Posts

The Muscle Of The Soul, Or Just A Good Stabilizer?

It may be the most popular muscle in the world. 

For some reason, it gets a lot of credit for things and stirs up more debate than any other muscle (at least from what I’ve seen). 

Yes, we’re talking about the muscle of the soul! The wonderful Psoas. 

It’s been given credit for many a thing, including but not limited to: 

  • anterior pelvic tilt
  • breathing disruption
  • manifesting physical symptoms of fear
  • knee pain
  • digestive problems
  • low back pain
  • and even somehow is part of our reptilian brain?

Whoa, this muscle is doing a lot!

When we look at some of these statements, they are often prefaced with “believed to,” and while people are entitled to believe whatever they want, some of these things are also taken as fact within our profession. 

When I was in college, this was often touted as the main reason people have low back pain. 

The muscle’s biomechanics showed us how a tight psoas was creating an increased lumbar lordosis when it was in a “shortened” position in everyone from office workers to cyclists. 

But what does the updated research say? Well…let’s get into that!

Biomechanics

First, it’s probably important to do a quick review (and yes, I had to look this up). 

It starts on the transverse process of T12-L4 as well as the intervertebral discs and inserts on the lesser trochanter of the femur. 

This research article(1) takes that a bit deeper and shows there are attachments on the anterior part of all lumbar TVP’s and the anteromedial aspect of the lumbar discs and bodies except on the L5/S1 disc. Where it attaches to the TVP’s is considered the posterior attachments, whereas the disc and bodies’ connections are considered the anterior attachments. There was an argument that those anterior attachments would pull the lumbar spine into and increased lordosis, but that  was with an assumption the attachments were more on the anterior surface of the vertebral body, not the TVP. 

When I was in school (and granted that was quite a while ago), we were taught that Psoas was primarily a hip flexor that worked along with Iliacus to accomplish the movement. However, some more recent studies(1) have shown it plays some other roles, including: 

  • advancing the lower limb while walking
  • controlling deviation of the trunk while sitting
  • some action with rotation, abduction, and adduction of the hip
  • lumbar spine stabilization
  • hip stabilizer

Interestingly, the study (1) looked at how the Psoas influenced hip pain in a hockey player, but not much discussion around low back pain. 

So, is the Psoas a culprit for patients presenting with low back pain?

Size And Role

A couple of studies looked at Psoas under MRI to compare cross-sectional size between those with low back pain and those without, and the results are pretty to interesting. 

They found those patients dealing with low back pain had a larger Psoas Major than those without pain. (2)

One possible reason for this is that Psoas is a lumbar spine stabilizer; the muscle’s hypertrophy was due to increased activity in those with some degenerative disorders in the lumbar spine, so it’s working as a support or protection for the area. (2)

When they looked at fat infiltration and whether it plays a role, there was a correlation with some atrophy of the lumbar paraspinal muscles, which would cause Psoas to increase its activity as a stabilizer for the lumbar spine. However, there was minimal infiltration of fatty tissue within Psoas. 

One other study looked at how Psoas was affected in older generations and did show there was a difference in size between men and women, which is likely due to hormone deficiencies after menopause. (3)

When there were degenerative changes with the lumbar discs or segmental instability in the spine, they noticed that Psoas actually got smaller. However, this is likely because more pain is associated with these degenerative changes, so the size change is because of disuse. This could also directly correlate to fear avoidance, where a person stops certain activities because they’re worried about reinjuring the area or making it worse, especially after getting what sounds like a scary diagnosis. 

To me this is a little bit of a chicken or the egg. Could Psoas be causing pain, or is it’s size adapting because of pain resulting from something else? I’d argue it’s the latter.

So now we understand that Psoas is more of a support to the lumbar spine rather than something that is pulling it into lordosis or causing pain; the question remains…do we treat it?

Well, there’s a lot of controversy around this, and I’d say it depends.

Although I know if I do a treatment in this area in the way I was shown in school, I can definitely feel the psoas “pop up” under my fingers. However, we also know there is A LOT of stuff in the way to be able to palpate something that deep. Because in reality, we can’t palpate something that deep even though we can feel it “pop up”. 

