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Have We Ballsed Up The Biopsychosocial Model?

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One of the most widely discussed topics in healthcare and especially in pain circles of late is the Bio Psycho Social model conceived by George Engel.  The BioPsychoSocial (BPS) model was developed in reaction to the dominant biomedical viewpoint that involves reducing medicine to specific diseases or pathologies that can be identified and treated and this model forms the backbone of most western healthcare systems.

Engel felt the biomedical model:

“does not include the patient and his attributes as a person, a human being”

But the question is, have we misinterpreted the BioPsychoSocial model?

Are we simply applying it in the same way as the biomedical model it was trying to replace?

It’s People Not Just Pathology!

We know that people’s experiences of pain and pathology differ. The same painful problem may manifest as huge issue for one person disabling them from work and reducing dramatically their quality of life, whilst another person may remain relatively unaffected. This has to be taken into account both in treating the problem but also how the person is TREATED by their healthcare professional, their family and social network and the wider healthcare system.

We can see below from Engel’s view that it is a bi-directional model that involves the layers in which we exist rather than discreet treatment targets as we now see.

Download 4We could perhaps determine this interaction between layers as the wider impact OF the problem rather than just as impacting ON the problem. Rather than seeing the BPS as a direct treatment model where we dissect the three domains to find new pain ‘drivers’ to treat, the BPS perspective should really be seen as a CLINICAL philosophy and guide that can be used for improved patient care.Here is another interpretation from a recent paper ‘How do physiotherapists solicit and explore patients’ concerns in back pain consultations’

“underpinning the bps model is patient-centred care (pcc) which involves incorporating the patient’s perspective as part of the therapeutic process”

One of the issues that are often encountered in healthcare however is that clinicians AND patients want solutions and treatments rather than philosophies and the conversion into a treatment model conforms to the biomedical perspective that dominates healthcare.

Maybe the BPS asks us, as clinicians to better understand our patients and their subjective experience? And it may be better defined as a model of care rather than a model of treatment. Now, this does not mean we cannot involve a BPS thought process IN specific treatment but remember that this is just not really the major focus of the model, certainly as I understand it anyway.

So it is really treating people and their overall existence, not just treating their painful problems. These differing aspects cannot just be separated and simply targeted without an understanding of the person and the context they exist in, doing that for me is the biopsychosocial model in biomedical clothing.

Other commentators such as Leventhal have looked at concepts such as the disease and the illness *HERE*. The disease being the specific issue and the illness being the wider issues surrounding the problem, in my interpretation, this is similar in concept to the BPS. How is this PERSON individually affected by the problem that may even BECOME the problem itself?

Just Treat The Pain?

I can already hear some readers shouting, “Just treat the pain – then you will not have any more problems”

Well, that is the biomedical view in a nutshell!

Firstly we have been attempting to do this for ages, hence why there has been a call for a different model. Often treatments for pain are not successful and people need help in other ways and we treat pathology but pain persists. Perhaps the interaction with healthcare even makes the problem worse!

Can we treat the person and pain? Yes, I believe so. We should not forget this, just realize our limitations at doing so and also avoid pain being the only focus.

The question is do we often attempt to treat the person AND the pain? I don’t think this happens as much as we would care to admit.  Maybe treating people rather than their pain can lead to reductions in pain? Maybe we cannot have an impact on people’s pain but affect suffering, disability, and quality of life? We may not be able to do this in a pain-focused model and why we end up with repetitive surgeries and the opioid epidemic?

People can still have pain and live a positive life; the BPS model is really well placed to help them do so and does life simply return to normal even after pain has reduced for all? I would hazard a guess that for many people their lives are fundamentally changed even AFTER persistent pain has decreased.

BPS Model Of Pain

A pain-oriented BPS model has emerged more recently and two examples of this can be found *here* and *here*. These interpretations should NOT be confused with Engel’s model I feel, and perhaps misses the essence of what he was reaching for. Maybe an issue with the BPS model is its breadth and how far-ranging it is? It is quite easy to place our interpretation anywhere within it.

The pain focused model looks at how Biological Psychological and Social factors can influence pain.

This diagram is a great example with the arrows pointing solely inwards.

