Applying The Biopsychosocial Model In Clinical Practice

 

The biopsychosocial (BPS) model is one of those things you probably feel like you should be doing but maybe don’t know exactly how or you don’t have the skills? There does seem to be a fair amount of uncertainty and a bit of anxiety associated with the BPS model HERE and even the papers that discuss it rarely seem to actually define it!

This take on the Dan Ariely “big data” quote sums it up quite nicely (kudos to the author!)

Biopsychosocial management of back pain

Is like teenage sex;

Everybody talks about it;

Nobody really knows how to do it;

Everyone thinks everyone is doing it;

So everybody claims to be doing it.

But maybe we don’t need to FULLY define or understand the BPS to start to implement it in some way. The first thing we need to do is actually know MORE about it. I was told recently that the BPS model is “old and we should move on” in a Twitter discussion. A little bit further into the discussion, it turned out the other party had not read much about it, I think this happens a lot. We all seem to have our own interpretations around what BPS is and is not, so this is my attempt!

What Is It?

 

There seem to be two main perspectives that are summed up in these quite differing quotes:

“The centre of interest in biopsychosocial model is not the disease but a sick individual”  – Havelka  

 “The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person’s medical condition it is not simply the biological factors to consider, but also the psychological and social factors” Physiopedia

The first is focused more on the person we are treating and the second is more focused on the condition or problem, so no wonder we have a bunch of confusion and NEITHER really give much guidance about what to do next.

One of the perspectives that I feel gets lost in some views of the BPS model is the focus on the ‘humanisation’ of healthcare which is a feature of Engel’s writing. To understand the biopsychosocial model we also have to understand why we needed it in the first place and this was to come away from the reduction of healthcare to pathology and numbers that was the biomedical model.

Isn’t it fascinating we now quantify the success of a BPS approach simply by an outcome measure!?

Philosophy Of Care And Person Focus

 

Maybe this is the real spirit of the BPS? A ‘philosophy of care’ and a person focus.

The cool thing is it does not require extensive training to implement, instead, it simply requires us to appreciate there is another person who is more than a disc or a tendon or whatever issue they have. They also will have a history and experiences that shape their emotions, perspectives and ultimately behaviours.

This for me is summed up nicely in this quote.

“Look at the world through the patients eyes and walk through the world in the patients shoes” –   

 This quote from Joanne Bourke also sums up how we can focus more on the pain than the person who has it.

Pain’, rather than a person-in-pain, is given agency. A pain-event always belongs to the individual’s life; it is a part of her life story”  

When it comes to the human side of the BPS perhaps we can get stuck on the idea that everything we do has to result in a better outcome e.g. a change in pain. So this interaction is measured and judged via change in pain, empathy is measured via change in pain, you get the idea. This is exactly the positivist/empirical perspective Engel seemed to be arguing against, reducing everything to a hyperfocus on the problem and then measuring its change! We should be being aware of how we interact NOT just to get a better outcome measure but also because it’s the RIGHT THING TO DO!

Evidence-based medicine is important but not at the expense of a person. We really need to zoom out to the whole often rather than separating into smaller parts and descending DOWN Engel’s hierarchy of systems.

The aspect of the BPS model that is probably most important is our own self-reflection on how we think, act and interact but I have rarely seen this discussed. Just reflecting on how we communicate or care for the other party or conduct ourselves is enormously valuable.

The thing is that if we want the BPS to be an effective treatment tool then it probably requires the human aspect that is being discussed here. Many psychosocial factors that relate to pain require changes in behaviour. These changes also require trust and belief in what we are saying and this can be tough when it is contrary to all the other concepts and ideas around pain that people get exposed to.

There are a number of points that we can appreciate to implement a more person-focused version of the BPS model that is NOT directly treatment-focused but might have an effect on the process.

  • Having pain can affect our emotions as much as our emotions might affect pain. It is a BI-DIRECTIONAL model.
  • Socioeconomic status and health literacy directly affect the entire therapeutic process
  • Appreciate how beliefs are in part formed at a societal level and this can make them pretty sticky. They often don’t simply change in a session
  • Having pain is HARD and can limit motivation and belief in recovery
  • This person may have had to tell their story multiple times and this can be very frustrating
  • A constant search for the answer can be frustrating and tiring. Modern medicine can paint the picture there is one to be found
  • Uncertainty and the worry it brings makes people feel worse. Not just their pain but also their well being
  • Hope, motivation, optimism and instilling confidence are important not just for pain but also for LIFE and the person

None of these things are treatments but do help us understand the person and their levels of engagement, optimism and outlook for the future. The appreciation of these points also does not require a huge amount of training to implement.