I have a person who comes in once a month for treatment and really enjoys getting their Psoas worked on. They feel it benefits them greatly for the activities they participate in. So, yeah, I’ll treat it for them. However, if this was a new person coming in and saying their back pain is a result of the Psoas, well then I’d be digging a bit deeper into their reasoning and having more of a conversation to educate them on how Psoas is probably helping more than it is causing an issue. It’s one of those things where our clinical experience and decision making have to come in to play. Some say we should never treat the area but we also have to take patient preference into account and what they believe will help them. If you’ve been treating the area and having reasonable success and your patients like it, then keep on keeping on. But change the narrative around it. Take the time to educate a little and see if it’s really necessary. Especially if you’ve been giving this kind of treatment and the person is uncomfortable during the treatment (let’s be honest, it’s a pretty sensitive area), then offer to change things up and try something different. Just make it a joint decision between the two of you and strengthen that therapeutic relationship. 

If you haven’t subscribed yet, check out our new podcast HERE, we’ll be discussing Psoas this week and discussing some of the research around it. 

References

  1. Sajko S, Stuber K. Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications. The Journal of the Canadian Chiropractic Association. 2009 Dec;53(4):311.
  2. Arbanas J, Pavlovic I, Marijancic V, Vlahovic H, Starcevic-Klasan G, Peharec S, Bajek S, Miletic D, Malnar D. MRI features of the psoas major muscle in patients with low back pain. European spine journal. 2013 Sep;22(9):1965-71.
  3. Sions JM, Elliott JM, Pohlig RT, Hicks GE. Trunk muscle characteristics of the multifidi, erector spinae, Psoas, and quadratus lumborum in older adults with and without chronic low back pain. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):173-9.

Posture, Babies, And Bathwater

Posture is a controversial topic. It’s relevance for pain has been properly questioned by fans of “pain science,” biomechanically-minded crowd has worried that a baby is getting thrown out with the bathwater. In previous posts I’ve written about the very dirty bathwater that does indeed need to be thrown out. In this post I’ll provide a few thoughts on taking care of the baby (assuming there is one under the dirty water.)

Extensive research shows that objective measures of postural alignment correlate very poorly, if at all, with pain. But this doesn’t mean that posture is irrelevant to health and especially performance. Posture is a fundamental part of coordinated movement, one of the first skills that a baby learns. We need a well-organized trunk and neck to see the world, coordinate movements of the arms and legs, protect vital structures from injury, and maintain balance. We can barely do anything without a minimum level of postural skill, and that skill must elevate to an elite level if we want elite level athletic performance.

In the context of pain, common experience makes clear that posture is sometimes a dominant cause. For example, I have noticed that standing in the same place for long periods of time at a cocktail party or museum will sometimes make my lower back stiff. It feels better almost immediately when I sit for a few minutes. A slumped position works best, and is also my most comfortable way to rest over long periods of sitting. I have clients with literally the exact opposite set of preferences, which is why they use a standing desk at work and lumbar supports while sitting..

Nothing about these anecdotes is inconsistent with the research on posture and pain, which does not imply that people are equally comfortable in all positions, or that they don’t benefit from tinkering around with different options. Adjusting your posture to be more comfortable is not rocket science, and most people will do it unconsciously. But our natural tendency to self-organize can get stuck in a bad groove if we don’t give our bodies the feedback it needs, in the form of variable postural challenges. And we can really get stuck if we decide that certain postures that feel natural are wrong and to be avoided. Consciously trying to mold posture to some assumed ideal is probably a bad idea, as it tends to encourage stiffness..

So how do you get unstuck from a bad postural groove and make progress? One way is to play with the different constraints around which your posture tends to self-organize. I’ll review five: coordination, strength, mobility, social context, environment, and pain.

Coordination

There are many common exercise methods that focus on training postural skills. For example, yoga, Pilates, or tai chi develop are very much about maintaining a specific postural alignment in a variety of functional contexts. Do you need that specific alignment to be functional and healthy? Probably not. But trying to maintain it under variable conditions is a way to build coordination.