Screen Shot 2019 08 21 At 07.34.26(Figure Fillingim 2017)
The problem here is that it is a return to a biomedical view in which the person is less of a focus and instead the disease (in this case pain) has returned to become the primary focus. Instead of being a comprehensive BI-DIRECTIONAL clinical philosophy, it has in many cases become a unidirectional treatment model.  We also have much more evidence for BPS aspects being associated with pain than we do actual data to support treatment for pain using these BPS aspects.Seeing PsychoSocial factors simply as pain influencing factors is missing the wood for the tree’s I feel. This would be a multifactorial pain treatment model, not the BPS model set out by Engel.This has drawn critique, and rightly so, of the BPS model and its interpretations. A recent paper from Stilwell and Harman can be found here called “An enactive approach – Beyond the BPS model”(Thanks to the authors for the full-text link!). This critique, I feel and highlighted by the authors, is not really of the Engel’s model but instead, the pain focused interpretation that has evolved. We may not need to move beyond the BPS model, more just apply it in its intended way. Let’s try to do that before we think beyond it.Stilwell and Harman go on to say

“Pain is…..a process that emerges or unfolds through a whole person who is inseparable from the world”

but we should also consider the BPS perspective already to consider the whole world and our existence within it and not just its effect on pain!

The very essence of the BPS model was NOT to delve further and further into the microscopic components of biology but instead to also zoom out to encompass the other factors that may be at play in both pain and quality of life.  I have written about this *HERE*. But if we consider most of the discussion, theories, and dominant messages around pain they focus on the reductionist view that Engel was trying to get away from.

As an example please insert any painful problem here ‘XXXXX’. Even the most uni-factorial biological one you can think of… let’s say a fracture.

How does their perception and knowledge, sense-making, around the issue affect them and their behaviors?

How does the injury affect their work and family life?
What are their perceived implications for the future?
How confident are they to return to sport or activity?

How motivated are they to engage in rehab or treatment?

This is considering the PERSON and heir engagement and embodiment in the world not just breaking down pain ‘drivers’ as the trend seems to have become and accusations of people forgetting the bio (eye roll).

Straight Lines & Trichotimies

Some of the criticisms of the BPS pain model focus on the division into three distinct components biological, psychological, and social as well as a perceived linear causality between the associated factors and pain.

My view of Engel’s work is that he objected to a linear causality model. Emergent properties such as pain NEVER have simple linear relationships with causes (whatever they are?). Again this is a misinterpretation and application specifically to pain of the original work. Linear causality is a criticism of previous Cartesian pain models but appears to be alive and well in the BPS.

The term ‘non-linear’ means that small things can give large effects but also large effects in one area may also give rise to no effects in the targeted area.  There are so many interactions occurring that can affect each other that the same treatment may give rise to DIFFERENT positive or NEGATIVE outcomes dependent on the current state of the organism.

We seem to be happier for this to be the case now biomechanically, but less so biopsychosocially. If we are being honest then we have many more associations WITH pain from what is termed BPS factors than actual data from using these factors to treat pain.

The trend of splitting pain into separates categories of Biological, psychological, and social to diagnose and treat is another critique that Stilwell and Hartman highlight in their paper and neatly term a trichotomy. I feel Engel’s point was not that they exist distinctly as pathologies to treat but in their own right but to consider these things within the wider appreciation of the patient’s experience.

Conclusion

  • We should really see the BPS model as a CLINICAL PHILOSOPHY and way of incorporating the patient into healthcare.
  • It is intended to understand patients, their lives, and contexts.
  • The biopsychosocial model COULD be used as a pain treatment model, but this is probably not how it was intended. This may be better termed a multi-dimensional pain treatment model.
  • There is not really much data on outcomes from treatment using a BPS pain model.
  • BPS factors are not simply linear treatment targets.
  • We may need to better apply the BPS model rather than move beyond it.

How Beliefs And Communication Can Influence Pain

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I was listening to a podcast today where the host was talking about successful entrepreneurs.

Since we’re all entrepreneurs I couldn’t help but notice how the information applied to us as therapists.