Causes And Treatment Focus

 

A more traditional diagnostic and treatment-focused use of the BPS seems to be the most popular way it is interpreted and implemented and perhaps this can cause a bunch of issues for both clinicians and patients. To treat thing’s specifically the thought is we have to kind of know what the problem IS first and we can get hyper-focused on finding the CAUSE of the problem, but now we have way more potential problems across lots more areas to confuse us! Sticking to traditional pathologies can be hard enough and this is without having to be an expert in other fields too!

I think there is a case that we could see this as a biomedical application of the BPS as we could treat multiple BPS ‘factors’ WITHOUT actually treating the person in the spirit of the BPS and with a focus on person-centred care. A real aim would be to successfully implement a person AND pain-focused model.  Many of the factors we need to identify to implement a pain-focused model actually need the person-centred model to make them work anyway. Without a good therapeutic relationship and trust and rapport, how do we get people to tell us the information we need? How do we help implement the behaviour changes that are often required? The simple answer is we don’t.

Triggers Not Causes

 

Maybe a better way to see this all would be factors/behaviours that TRIGGER pain not always viewing it through a causation lens. Many things might trigger, exacerbate or modulate a painful state. Is this semantics? Potentially, but maybe less focus on CAUSE might take the pressure off clinicians to pinpoint a cause and does not feed people’s desire to find the one thing that they need to fix their pain. We might swap disc/nerve/alignment for stress/sleep/job and a triggers perspective may help people make sense of their pain situation rather than search for the cure or fix it in the same way that can often prove frustrating and demoralizing.

As we can see HERE 9, yes 9 psychological factors were identified as being involved with rotator cuff tendinopathy pain, function and quality of life. No wonder a BPS find and fix it model is seriously daunting for most clinicians.

A good analogy might be that of a cut that is grumbling away in the background. Sometimes I am unaware of it, others it is giving a slight twinge. But get something in it that irritates it and it’s a whole other story. This added element has interacted with the cut and triggered a response. Without the cut it might not have done so perhaps on its own we might not see it as a casual element. There is sometimes a danger we simply swap biomechanical impairments for psychosocial ones.

The interaction of BPS factors is inherently messy. Humans are a complex web of interrelating systems that display non-linear responses between things acting on the system and the responses it makes. This can mean we could have huge changes in a variable such as stress but only minor changes in how it affects a target variable such as pain. We also might target one variable, that may not change significantly, but another mediating variable change and this changes a target variable. This may be different to the sometimes linear approaches that we can see in research and clinical models that involve a primary outcome measure and intervention.

If we approach the BPS model as a simple view of linear causation and impairment fixing this kind of goes straight back to a biomedical perspective.

 

Positives Not Negatives?

 

There are positives and negatives to this messy non-linearity of the BPS with treatment. Positive in that treatments can have wide-ranging effects across many variables and the negative that they also might not! Exercise can have implications for general health, mental health and pain through a whole bunch of different mediating variables. One way to start to approach the BPS model is not in trying to fix an impairment but to improve aspects we know are beneficial and may provide an overall effect. This would fit with Antonoskys salutogenic model of focusing on wellness rather than illness.

Screen Shot 2020 06 10 At 11.04.02

 

Perhaps an issue is we now see it as “just do some exercise” and the person will be ok.

Exercise ‘works’ is a common perspective but this really does not tell the story of the data. It is not so much if it ‘works’ at a population level but how much effect does it have for this person in front of me. For all this potential to have wide-ranging effects we still don’t see dramatic benefits in the research and often clinically too on the outcome measure of pain. Maybe this is because we expect exercise to automatically transfer to whatever the issues are? Effects on strength, sleep, mental health and ultimately pain are all potential effects/mediators that we see in the research base but we are not GUARANTEED these effects. This paper found HERE found that strength and power scores did not make people feel automatically ready to return to play. Although physical conditioning MIGHT make people FEEL mentally stronger it is not an automatic and linear relationship.