Locomotive activities all challenge the ability to coordinate alignment of the spine with movements of the arms and legs. Therefore, improving your performance in activities like crawling, walking, running, climbing and swimming are likely to improve your posture as well.

Postural skill is also about helping to maintain balance, and therefore we might expect it to be improved through activities that challenge balance, like gymnastics, dance or skateboarding.

Strength

It’s hard to hold a safe and functional posture when lifting a heavy weight, running a distance at a brisk pace, or performing a powerful throw. You need strength to resist the forces pulling you out of alignment. Like Yoga or pilates, “good form” in most weight training exercises is usually about maintaining a long spine. Once again, the neutral spinal position is not absolutely necessary for safe and functional lifting, but the effort to maintain it is a challenge that may create beneficial adaptations.

It should be noted that any postural skills built lifting may be specific to context. Fitness and strength are not likely to be limiting factors for organizing posture in everyday activities, which require surprisingly little core strength.

Mobility

Another potential constraint on posture is mobility. For example, you need pretty good range of motion in the hips to sit upright on the ground with the legs extended, or even crossed. If you don’t, the hamstrings or glutei will pull your pelvis into a backwards tilt, and you will therefore need to round your back to keep your head level. If you improved your hip mobility, your sitting posture would immediately reorganize to make your trunk more vertical, perhaps improving comfort and efficiency. But this change would probably be specific to sitting with extended legs and might not affect other postures.

Social Factors

Posture has a psychosocial dimension. Body language sends social signals about mood and confidence. Teenagers may slouch to look cool. Some people suck in their stomachs to flatten their belly, lift the chest to show dominance, or collapse it to be submissive. On vacation, body language might change to reflect a more relaxed and comfortable mind. I have noticed that my back gets tired after a formal social function where I have to wear a coat and tie. Something about the occasion inhibits my natural movement and literally makes me feel stiff.

Environment

Attention and environment regulate posture. One of the reasons you tend to slouch when you look at a computer screen is that it helps you get closer to the object of your attention. If you direct your attention to the wide world around you, to objects both far, near, up, down, left, right and even behind you, your head will naturally move into a more upright position. Next time you are hiking, imagine you are in untamed wilderness, and need to be aware of potential threats coming from 360 degrees. You will notice a spontaneous change in the organization of your trunk and neck.

Pain

Pain can be a major constraint on posture. We instinctively move away from positions that hurt us. Many people who have their backs “go out” will find to their surprise they have spontaneously adopted a very crooked posture. The postural system immediately reorganizes to protect a tender area. Any time you can get something stop hurting, you open up a new set of possibilities for postural alignment.

In summary, anything you can do to improve your general physical function might also improve your postural organization. Not in the sense of looking more vertical, but in the sense of having a body that is a more functional and comfortable place to live.


The preceding was an adapted excerpt from my new book Playing With Movement: How to Explore the Many Dimensions of Performance and Health, now available on Amazon and Barnes and Noble.

Articles of the Week – January 17, 2021

It’s out of scope for many of us in our professions and jurisdictions to recommend medications. However, it’s important to retain knowledge about the effects of drugs, especially extremely common NSAIDs, on musculoskeletal injuries in our clients.

What Every Physiotherapist Needs to Know about NSAIDs and Musculoskeletal Injuries – Claire Knott

 

A physiotherapists documents her experience of witnessing racism in the workplace. This acts as an important reminder to not just avoid passing judgment on our clients but to also be aware of the past experiences they may have had elsewhere due to marginalization.

I Didn’t Say Anything: An Essay on Implicit Bias, Emergency Room PT, and My Biggest Regret – Dr. Yusra Iftikhar

 

As manual practitioners, we all know that physical touch is a beneficial thing to health. It’s great to be able to define what those are.

The sophisticated language of touch  – Timothy Cocks

 

A summary of research that shows some detrimental effects from children’s TV programming that may be emphasizing many unhealthy attitudes and perceptions of pain in our youth. The takeaway from this should be contemplation on what we can do to mitigate this and educate our kids about pain in a healthy way.