While the host wasn’t directing the information at healthcare professionals, the main point he was talking about was being good coaches. His biggest point was that being a good entrepreneur meant being a good coach and communicator.

This is especially true in our profession.

The way we communicate and “coach” our patients can have a profound effect on the results we get with them. Both in a negative and a positive way.

The words we use can have both a positive and negative effect, which sometimes can last for years, depending on how it’s delivered.

As we have been preaching about the evidence-informed practice and implementation of the BPS framework for some time, we felt it important (and it was also requested) to look at how the words we use affect patient outcomes.

Fortunately, Darlow et al. has done a number of papers on this so we can draw from some of the research that has been done!

For now, we’ll look at how not only our beliefs and communication but also our patient’s beliefs can affect outcomes.

Patient Beliefs About Their Back

When we look at the BPS framework of pain it can sometimes be difficult to separate what the differences are between psychological and social influencers that could be causing a patient’s pain.

This first paper(1) lays it out quite nicely and shows that psychological influencers include; fear-avoidance beliefs, catastrophization, self-efficacy beliefs, depression, emotional stress, and outcome expectations. Now, this can certainly be a lot to take in if it were someone’s first visit to come and see you, so don’t think you have to get it all figured out on the first visit.

When they looked at much of the data collected in this paper, they further broke down the information into five main themes.

  1. The vulnerability of the back
  2. Special nature of back pain
  3. Prognosis of back pain
  4. Activity and back pain
  5. Influences upon beliefs

Vulnerability Of The Back

Not surprisingly most of the people in this study(1) equated their back issues to physical injury, damage, or dysfunction.

While most were not sure what exactly was damaged they also believed it was possible to hurt their back without being aware they were causing any damage, they also believed that an increase in pain meant more damage, while a decrease in pain equaled recovery.

The interesting part is that while most participants didn’t understand what caused the pain or “injury”, they also came to the conclusion that somehow their back was vulnerable, or designed poorly due to a variety of factors that included genetics, previous injury, or misuse.

There was also a belief where activities that included bending, twisting, and sitting were dangerous things that could cause further injury or pain. In reality, how many times a day do we do these things which are quite safe activities!?

In addition to all these beliefs, many of the patients tended to catastrophize about the possible explanations about the cause.

The Special Nature Of Back Pain

This is another area that brought about some surprising results (at least for me).

People believed that pain was a function of the back and in order to protect itself, it was forcing the person to stop any activity. There were even beliefs associated with the back being its own entity that could achieve its own goals which a person had absolutely no control over.

While this hindered simple things like walking, it also became a threat to people’s financial security as they did not think they would be able to work at their secular jobs.

An interesting consideration was that back pain was difficult to understand without personal experience, however, it was acknowledged that their psychological well-being was affected making people feel old, depressed, and irritable even to the point of impacting their relationships with other people.

The Prognosis Of Back Pain

While the previous sections demonstrated getting a prognosis was important to patients there are some things that proved worrisome for patients.

Some things that stood out were the back’s ability to heal, timeframes, and the quality of healing. This was influenced due to thoughts of vulnerability, not sure if the back could heal, and also because of seeing how back pain affected those with chronic back pain. Most thought due to the type of injury they had, or because of not doing the right things their own back was not going to heal.

The paper(1) concentrated on those three topics, but in just looking at the beliefs around that, is it any wonder people end up developing chronic pain when their belief systems are basically telling them there’s no way they can get better?

Client, Clinician, and Community

To continue on the topic of back pain and beliefs Darlow(2) looked at three different entities that influence our beliefs about back pain, the client, clinician, and community.

We know that psychological factors play a role in all pain but do we really understand why? Because if we did, we could more positively change patient’s beliefs and decrease things like catastrophization, for better outcomes.

As mentioned earlier there are different themes which influence how a patient perceives their back pain. Things like genetics, previous injury, and worries about movement reinjuring the area and are seen as dangerous. So a person can weigh out the risk vs. benefit of not only engaging in activity, but also seeking out care.

As pointed out in this paper (2) almost half of those experiencing back pain don’t seek out care, but for those who do, they see more than one healthcare professional. The things that do cause people to seek care are things like high levels of disability, pain, and maladaptive beliefs like catastrophization.