Summing Up

 

We probably need a bit of both perspectives to make things work effectively.

If we put this into context, firstly we need to consider the effects we might want from exercise based on finding out more about the person we are working with. Do we want to improve health? Wellbeing? Function? Exposure? We might have to set up exercise in some different ways to achieve these different aims. Secondly, our deeper knowledge of this person and their journey might help us frame, explain and implement the exercise in some different ways that could have a better potential to have the desired effect.

If a BPS approach just ends up in do some exercise because it CAN have wide-ranging effects I think we have lost sight of what the BPS just might be!

 

Learn How Volunteering Can Benefit Your Career

The phone in the clinic rings from a number you’ve never seen before. 

You answer, assuming it’s someone looking to book in for an appointment, and then you hear the same pitch you’ve heard a thousand times: 

“Would you be willing to donate your time, or a gift certificate to our charity, or upcoming cause”? 

We’ve all had those calls, and usually, the person on the other end has the best of intentions, and it’s usually a good cause. 

However, with many requests per year coming in, at what point do you say no, and at what point is volunteering your time worth it?

This is certainly an individual decision that you have to make, but I think there’s value in volunteering your time, especially if you’re new in practice. 

Is Volunteering Worth It?

I should preface this by letting you know my bias to this is yes; however, it should be done selectively. 

I would not be where I am in my career(s) today if it wasn’t for volunteering, and all the volunteer work I’ve done has lent itself to each of my careers. 

For those of you who may be new to this blog, in addition to being an RMT, I’m also a full-time firefighter, so I’m fortunate to have two great careers. 

However, I didn’t always have both as a career. 

I spent 16 years as a volunteer firefighter before getting hired full-time last year with my present department. 

The cool thing is that much of the experience I gained as a volunteer not only helped me get the career job, it’s also been pivotal in my career as an RMT and continues to be. 

Back in 2009 when I was still a student, I knew I wanted to be involved in sport as a therapist, so I approached our local Junior A hockey club and had a chat with their head Athletic Therapist to see if I could come in and volunteer some time with them to get some experience as a student. 

When I told him my background as a first-aid guy and firefighter, he looked at me and said, “Oh so you’ve seen some stuff!” and then invited me to come and start at the next game. 

So, volunteer experience in one area helped me get my foot in the door to another part of my career that still serves me today. 

Another thing that happened was back in 2010, our regulatory body came out and put the rule in place that every RMT in British Columbia had to be certified in First Aid to maintain their license. 

It was also around that time that my fire chief approached me and wanted me to become one of the First Responder instructors for the department. As a result, I became a Red Cross First Aid instructor and have taught First Aid and First Responder courses to RMT’s and Athletic Therapists all across BC. This makes up a pretty big part of my brand and business today, and I have even been fortunate enough to teach courses to the Vancouver Whitecaps medical staff. 

When I look at the seven years I spent with that Junior Hockey team, while it wasn’t a paid position, there were several other ways in which it paid off. 

The team chiropractor became a referral source for me in the clinic for the following ten years. In fact, I can remember when I first graduated, there were weeks where half of the people who came to see me were referrals from him. 

Many of the staff members would also come to see me, refer friends and family to me, and some still come and see me today. 

This volunteer work also helped establish me in the community as a “sports therapy” guy, and many patients over the years came to see me because of that reputation. 

During my time with the team, I was fortunate enough also to mentor some Athletic Therapy and Kinesiology students who were getting their practicum hours. Many of those connections are still in place today and have helped me become known as a First Responder instructor in the Athletic Therapy community because of those students. 

One student even convinced the clinic he was working at to contact me and hire me to work in their clinic when they were looking for an RMT, and I spent six years working at that clinic. 

Funny enough, one of those students went on to be a chiropractor and just recently contacted me wanting to refer some of his patients who were moving to this area. 

Once again this volunteer experience lead into more opportunities. 

Because of the experience I gained working there, this was my foot in the door to get hired by Hockey Canada, and have been able to work and travel with them over the past six years. 

As a result of working with them and the connections I’ve made with the other healthcare professionals, this has opened up other sports opportunities. 