Kids’ TV teaching children wrong lessons about pain: new study – Andy Dunne

 

We’re not here to debate about vaccines right now. However, one interesting study was able to directly demonstrate that the simple act of smiling (and to a lesser extent, frowning) helped to reduce the perception of injection pain. A great example of how expression, especially positive expression, can help our health.

Grin and Bear It: Why Smiling Makes Vaccine Shots Less Painful – Pat Anson

Beliefs, Communication, And How This Impacts Our Patients

I’m sure I’m not alone when I say I’ve seen some horrific things in my practice.

Now, when I say this, it’s not in the sense of major catastrophic injuries, or gory blood scenes, or something like that.

What I’m referring to is what I’ve seen and heard from patients as a result of what another well-meaning practitioner said to them. 

A patient comes in, sits down, and starts crying because another therapist told them they will never get better.

Another person who has been dealing with chronic pain for several years comes in and equates the pain they’re feeling in their back to a “rib being out”, or “their S.I. Joint is out again”.

And in the more extreme ranges someone giving up a career they love, in exchange for a job they hate because two people told them they would never be able to do their job again because of the surgery they just went through. In fact, told them if they continued doing the job they loved (and were very successful at), the surgery they just had would pale in comparison to the one they would need.

While I know none of these practitioners would intentionally have someone change their job, believe they won’t get better, or would constantly relate pain many years later to a simple biomechanical diagnosis, the reality is, their words changed people’s lives. 

And not for the better!

So, why then does this happen? Why are these enduring effects of words having such a dramatic impact on patients? And, more importantly, how do we stop this?

When Well-Meaning Beliefs Go Wrong

When we say “well-meaning” practitioners I do believe it’s just that. I doubt there are many out there legitimately trying to say harmful things to their patients (although I do believe there are some who use less than scrupulous language as part of the rebooking process).

So, when we have these well-meaning professionals saying things to patients, part of why they are saying the things they are is because they truly believe it (even if modern research refutes it). Part of the issue is when these belief systems are passed on to our patients it can have a lasting effect in a negative way. 

Unfortunately, many of these belief systems can come from continuing education courses that haven’t been updated in years and are still preaching these outdated belief systems.

A great systematic review (1) looked at several medical and paramedical professions to look at how their belief systems, (including biomedical and biopsychosocial treatment, fear-avoidance beliefs, and attitudes) affected patient behaviours.

There were several things that stood out to me reading through this(1):

  1. High levels of fear-avoidance in practitioners are related to the same fear-avoidance in patients.
  2. Practitioner beliefs are associated with the education they give patients.
  3. Practitioners with a more biomechanical base are more likely to advise acute pain patients to limit work and physical activity.
  4. Those with high fear-avoidance beliefs are more likely to recommend bed rest (which we know is not good for low back pain) and are also more likely to recommend this if seen in a media campaign.

Now I realize it probably sounds like we’re bashing anything related to biomechanical explanations here but honestly we’re not.

As we have said so many times over the years, biomechanics are still important, it’s just one piece of the puzzle. What I’m taking from this review is that if we’re strictly relying on biomechanical explanations we’re more likely to also cling to fear-avoidance beliefs as well, which isn’t doing our patients any good.

Part of the problem here is that if a practitioner has these beliefs, they get passed on to the patients we see. One of the major issues with this (as pointed out in the review)(1) is these beliefs result in persistent disability but not necessarily a change in pain.

So, if these beliefs are held, the patient’s pain won’t always change, but there is an increase in disability. Imagine your patients coming in for care and strictly because of a belief system, not only does their pain not get any better, but they become more limited in the things they can do. 

In light of all this information, I look back and think about early in my career and how I was saying very similar things to my patients. There comes a time when we have to sit back and ask ourselves whether the information we are conveying is correct, but also, is it in their best interest?

This review showed that even though some health care professionals believed in the biopsychosocial framework (it was originally introduced over 40 years ago), they were still operating from a biomedical orientation. In the case of doctors, they understood how important psychosocial factors can be yet, they lack the time to properly integrate this into practice.

