can do the things important to them. Yeah, yeah.

Eric Purves 24:00
I agree. I love that term, engaging in treatment, rather than just doing something, doing a tree gauging your dramatic that’s, that’s a very important distinction to make. So hopefully, I’ll catch on. I hope you should do like a social media campaign hashtag engaging in treatment or something.

Jamie Johnston 24:15
Yeah, yeah. Well, I’m working on some stuff now, but doing some thought reversals and things about that to cool. Medicine, but but we’ll see. We’ll see if anybody wants to listen to me now.

Eric Purves 24:28
Yeah, well, some people listen, some people listen this podcast so enough to keep it keep us keep doing them. So there we go.

Yeah. What it was, it’s just kind of keep talking about this, the biotherapy about it and just kind of expanding on the bio to like expand into the bio psychosocial. And this is a there’s gonna be a bias statement here, but it’s okay. It’s our podcast. I just I just think it’s really important for us to emphasize that. Even though we are engaged, we are educated in a bio dominant biomedical We’ll thing and we are hands on therapy is mostly, mostly by Oh, there is always going to be psychosocial stuff, right? With moving exercise coming for treatment, there’s an interaction between two people that’s social, right and psychological. So it’s just that we are, regardless of what you think of the biopsychosocial. Every aspect of a human is being engaged with during a during a treatment. And this was the thing is, though I find interesting is I find it very difficult to understand how any other MSK profession other than massage therapists and physical therapists are able to actually provide a full BPS experience in their treatment. Like if you’re coming in and say it’s chiropractic, and it’s like five minutes and just getting adjusted and gone. Is that biopsychosocial? Like, can you actually apply all the kind of aspects of this? I don’t know, I would say that I think what we have as physios is we have time. Some points are short, but I would say on average, they’re, you know, 30 to 45 minutes long. Least we are.

Jamie Johnston 26:09
And I think that, in fairness, some chiropractic appointments are as well, depending on the look.

Eric Purves 26:16
Yeah, yeah, I am not saying all I’m just saying, like, if you look in general, the two professions that are set up to be able to really do this properly with the problem if we have proper education or proper understanding, I think we we should, you know, chiropractors only are listening to this podcast anyway. But massage therapists, you know, I think we really are set up to do this, because we have so much time with people, we can listen and validate. And we can educate, and we can rule out red flags. And we can reassure when, if it’s, you know, there’s nothing nasty going on, and we can revive touch, soothing, safe, comfortable environment, and educate and engage with people to do the things that are important to them. And that’s something you can’t do in 10 minutes. 15 minutes. No, I and some people I mean, I’m sure somebody’s gonna bother, you can you’re full of shit. Okay, maybe. But I would say that’s, I’m not convinced. No, no, anytime you do this. And so when you’re looking at just quick, quick, quick appointments, boom, boom, boom, those are bio nature, bio focused, you’re missing the bigger part of treating the person.

Jamie Johnston 26:40
And interesting, if you look at the psychosocial aspect of things, I don’t know, of any, or if there are any psychologists or counselors that offer a 15 minute treatment. They’re all 45 minutes or an hour. Exactly. Because they want to have a long discussion with people they want to, they want to have that chat, and they want to figure out what’s going on with them. So, you know, when we look at the other aspects, there’s very few that are that short of a treatment. Unless it’s maybe a quick check in about something. Right?

Eric Purves 27:57
Even medical doctors right like USC Medical Doctor for something like they they’re gonna rule then a like, Oh, you have psychosocial that might be that stuff happens. But they’re looking at the bio, they’re looking, what’s the disease? What’s the pathology? What can I rule out here? Right? So it’s when you read this stuff, and we can go and talk about, you know, the, you know, how this is often applied in these kind of interdisciplinary or multidisciplinary pain clinics. You know, those little requirements, we will have a long time, these are something you can’t just like, have, I don’t think you can have like a high volume, bio, psychosocial practice, and do really good work with engaging in small amount of time, a small amount of time, I think it’d be really hard. Yeah,

Jamie Johnston 28:40
I agree. So this, this is where I think we could get into it now is when we’re talking about, they’re talking about the social aspects. And they they talked a lot about the workplace, and people who are on a return to work program. And this is where it kind of hit home to me because of my past, being a first aid attendant in a, in a sawmill, and watching, you know, treating dealing with people who got injured, and then watching them deal with compensation and coming back to work. And they really focused on this about the importance of communication with the workplace, and how important that is for, you know, the person who’s trying to get back to their job, where the physiotherapist or the therapist who’s helping them should be in contact with the workplace, but then also in the workplace, that the supervisor should be trained in how to speak appropriately to the person who’s injured. And to me that just like that would be phenomenal compared to what I’ve seen in the past, because, from what I’ve seen in the past, companies would always be like, Oh, safety is our number one priority, until it cost $1 To change the safety program, and granted, you know, this is back in like 2006 Next one, I was doing this. So hopefully things have changed a lot since then. But the I just think it’s amazing that they looked at it and said, if you’re in communication with the workplace more, then you’ll have better outcomes for the person who’s trying to get back to work. Right? just phenomenal. And that’s where, like we talked a little bit before we came online. That’s where our friend Corey Blickenstaff who is a physio who works in a workplace, and helps people who are injured, like how, how that, like the outcomes that he must have, compared to somebody who was maybe off site. And I don’t know if there’s ever been a study done on it, but it must be amazing. And give the workers confidence that they’ve got somebody there, who’s there to help, should they get injured? So the social aspects of that must be phenomenal.