Now, this is where we can play either a positive role…or sadly, a negative one.

This is because the beliefs of the therapist can influence the beliefs of the patient. Remember, those who are seeking care are typically experiencing disability, pain, catastrophization, so they want more information from a trusted source…YOU!

If we are providing a strictly biomechanical explanation, this can seem threatening as most of those explanations involve things like muscle strain, discs out, hip rotated, the rib is out, etc. In turn when these kinds of explanations are given, if the person feels pain in the area weeks, months, or years down the road, they equate the pain to that biomechanical explanation they were previously given. I’m sure we’ve all seen this in practice when someone comes in and automatically equates the pain they’re experiencing to that “same old injury” that has been going on for years.

Since we know it is likely they are seeking care from multiple professionals, if they are getting different explanations, this can result in not only frustration but increased uncertainty about their capacity to get better.

Interestingly, while very well-meaning professionals give instructions on proper lifting or moving techniques, this can be understood as a need to protect the back creating hyper-vigilance about movement.

However (as we have preached so many times on this blog) providing reassurance, validating a patient, showing that movement is safe, can empower a person not only now, but in the future.

When they looked at community in the study (2) some things that stood out were how messages stemming from places like schools, workplaces, media, and the internet had an influence on people’s beliefs. These actually influenced the amount of support given by friends, family members, and even colleagues. As it turns out, a spouse’s beliefs about pain can actually influence the amount of support or care they give to their significant other.

Now, if your beliefs about pain can actually influence the amount of care you give to someone you love, imagine how this is influenced in the workplace!?

In my past life (before becoming an RMT) I was an industrial first aid attendant in a sawmill, I would see this first hand (although I didn’t understand it at the time). When people were injured at work (keep in mind this was a very bravado-filled environment) people were called wimps (and a host of other names I dare not repeat on this blog), or it was commonly believed they were just trying to get an insurance claim.

If a person is facing this in the workplace, and say their spouse isn’t overly supportive, combined with bills piling up due to the added stress of not working, imagine how this influences not only a person’s beliefs around pain but also the amount of pain they’re in.

The spouse can also have a directly negative effect by emphasizing what the injured person can and cannot do. They can become overbearing in trying to do too much for the person, or by doing too little, again, this comes down to their beliefs.

Part of the issue is that so many of these beliefs don’t match what the current evidence says.(2)

A great example of how this can be changed is the pain revolution cycle tour put on by noigroup. Every year they do a cycling tour to different communities in Australia where opioid usage is high. They visit these communities and put on education events about pain and have seen significant reductions in opioid usage through their education and changing people’s beliefs. 

So, imagine what we could do with each of our patients by just providing a little education!?

We’ve heard so many times practitioners saying things like “I don’t need research, my work speaks for itself, I get results”. One small part of the issue with statements like this is that many times a practitioner has been practicing for years and hasn’t updated themselves, or their beliefs, so are still saying things that are way out of date. While they are very well-meaning (and yes probably have some good results) they are still instilling beliefs like “my pelvis is rotated, rib is out, bad back due to genetics etc. etc.” which as we have seen is actually harmful to a person. We have a golden opportunity to provide education to patients that will change this narrative and alter their belief system in a very helpful way. (2) If we can confidently sit in front of someone and provide reassurance that they aren’t broken and concentrate more on education that will be interpreted positively by not only the patient, but their significant others will bring about far more lasting benefit. However, the only way we can gain the confidence to do this, is by reading current research and staying on top of new information and resources like the ones we’ve cited here. Because really, while you owe this to your patients, you also owe it to yourselves.

If you’d like to learn more about how to incorporate these kinds of things in your practice, we have an upcoming course on the low back, hips, and pelvis we are offering via zoom in February where we will be discussing many of these strategies as well as therapeutic exercise that you can check out by clicking HERE

References

  1. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: patient views about the back. Spine. 2015 Jun 1;40(11):842-50.
  2. Darlow B. Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine. 2016 Jun 1;20:53-61.

 

In Defence Of The Advice To Remain Active For Back Pain

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There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

To Predict Chronic Pain, Look to the Brain

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Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain –  the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability?  Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.

