Using the BPS model in clinical practice – Part 1

Hi all here’s another instalment of the naked tales of a studying physio. Part 1 of my first assignment from my postgraduate studies. I’ve decided to share it with all my readers as I want your thoughts and opinions on this. The more we engage in collaborative communication and sharing of knowledge the better we can provide care and support personal growth.

 

Abstract

In persistent pain, it can be concluded that the clinical picture does not fully match the pathophysiological presentation of the tissues (Louw & Puentedura, 2013). While it is commonly understood that acute pain likely has more tissue involvement than persistent pain, Gifford (2014) states that all pain problems, acute or chronic, have a reasoning, thinking and emotional brain attached to them. This is supported by the International Association for the Study of Pain’s (Merskey & Bogduk, 1994) definition that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

A contemporary paradigm shift is required, therefore, in the understanding of pain from biomedical to biopsychosocial (BPS). However, this carries many personal and professional challenges for both people living with pain and clinicians (Stewart, 2015).

This assignment outlines the clinical challenges and experiences faced in my everyday practice and how I integrate the use of a biopsychosocial approach to facilitate my clinical practice.

 

Introduction

Originally, my clinical practice utilised the assessment format I was taught at undergraduate level. This assessment was based on the Maitland biomedical structure to ascertain a clinical picture of an individual’s presenting complaint. There was a strong emphasis on how pathology affected the individual, relative to the body part and pain associated with it. Assessment included identifying the behaviour of the symptoms, aggravating and easing factors, and identifying the severity, irritability and nature of the complaint (Hengeveld & Banks K, 2005). This method is still commonly used by physiotherapists and where it may hold some credence in the use of diagnosis formulation, it does not consider the contextual factors that also make up a pain experience.

In persistent pain, it can be concluded that the clinical picture does not fully match the pathophysiological presentation of the tissues (Louw & Puentedura, 2013). While it is commonly understood that acute pain likely has more tissue involvement than persistent pain, Gifford (2014) states ‘that all pain problems, acute or chronic, have a reasoning, thinking and emotional brain attached to them.’ This is supported by the International Association for the Study of Pain’s definition that ‘pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ (Merskey & Bogduk, 1994).

A contemporary paradigm shift is required, therefore, in the understanding of pain from biomedical to biopsychosocial (BPS). However, this carries many personal and professional challenges for both people living with pain and clinicians (Stewart, 2015).

Originally proposed by Engel (1980) it has taken many years for the BPS model to become fully recognised. Louw & Puentedura (2013) state, ‘The model encompasses three key aspects: the biological (anatomy and physiology, pathophysiology), the psychological (thoughts, emotions and behaviours), and the social (work, culture, relationships).’  These aspects play a significant role in a person’s pain experiences. Waddell’s BPS model (Fig. 1) accounted for psychological research in chronic pain, which include the effect of disability and the socioeconomic environment that previous models had not (Waddell, 1992; Loeser & Melzack, 1999).

Waddell's BPS model
Figure 1. Waddell’s adaptation of the biopsychosocial model

 

Combined with Melzack’s neuromatrix theory (Fig. 2) it can support the clinician in thinking critically about the multi-dimensional construct of the pain experience (Melzack, 2001). There have been adaptations of Waddell’s model such as the work of Butler & Moseley (2003) and these models have helped as a framework to support my clinical reasoning.

The models come with their own level of complexity, in that they demand the clinician to broaden their knowledge and skills and cross boundaries into other fields that may be perceived as beyond their scope of practice (Nijs, Roussel, van Wilgen, Koke, & Smeets, 2013).

Body Self Neuromatrix
Figure 1. Melzack’s Body-Self Neuromatrix

 

A study by Synnott et al (2015) identified that clinicians may feel underprepared to treat some elements of a BPS nature that contribute to persistent pain problems, and thus may stigmatise patients who present with these factors. Therefore, patient centred, integrated services that provide adequate support networks through the work of multidisciplinary teams will facilitate better models of care. Furthermore, studies have shown that multidisciplinary approaches provide better outcomes than a single discipline approach (O’Keeffe et al., 2015)

A recent systematic review by Kamper et al (2015) has shown that, based on the largest collection of trials and participants reviewed to date, there are robust positive effects of multidisciplinary biopsychosocial rehabilitation programs. Patients participating in these programs are more likely to gain small, long term benefits in improved pain and disability compared with usual care or physical treatments.

Clinical setting

My clinical work is based within private practice. The majority of my caseload consists of patients referred by the pain management services arm of the Accident Compensation Corporation (ACC). I am a pain physiotherapist as part of a multidisciplinary team (MDT) carrying out pain programmes. My patient caseload is primarily musculoskeletal pain either following injury or post-operatively. Most patients that present to me have gone beyond the normal tissue healing timeframes (Watson, 2006)  and have either failed to return to work or continue to experience long term pain following the injury.

The pain management programs require the clinical expertise of an MDT, commonly between a medical specialist and allied health professionals such as Physiotherapists or Occupational Therapists and a Psychologist. I have faced a number of issues with this approach. The most apparent is the individual appointments that the patient has to attend in order to ascertain a clinical justification for care. This method, according to the literature, can involve a number of barriers including lack of MDT cohesion (Ratcheva, 2009), patients and clinicians appearing to define terms differently, and misunderstandings amongst health professionals as a result of differing access to background knowledge, personal views, and experience (Barker, Reid, & Minns Lowe, 2009).

Well done you got through a thousand words! I’ll leave it there for now and follow-up with part 2 in a weeks time. Following on from that I’ll add a short reflection of my thoughts on my assignment. Of course as always I welcome any comments or red pen marks, gold stars, lollipops etc.

Thanks for having a read

TNP

 

References to Part 1 and 2

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