Eric Purves 30:50
Yeah, it makes sense to me, it just, I mean, okay. Sometimes things that make sense logically, aren’t always true. But, you know, using making an informed opinion, based on this, some this body of research, you know, if you had if, if a large enough workplace could afford it, and I’m places probably could write, you know, a large enough workplace could afford to have a physiotherapy physiotherapist, for example, on on staff or on a contract to come by? I mean, that would that would be such a benefit. And I bet you, I would be, I would love to see if that increased productivity, if that decreased, miss. Locks, work, you know, less work safe for workplace injuries, you know, I think that would be such a great thing. And there’s probably studies out there and for anybody has them, please send them our way. I just thought it would be that would be such a brilliant thing. And maybe some parts of the world they do it in. But if that’s I’ve never heard of that here in Canada. No. Having like an on site, or something that comes by once a week or whatever, or every two weeks to to treat staff.

Jamie Johnston 32:02
I’m actually starting to hear a bit more because I have a friend who is an athletic therapist. And I can’t remember the name of the company. But she had me come in to do some first aid stuff with the company. And she’s there as like, a director of like exercise and things. So they have an exercise room there for the employees where she can take them in. She has somebody who’s a massage therapist that comes in once a week. And she she organizes all of this for for everybody who works for that company. So it must be catching on a little bit. That to the point that she’s got a full time job doing this. Yeah. That’s brilliant. Yeah, great. Yeah. It’s very cool.

Eric Purves 32:37
Shouldn’t you think it’s such a hard worker, particularly in the the environment we’re in right now where it’s impossible to find workers like, like everyone, everyone’s hiring and you know, what a great perk it would be to if you’re like, hey, it comes with our workplace. We got you a massage and physiotherapy come in. It’s all included as part of your years. Part of working in package. Yeah, that’d be brilliant.

Jamie Johnston 32:59
Yeah, I’m sure it would be a draw. Yeah, huge. Bigger companies like Google in that have, like full time massage therapists to work there. And yeah, and things like that. So but I mean, that’s a multibillion dollar company. So you know, compared to smaller companies, that’s a lot tougher. But one of the things that I that I think is important to touch on that I would love to see is they didn’t, they didn’t talk in here about educating the workplace, about educating all of the other employees who aren’t injured.And I don’t mean that like when somebody’s injured, the rest of the people have to be educated about that person’s injury, it’s educating them about why Return to Work Program is important. Because like, for instance, when I worked at the mill, it was always if somebody was off injured, they’d come back to a place that’s, you know, full of bravado that guys are going, you’re just a wimp, you’re just trying to get a claim, or you’re an idiot, there’s no reason you weren’t hurt. And so when you look at that social aspect of it, that can be really detrimental for the person who’s trying to get back to work. So if they would be really interesting to see if there was a really good education program they could do in those places to be like, Hey, we know that we’re going to have better outcomes if this person isn’t made fun of if, you know, your opinions are kept to yourself, and we’re able to work through whatever the person’s injury is, and we’re here to support you as well. So that if you get hurt, we can take the same approach with you. And, you know, research has shown us we have better outcomes, and this is going to be better for your home life. It’s going to be better for when you have to pay the mortgage, and all those other things and explain to them, you know, the benefits of that? Because I think that would make a drastic improvement on those return to work programs withwith people coming in.

Eric Purves 34:51
I think that sounds like a brilliant idea. You just said. Education regardless, it seems like doesn’t matter what The topic is, you know, education often seems to be the answer. Yeah, you know, the more you understand what’s going on, the more accepting we are the better decisions we make about things, generally, right? These things all play a role. So, you know, why would that be any different in the workplace? I think it would just be a brilliant thing for it to educate the workers as well. What’s going on? And why it’s important? Yeah.

Jamie Johnston 35:24
Yeah, it would be cool. Maybe I shouldn’t approach the firewall a little bit and be like, hey, once a month, I could do like a safety education thing or something?

Eric Purves 35:31
You really should, I think you should see it just I think it’d be probably more rewarding as well as probably see, I would, I would be surprised if you didn’t see. Cause of benefits from that with your coworkers. Yeah, yeah.