One of the Physio’s brought me in to do some work with rowing Canada. One of the doctors recently brought me in to be a “biosecurity officer” for the FIBA Basketball Olympic trials. In addition, this has also given me the opportunity to travel to places like Russia and Slovakia that I would not have gotten otherwise. 

Now it’s also important to mention that while volunteering has given me many opportunities, a crucial part of this is also building relationships with people along the way. 

This is an important aspect of any part of our business, whether you’re volunteering or not. I was exposed to many people who later gave me opportunities because of the relationship I built with them through volunteering. 

Here is a bit of an overview of how volunteering has lead to more opportunities within each of my careers.

 

 

The Professional Side

This blog is one of the professional volunteer things I do. 

In the last few years, writing and promoting this blog has led to opportunities where I profit off it by teaching courses. However, it was strictly a volunteer project for many years and a chance for me to learn more about research and our profession. 

But, it led me to sit on the board of directors of the RMTBC for five years, which again was another great learning opportunity. 

While I’m a big proponent for volunteering, I understand there are those in the profession who are against it and believe we should never work for “free”. 

To a certain extent, I agree, but when I look back, there were so many of those volunteer experiences that, in the long run, made me more money than if I had never done it. 

Something essential to consider is many who think we should not volunteer are also willing to jump into Facebook groups and ask questions of their colleagues for advice. In such instances like this, you ask your colleagues to “volunteer” their time to answer your questions. While this is part of professional courtesy (and should be encouraged), shouldn’t you compensate those colleagues for their time if you believe we shouldn’t volunteer? And wouldn’t it be the same if you’re sending private DM’s or emails for their professional opinion on something? 

These are clearly all things you have to take into consideration for your business. If you’re a new grad and debating whether it’s worth taking the time to volunteer on something you’re really passionate about in the profession, give it a try, the long term rewards you can reap will be worth it. As time goes on and you get more experience, then you can start being more choosy about where and when you volunteer your time should you decide to do so.

Here’s a LINK to Tanner Thompson’s podcast I was on last week talking about the value of volunteering and getting involved in sport.

 

Articles Of The Week July 18, 2021

We have written posts on this topic before but this is a good refresher on some issues our patients could be having with their sleep. Some of the results of sleep paralysis include muscle soreness and headaches. So while someone may not know they have sleep paralysis it could be something we recommend they have checked out by another professional.

Sleep Paralysis – Krista O’Connell

Quite often people with joint pain (especially stemming from arthritis) are prescribed steroid injections to help with the pain. As it turns out, new studies are showing this may be doing more harm than good.

A Warning From a Doctor Who Has Done Thousands of Steroid Injections for Arthritis – James Hamblin

No matter what our profession is within the manual therapy community, we all have a defined scope of practice from our regulatory bodies. It’s important we stick to these as giving advice that is out of scope can have some serious ramifications.

Chiropractors aren’t qualified to give COVID-19 vaccine advice, health experts warn – Scott Fralick & Denise Wong

Ahhh yes, anecdotal experience. This is often used in discussions online as a way to say someone doesn’t need to read or apply research in their practice. There are a lot more reasons something works in practice and a technique itself is probably not the reason.

The trouble with “it worked for me” and “athletes use it” – Paul Ingraham

We’ve written articles before on how many of us deal with “imposter syndrome”. But what about the opposite outlook “the dunning-kreuger effect”? Well, this might be the reason for some anti-vax attitudes that we are seeing right now.

How the Dunning-Kruger effect explains anti-vaccine attitudes – Paul Ratner

My Response To The EIP vs EBP Debate

Sometimes we write posts around here that ruffle some feathers. 

This happened a few weeks ago when we talked about being evidence-based or evidence-informed. 

The post was basically making some arguments for being evidence-informed and looked at some of the limitations or downfalls around being evidence-based. 

A number of articles were thrown my way to look at the contrary, so let’s dig into those and see what they have to say and perhaps I’ll have to change my stance. 

Successful vs. Unsuccessful

It’s probably important to state right from the start there are limitations to both evidence-based (EBP) and evidence-informed practice (EIP). 

As I read through some of the research cited on EBP a few things stand out to me. 

First off, the literature (¹) fairly consistently talks about EBP in a multidisciplinary setting, typically in a hospital setting. 