Resources/Citations

Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

Vachon-Presseau, E, M V Centeno, W Ren, S E Berger, P Tétreault, M Ghantous, A Baria, et al. 2016. “The Emotional Brain as a Predictor and Amplifier of Chronic Pain.” Journal of Dental Research 95 (6). International Association for Dental Research: 605–12. doi:10.1177/0022034516638027.

Baliki, Marwan N, and A Vania Apkarian. 2016. “Nociception, Pain, Negative Moods and Behavior Selection” 87 (3): 474–91. doi:10.1016/j.neuron.2015.06.005.Nociception.

Apkarian, A.V., Balik, M.N., Geha, P.Y. 2009. “Towards a Theory of Chronic Pain.” Progress in Neurobiology 87 (2): 81–97. doi:10.1016/j.pneurobio.2008.09.018.Towards.

Motor Learning Pitfalls and Autonomic Resilience

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Sometimes, I’ve found that teaching a movement cue to a client can backfire.

Coaching a neutral pelvic position or a braced core to do exercise, for instance, are great techniques to perfect a squat and deadlift and train a person to lift a heavy load. However, if a client experiences pain or discomfort out of a regimented exercise setting, are these necessarily the best strategies to focus on?

Very often, I’ve seen individuals become extremely hyperaware of their body mechanics, whether it was due to cues from a clinician or because the assumption is that patterns from high-load fitness routines need to be maintained outside the gym.

My experience is that this can result in a couple of problems.

Pain Science

 

One is a concept that you’re likely familiar with by now; that being catastrophization. If we, as clinicians, don’t mind our language during our movement coaching, often enough, a person can develop a belief that anything outside of these trained movement cues will result in injury.

As you can guess, believing that “losing form” will equate to pain can lead to that belief becoming a reality. This is classic fear-avoidance coping and is why someone can perform a 300lb deadlift and then throw their back out when they finally bend their spine to tie their shoes.

For this reason, it’s important to educate clients about the resilience of the body to perform non-deliberate movement as well as to mix these types of movements into their exercise programming. While it’s important for me to teach many of my clients how to do a proper hip hinge, it’s equally important to recondition them on how to round their spines to pick up a sub max load.

At the same time, it’s also crucial to teach clients that these cues are not meant to be minded for every movement in day-to-day activity. Again, this would enforce these fear patterns and lead to what we discussed above. However, it also enforces a reliance on deliberate thought to perform these movements, which takes us to our second point.

Autonomic Neuroplasticity

 

Once we remember to add in these additional “natural movement” cues to accompany exercise instruction, there might still be a disconnect between the clinic and real-world conditioning.

What we need to consider is that the conscious focus on movement in the clinic or fitness setting (whether it be a traditional exercise or a natural back bend) doesn’t necessarily translate to the nervous system being able to replicate those cues in a safe manner, subconsciously.

This boils down to neuroplastic deficits within the central nervous system itself following an injury, with altered motor patterns becoming the new norm (Grooms, 2016). We can describe this by thinking about the thought processes that lead up to movement. In an “exercise” environment, the signals that precede movement are directly to do with that specific motor pattern; sending the signal to the muscle and joint on what to do and how strongly and fast to do it. Outside of this environment, these thought processes are much more complicated and the movement will need to follow more complicated reactionary signals. For instance, often we will need to simply extend our arm, reactionarily, in order to catch an object rather than having that moment of anticipation to ready the nervous system and compute the necessary speed and force that will be required beforehand.

What this implies is that being able to do a back bend in the clinic when all of your focus is on it only gets us part of the way toward being able to do the same thing at home when relying on autonomic function instead of deliberate action. This is why athletes who have undergone ACL reconstruction and rehab can be, clinically, cleared to return to play yet still be 40 times as likely to reinjure their knee compared to their peers (Wiggins et al., 2016).

Clinical settings commonly revolve around focusing on internal cues when learning movement patterns, such as relaxing one muscle, stiffening another, or bending deeper at this joint. However, external cues, such as “reach for the floor”, “aim for the target”, or “focus on the field” have been observed as being incredibly important in sports settings. These cues help to bring the attention away from the body and to the environment instead, creating a more practical situation by decreasing conscious body control.