Jamie Johnston 35:44
Cuz and it’s great, because we have a, like a light duty program, because we do our own dispatch. So if somebody is injured, we have it set up that they can actually just go and do dispatch, so they get to sit in the in the room, and they’re answering the phones and doing all that stuff. So they’re not out, you know, having to find a structure fire, but they still get an hour or two a day to go in the gym and do some movement. And you know, try to be healthy. So it’s, it’s a pretty good program. But there’s definitely improvements we can make.

Eric Purves 36:10
What it mean for meeting this paper here, too, it’s definitely in the workplace, engaging workplace is under utilize, you know, the one of the quotes here says, engaging with the workplace as part of the treatment seems to be rarely attempted. And I don’t have the paper in front of some notes I made. And I think it said where it was, like maybe only three papers that actually involved, you know, family or social networks in kind of Pain Rehab. So it’s almost it’s rarely done.

Jamie Johnston 36:42
Yeah, I’m just scrolling through to see if I can find it. But yeah, that’s basically what’s sad is that it’s rarely done in that way. So yeah, and I think the maybe the difficulty as well is that, you know, if we’re trying to help somebody who’s injured, the workplace isn’t necessarily going to want to talk to us. Right. So it might be a big hurdle for us to overcome, if we’re trying to engage in that way, whereas they probably be more likely to listen to a physio if they if they recall it, but hopefully, hopefully, if it’s a multidisciplinary approach, and we’re working with a physio about and with somebody, then we can have some input on that as well. But it would be, it would be great. If you know, even if you could, if you could have the person go back to work and say, hey, if your employer wants to talk to me, I’m happy to have a chat with them about, you know, what we can do to help you out, then that might be an approach where the employee is making the approach rather than us approaching the employer?

Eric Purves 37:43
Yeah, yeah. Yeah. The I think one of the barriers you do you have, though, at least in our profession here in BC, and probably throughout Canada, as well, is that nobody wants to work with the, like, WorkSafe or, like, workers compensation. Yeah. Because it’s a pain in the butt lot of paperwork for like, no pay. So even though, it’s probably would be really good to have more of this return to work, thing involved in our profession, and these opportunities to be able to go into people’s work, you know, finances are gonna are gonna win, right? Like, I could treat somebody my clinic and make this much money, you know, or I could go over here and leave my office and treat people that are returning to work and make like, totally, like, no money, almost. Right? What am I gonna do, people are gonna look after their families or unpaid bills and mortgages, food, you know, the gas, they’re going to say, in the clinic, so the idea would be not lovely to do this. But it’d be I would be so I would think that in a lot of these cases, the the money’s out there for it. Yeah.

Jamie Johnston 38:50
Absolutely. And but I mean, again, hopefully, that’s changing as well, because 10 years ago, there was absolutely no money. Yeah, to be able to do it, and now there’s a bit so hopefully, that will continue to go up and we can have more of a roll.

Eric Purves 39:05
Yeah, for sure. No, yeah, I think it definitely be beneficial. Yeah. to kind of wrap up the the the rest of this paper, they talked about the interdisciplinary bio psychosocial treatments for chronic pain, and camper did a review. And so despite their concerns about definitions of bio psychosocial interventions, camper et al found that a coordinated intervention covering several domains of the biopsychosocial model and delivered by clinicians from different backgrounds is more likely to benefit patients with chronic low back pain in the long term than his usual care or physical treatment alone. Which I thought was good because it talks about like the interdisciplinary right so involving multiple different disciplines the problem that you’re going to find me obviously in a in a like this was in a like a pain, kind of rehab or pain. in clinic, everybody’s going to all the treating clinicians are going to be working from the similar model and understanding about pain and they’re gonna stay in their lanes of what their areas of expertise and education are. What we see all the time in practice, I’ve seen other papers on this I don’t have I don’t have a reference here, unfortunately, is that there is an association between seeing too many different people. Oh, yeah, and poor longer term outcomes. But what what I understood from this and other parts of this, this paper is that you see multiple people as long as you’re working together under the same framework, to provide the best care for that person that they need. So that’s an important distinction to make. So I know oftentimes, in the courses I teach, I’m like, get the more people someone sees the less the worst, their outcomes tend to be, right clinically, as well as there’s data to support that. But doesn’t that that’s if you’re getting, I think, if you’re getting different stories different, you know, you see your physio, your car, your massage, your osteopath, your acupuncturist, your medical doctor, specialist, they’re all telling you something different. They’re all doing something different to you, and there’s no coordinated care. And that’s when you get these problems. But it seems, seems this one, if you have a singular model of care, everyone’s kind of falling as bio bio psychosocial. And they’re working together, outcomes tend to be better than doing nothing more than what they call the usual care, which is usually medications or rest.