This is not the same as working in a multidisciplinary musculoskeletal care clinic as most of us work in. In our case, you can’t interview your patient, then leave and chat with a few other colleagues for an extended period, then go back in and conduct your treatment. 

This is a situation that is probably very valuable for our Physiotherapist friends who are working in a hospital setting; however, there aren’t a lot of Massage Therapists who work in this environment (I know there are a few, but it’s not the norm). 

Part of how to successfully apply EBP is by giving staff opportunities for discussion. So, when we look at a hospital setting, you typically have union, hourly paid positions which enable this to happen. They are encouraged and given paid time as part of their employment to engage in this kind of activity. 

However, in our case, if we aren’t working, we aren’t making money, so implementing this is a lot more difficult. I know some clinics try to have monthly meetings and discussions (which is a noble effort), but I think most of us want to go home at the end of the day. 

Another caveat is that people are placed into (again paid hourly positions) leadership roles to accomplish the efforts mentioned above in these hospital settings; their sole job is implementation. 

When they compared hospitals who were trying to implement EBP, they were referred to as “high performing sites”, and “low performing sites”. 

The high performing sites had a consistent and strong emphasis on EBP throughout the organization along with: 

  • guideline development and implementation
  • evidence-based teams
  • leadership that provided an environment of support
  • they strove to build relationships with patients by placing them at the centre of the organization
  • structural mechanisms in place to support patient-centred care with contributions from all staff

When they looked at the low performing sites, they saw things like: 

  • it was up to individual providers to stay up to date
  • staff felt it was everyone’s responsibility to keep up with new developments
  • low numbers of implementation and support
  • more variation in leadership support 
  • more transactional interactions with patients
  • staff delivering patient-centred care instead of it being done as an organization
  • a passive or punitive culture

This is important to take into account because while we may be working in a multidisciplinary clinic, the values of each practitioner working there can be drastically different. 

We are most likely involved in what this paper would have called the low-performing site.

Even if we as Massage Therapists strive to be evidence-based, it doesn’t mean everyone else in the clinic is. We could be working with other practitioners pushing old narratives, so we don’t get the team environment that would make the clinic more successful as EBP and us. 

The Sicily Statement

There is a quote in this paper(2) that I love: 

“Knowing is not enough, we must apply. Willing is not enough, we must do.”

A few other things stand out in this paper. First off, it points out there are increasingly growing specialist databases for the professions working on EBP. However, there is very little research specifically on massage therapy. So we regularly have to depend on research being done in the Physio or manual therapy realm and using that to apply in our practice. 

So, there is no “specialist database” for us to rely on (hopefully, this changes at some point). 

Another part of implementing EBP is reading research, applying it in practice, all so you can build your knowledge and wisdom (which is something I hope we’re all doing), but this can take years of work to be proficient at. 

They propose we go from EBM to EBP to benefit entire health care teams and organizations adopting this approach. But, unfortunately, even in a multidisciplinary clinic, we don’t work in teams. So until our associations start setting firm boundaries and creating policies to put EBP in place, this won’t happen (and I doubt it will in my career). 

This is also hoping that EB practitioners are speaking the same language. So even in a multidisciplinary clinic, this won’t happen as many still believe they’re further up the healthcare hierarchy than us. Look at the fact it was only something like 53% of chiro’s here in Canada recently voted in favour of not using x-ray with every patient. This means that basically, 50% of the profession was choosing to remain doing something in practice that is not evidence-based. Think of how this would affect a team environment working in a clinic where this non-evidence-based approach is part of the culture. 

How in this setting could we expect to work as a team of EB practitioners, taking what an RMT says into account? It probably happens a little bit, but we have light years to go before this is standard. 

The resounding message I got from this paper is that it is necessary to work as a team for anyone to be successful as an EBP. While I think we should be working towards this, this isn’t something that happens in private practice in the manner recommended. 

The second big takeaway is that changes in education are necessary. 

Until students are taught about research, critical thinking, and how to have a critical attitude to your practice, we won’t be able to implement this as a profession properly. 

Part of the problem with this lack of education at the college level is that when students graduate and start looking for their first continuing education course they get blindsided by some of the (for lack of a better term) “guru’s” out there teaching non-evidence-based courses.