So, while I look back on my career and cringe at some of the things I used to say, I look at this information and see how beneficial this is for us as Massage Therapists. If we embrace new research and change our beliefs, we not only have the time to spend with our patients, we have the opportunity to create lasting change for what they are going through. 

Words Matter!

So, now that we understand the influence of both the patient and therapist beliefs, the question remains, where did these beliefs come from?

Quite often these beliefs are because of lived experience, observing others in pain, or things that have been told to them throughout their life. A big influence was just not having a framework or a reference of what they should do when experiencing pain.(2)

All too often we see patients going to Dr. Google for advice, however, while this is usually looked at cautiously, people do place higher importance on the advice of friends and family.(2) While people would often seek out care from a health care professional, they would sometimes reject the advice given as they questioned their competence, and would even keep their own beliefs if it conflicted with the advice of a professional.

Now, this isn’t necessarily a bad thing because there’s nothing wrong with a patient using their own intuition to choose what course of action is best for them. It’s important for patients to feel confident in the information being presented to them, in fact, it’s even possible for their symptoms to be influenced by their interpretation of the education they are given.(2)

However, even if we believe we are giving them a very simple explanation of what is happening, there can be an enduring impact. I can now hear my mother’s voice resonating from my childhood and what she would say every time my brother and I would fight: “it’s not what you say, it’s how you say it!”

This paper has several examples of the lasting effect of what we say, which I think are important to highlight.

When a doctor gave a simple diagnosis of a sprain in an attempt to decrease the seriousness of the injury, the patient understood this to mean they had moved in such a way they had strained the muscle and they would make it worse by continuing to move the same way.

In the case of a person getting help from an orthopedic specialist, the result was well…horrific:

[The orthopedic specialist] looked at my back MRIs for a little while and turned around with a grin on his face and said, “You’re a builder, aren’t you?” and I said, “Yes,” and he said, “You’re [expletive], ha ha ha,” and went back to his computer again…. So, you know, I think that was his rather odd specialist way of breaking the news to me that I wouldn’t be working as a builder for very long…. Every time I felt a little bit wrong [after that], I started to sort of add it up in my head. And then my usual way of thinking, “Oh, that’s fine, that’s nothing, that’ll go away, that’s not major enough to stop me working, I’ll carry on [changed]”…him saying that was definitely the point, because I probably would have just carried on(2)

This person actually ended up changing careers as a result of what was said to them! Sadly as I mentioned, I’ve seen the same result in practice as well.

Another example that stood out to me in the same paper was equally as life-altering:

Basically all I’ve kind of been told to do by physios is to work on my core…I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak…. I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it…carrying it, and having extra weight on my stomach(2)

Can you imagine what this woman went through dealing with this?

Again, I’m sure these were well-meaning practitioners but when our communication is focused more on the things we can’t do as opposed to the things we should do can have compounding long-term effects. If we shift this line of thinking and encourage movement, provide reassurance, and show people how they are safe to remain active it can (and most likely will) have the reverse effect of the quoted stories we shared.

While many practitioners have a belief in the biopsychosocial model, many are still using biomechanical explanations of tissue damage, etc in an attempt to help their patients. As we have seen this can be detrimental to the patients well being. So it’s important to have a discussion around how to change these beliefs in practitioners. Many of us went through college and learned these things (I know I learned many of these explanations in school) and unfortunately, there are many continuing education courses still offering these kinds of explanations. This becomes our responsibility as a profession to change this, and really it starts with each one of us. It doesn’t even mean you have to spend thousands on new courses, it can mean just reading blogs like this, or a new research paper a week (it doesn’t take that long I promise), because we must change our beliefs in order to have a better impact on the people we are seeing in practice. When our beliefs (and our messaging) start to change we can slowly change our patient’s beliefs for better outcomes. Then, hopefully…hopefully, patients feel safe to return to their careers or have babies, or just return to an activity they love.

 

References

  1. Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. European Journal of Pain. 2012 Jan;16(1):3-1
  2. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine. 2013 Nov 1;11(6):527-3

Have We Ballsed Up The Biopsychosocial Model?

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.