Jamie Johnston 41:26
Yeah, and I think the, you know, I’ve seen that so many times in my career where, you know, somebody’s coming to see me on a Tuesday, they’re going to their chiropractor, Wednesday, they’re going to Doctor Thursday, they’re going to physio Friday, and they’re just appointment hopping. And the added stress that that gives them of having to go and see all these other practitioners to satisfy what the insurance company wants them to do. Is that added stress that’s taking away from a better outcome. So like you said, if it was all under one roof, and you know, it was a conjoined group of people that are trying to provide that care in a reasonable amount of time and things like that, then you’re likely to have better outcomes. But the, the current way that it’s done, or that I’ve seen is when you’re constantly hopping from practitioner practitioner appointments all week. It’s just stressing people out.

Eric Purves 42:13
Yeah. And I’ve never gonna be careful saying never and always, I very rarely have seen that benefit people by seeing multiple practitioners over time forever, years and years and years. Because we’re all just looking for that fix, right? Everything’s like, oh, my gosh, scar tissue here or this isn’t here. No, this is weak, this is tight. This is short, this is inhibited. This is out, you know, they’re constantly just being put back together is that kind of general understanding they have their body and that that rarely works. And and each practitioner is trying to make a living and rebooking people. Yeah. Money, Money Talks, right, that the financial aspect of it is is as powerful. And that’s, you know, that’s a different conversation, I guess. But that’s comes down to the ethics of it, right? We have to pay our bills. But you know, ethically, if we know better, should we still be doing that? Probably not.

Jamie Johnston 43:06
Yeah, I know. I’ve fallen on the sword a few times and told people, you’re going to hold these appointments. Don’t come and see me next week, take the day off. Yeah, take a rest. I mean, somebody else will look at it. It’s not that big of a deal. Just go take a rest. And but it always comes back to that same thing. And really what this entire paper is about is patient centered care.

Eric Purves 43:24
Yeah, yeah. Based on its care, and providing team based care seems to be the thing too, right, that involves all of the domains. And it’s what I understand is it seems very difficult for one specific professional to treat all domains because we’re not educating them. We’re not We’re not bio psychosocial therapists. It’s not like its own brand is. It would be attendance. Yeah. Well, it’s, it would be a 10 year course.

Jamie Johnston 43:50
Yeah. Oh, manual therapy, and psychotherapy and social therapy, you’d be. So not it’s not a terrible thing. But you’d be in school for a long time to be able to do all that.

Eric Purves 44:00
So yeah, I think what we should get from this is that, you know, we have to start thinking about psychosocial, thinking, there’s a lot of influences on people. We never want to just say it’s just the bio, we don’t wanna swing too far. We don’t say it’s just a psychosocial we want to kind of, you know, play in that middle. There’s a pendulum swinging too far and be aware of, you know, is this more of a bio driver? Oh, yeah, you’ve got it. Like there’s tissue injury, there’s inflammation, there’s brake, there’s whatever, there’s something you know, or is this more like, is there more psychosocial things going on that are amplifying kind of some of that nociceptive sensory stuff that’s going on? Right. These things all work together. And it’s, you know, part of the problem we see in the research as well as what we see in these online discussions is, it’s like one swing to the right of one swing to the left, it goes back and forth. Right. And, you know, the quote that the authors use here, which I thought was great, it said when they’re talking about bio psychosocial interventions, it says, working closely together with regular team meetings, face to face or online agreement on diagnosis. therapeutic aims and plans for treatment and review is important to know the emphasis on the need for the treatment team to reach agreement on diagnosis goals and treatment plans, hopefully, before the plan is implemented. And this is just basically saying like, this is what you should be doing and ultimately, multidisciplinary treatment environment. But that in reality, at least for our profession, I, we’ve lived our lives before, that’s very difficult. When you’re one on one with person in a room for 45, 60 minutes, and you’re busy and everyone else is busy. It’s very, very difficult to coordinate care appropriately, at least the way things are set up here. But ideally, in a proper pain clinic. This is how things should be done. And I think some places they’re the only I got I can’t speak from my own knowledge, but I would hope that some places they do things that way.

Jamie Johnston 45:50
Yep. Yeah, hopefully, it’s, hopefully that’s coming. But we know how long it takes to implement research. So as long as as long as as long as we’re working towards providing better care whether it’s individually or as a team. And as long as we’re going after patient centered care, then hopefully that means we’re doing whatever’s best for the person in front of us.All right, everybody. We’ll we’ll see you next time on the podcast.

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Nicholas, Michael K.. The biopsychosocial model of pain 40 years on: time for a reappraisal?. PAIN: April 19, 2022 – Volume – Issue – 10.1097/j.pain.0000000000002654
doi: 10.1097/j.pain.0000000000002654