As the article points out: “Attitudes are caught not taught,” and unfortunately, a lot of this happens with these continuing education courses. 

Are We Even EIM?

So, the terms EIP and EBP often get used interchangeably, and I have no issue with this but it’s been brought to my attention this could be confusing to some, I just think when we really look at it, we’re closer to EIP than EBP. 

Fair enough. 

So, the difference I see is that EIP takes into account more types of research. As Massage Therapists, we need to consider this since there isn’t much specific massage research out there, and we have to be able to look at the research and apply it to the person in front of us. 

I like this image that was cited(4) in another article which shows the short-term and long-term goals of both EIP & EBP: 

I know it’s a bit tough to see in this image, but what stood out to me was the difference in the long-term goal comparison between EBP & EIP. While there are some similarities there are a couple of interesting differences:

EBP long term goals:

  • Improved patient assessment and treatment
  • Increased staff retention

EIP long term goals:

  • Improved patient outcomes (patient safety, reduced morbidity and mortality, and less healthcare costs to patients and patient relatives
  • An evidence-based practitioner who is a critical thinker and doer
  • Job satisfaction among practitioners

I don’t know about you, but I like the long-term goals of EIP a lot more, however it has it’s own set of challenges as well.

One of the more difficult challenges in EIP also has to do with education. One of the main factors to be evidence-informed is the ability to critically think, and be critical of research (3)

This again comes down to what is being taught at the college level; critical thinking skills are not part of the curriculum. 

When we look at the five steps recommended in EBP this is how it looks (2)

  1. The professions and their colleges should incorporate the necessary knowledge, skills and attitudes of EBP into their training and registration requirements
  2. Curricula to deliver these competencies should be grounded in the 5 step model 
  3. Further research into the most effective and efficient methods for teaching each step should be fostered and linked with ongoing systematic reviews on each step
  4. core assessment tools for each of the steps should be developed, validated, and made freely available internationally
  5. courses that claim to teach EBP should have effective methods for teaching and evaluating all components. 

Looking at those five steps it is clear to me (and also in the research papers) that changes in education are necessary!

EBP cannot happen successfully until our education changes. One of the major themes throughout the papers is leadership. 

For us, this means our associations, regulatory bodies, and schools need to step up and make a change. These organizations must create and implement policies that push the profession toward EBP. 

This isn’t limited to just our entry to practice education, it should include continuing education courses. When we look at the courses that our associations are willing to promote (and get CEC approval from the regulatory bodies), 1% of them are EB (yes, I’m making up 1%, but I’d be willing to bet it’s not much better than that).

When it comes down to it, I don’t care what we call it anymore, EIP or EBP. All that matters is we are reading the best available research and trying our best to implement evidence into practice while also putting the people in front of us first. My buddy Rey Allen left a comment on a thread that said something to the effect of “Let’s just call it science based practice”. I’m good with that too (in fact, maybe that’s better overall). But, until the leadership in our profession changes and starts to implement policies to make things like this mandatory, I’m not sure we can apply any of these titles appropriately. However,  this doesn’t mean we shouldn’t be putting every effort forth to make this happen, it’s quite the opposite. We HAVE to make these changes so the profession as a whole is applying evidence in practice. So, let’s start pushing leadership to make a change to make us better and do better for the people seeking out our help and truly deliver care that is being influenced by the best available evidence. 

References: 

  1. Engle RL, Mohr DC, Holmes SK, Seibert MN, Afable M, Leyson J, Meterko M. Evidence-based practice and patient-centered care: Doing both well. Health care management review. 2021 Jul;46(3):174.
  2. Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, Porzsolt F, Burls A, Osborne J. Sicily statement on evidence-based practice. BMC medical education. 2005 Dec;5(1):1-7.
  3. Finch PM. The evidence funnel: highlighting the importance of research literacy in the delivery of evidence informed complementary health care. Journal of Bodywork and Movement Therapies. 2007 Jan 1;11(1):78-81.
  4. Kumah EA, McSherry R, Bettany-Saltikov J, Hamilton S, Hogg J, Whittaker V, Van Schaik P. Evidence‐informed practice versus evidence‐based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of undergraduate students. Campbell Systematic Reviews. 2019 Jul 23.