With ACL reconstruction, again, being the studied example (Gokeler et al., 2019), it is found that relying solely on internal cues does not provide the best outcomes for when external factors are finally challenged again. Even when rehab conditioning is extremely sport or activity-specific, an ability to do a maximal sprint in a controlled environment might fail someone when they attempt to do the same thing with real-world distractions added. For this reason, a lot of rehabilitation research is actually starting to involve the use of virtual reality (Grooms, 2015) to retrain autonomic capabilities.

Obviously, we don’t expect every clinic to equip itself with a VR headset. So that brings us back to the importance of mixing in external cues with the internal ones as we educate our clients in new motor patterns. The clinical setting can take a lot of great lessons on how to do this from the performance world, with a mixture of the two types of cues, periodization of a program, and an understanding of individual variance being hugely important factors.

Takeaways

 

So from all of this, we can understand that mechanical cues and deliberate exercise patterns are still a step in the rehab process. Throughout, however, we need to reinforce that a client’s well-being is not dependent on these patterns being maintained around the clock or that conscious control does not need to be exerted over their maintenance.

Finally, we also need to remember that the quiet, clinical environment is usually not one that our clients spend the majority of their days in, so we also need to prepare them for the real-life hazards, distractions, and mental states that their normal workplace, sport, and home settings will challenge them with.

A client’s life is individual, and so is the preparation for it that we provide.

A Simple Guide To Patient Centred Exercise

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After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient-centered care’ or PCC for short.

Now for a buzzword, it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient Or Person?

Most of the available literature in this area discusses “patient-centered care” but I much prefer “person” centered care as it turns the patient well ….into a person and a much more ‘real’ entity in a two-way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

“Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlight the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What Actually Is PCC?

Maybe by definition, PCC is tough to define for all? What is person-centered for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centered care has previously been defined as:

“willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems” – Stewart 1995

“the physician tries to enter the patient’s world, to see the illness through the patient’s eyes” McWhinney 1989

“Two-person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz, and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient-centredness”

  • The biopsychosocial perspective (the patient’s life)
  • The patient as a person
  • Shared power and responsibility
  • Therapeutic alliance
  • The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC Is Not

There are some criticisms of PCC that seem to centre around the idea of consumer-driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

  • Define or explain the problem
  • Present options
  • Discuss the pros and cons (benefits/risks/costs)
  • Assess patients’ values or preferences
  • Discuss patient ability or self- efficacy
  • Provide doctor knowledge or recommendations
  • Check or clarify understanding
  • Make or explicitly defer the decision
  • Arrange follow-up

 

What Do People Really Want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end-user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel, and ultimately need.

This is a really interesting paper regarding a two-person perspective in back pain Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership With Practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask Me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

‘Understand Me’

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen To Me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   – Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction”

Does It Matter?

A question I often hear asked about person-centered care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an effect on outcomes we don’t know if PCC specifically improves the most common outcome measures, but, in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function, or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the person’s experience in healthcare (which might be an outcome measure in itself).

 

The Application Of PCC

Maybe we should NOT see a person-centered approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead, it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting With The End In Mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently, and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding is, in my opinion, the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent “From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system”  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert-driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” – Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully, this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals, is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person-centered approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared Decisions And Responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to have an influence on exercise outcomes “Autonomy: A Missing Ingredient of a Successful Program?”. Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move, and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally, it is a therapist’s responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each other’s responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family, and social pressures. One of the best ways to implement a BPS perspective is to realize that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort, and sacrificing something else.

People don’t just need something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place, and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from “From’Non‐encounters’ to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low-cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than a healer can be really helpful for many!

Support & Motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite of walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” – Holopainen 2018

 

Conclusion

 

  • Person-centered care is defined by the person
  • PCC is not just giving people what they want
  • People are people not just patients (passive recipients)
  • Think about “walking a mile in someone else’s shoes”
  • Think more about shared decisions (within evidence base)
  • Start with the end in mind, tie into valued activities
  • Help people navigate their ‘world’
  • Build people up rather than knock them down

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