Using the BPS model in clinical practice – Part 2

Hi all, after a pretty good response from part 1 here’s the follow-up to the naked tales of a studying physio – using the BPS model in clinical practice. I want to say thanks for the feedback for part 1, but more critical analysis is desirable. I mean I can’t imagine i’m that good a writer that all of you who did read it thought “nope, there’s nothing I would have added”. Perhaps part 2 will make you think otherwise?

 

Following on from the assessment I frequently see the same patient for follow-up sessions.  An hourly session twice a week for anything up to 12 weeks is typical. The MDT approach to the pain programmes is to provide people with better coping strategies to live well with pain. There are many instances that promote a return to the workforce through the adjoining return to work programmes provided by ACC.

Patient population

The majority of my patient referrals are Caucasian, often middle-aged, with a slightly higher prevalence of females to males, and have endured pain for long periods or have had minimal resolution of their symptoms. Back pain tends to have the highest referral rate and is more common in females, which is consistent with the literature (Hoy et al., 2014; Hoy et al., 2012; Schneider, Randoll, & Buchner, 2006; Vos et al., 2012). A study by Hoy et al (2012) identified that females between the ages of 40 and 80 globally had a higher prevalence of back pain. This raises an interesting socio-cultural question. Why do males tend to report less back pain than women? Studies suggest (Hunt, Adamson, Hewitt, & Nazareth, 2011; Schneider et al., 2006) that despite relationships between back pain and co-morbidities such as obesity it is difficult to determine what may be a causal link. Interestingly, the studies highlight stoicism as a factor that men are more likely to “tough it out” rather than seek help.

Domains to be assessed

Using a reasoning process is fundamental to the process of determining an appropriate application of care. It is through use of a biopsychosocial methodology that I clinically reason if a patient requires physiotherapy care at the time of assessment. I attempt to assess each component of the BPS model as I find having a broader understanding of the individual supports my critical thinking skills and allows me to dig more deeply into the many factors that influence a pain experience (Engel, 1980; Louw, Diener, Butler, & Puentedura, 2011; Nijs et al., 2013).

Biological

It is necessary to determine what potential biological sources contribute to a persistent pain state. Persistent pain, perhaps unintentionally, in more recent years has developed a stigma as either being ‘in the brain’, or that nociception and pain are not the same (Moseley & Butler, 2015). Respectfully, it is plausible that biological factors can be misinterpreted by clinicians, for example, mistaking that once tissue healing has elapsed pain that remains is a psychological state.

This is not that case. As we age, we continue a biological process and physical changes occur. Therefore, it is necessary to screen for physical risk factors or ‘red flags’ during the interview process to eliminate or identify those factors that may warrant an onward emergency referral.

I want to add here that red flags are important to rule out, yet it is also important to note that the evidence suggests that only 1 to 2% of people presenting with LBP will have a serious or systemic disorder (Henschke et al., 2009; Downie et al., 2013). The best predictors of fracture are the presence or cluster of a history of severe traumatic injury, the presence of abrasions or contusions (bruises), prior to corticosteroid use and being a woman over 74 years of age (Downie et al., 2013).

Once sinister pathology has been ruled out, it is important to consider there may still be a peripheral drive that compounds a persistent pain state, such as a nociceptive driver, or neuropathic pain (Bruehl, 2010; Van Wilgen & Keizer, 2012) or arthritic joint disease (Thakur, Dickenson, & Baron, 2014). Assessment would be based upon appropriate screening and if indicated referral to the appropriate secondary care provider. This may include nerve conduction test, blood tests or diagnostic imaging.

Psychosocial

It is important to have an understanding of barriers that may have a compounding effect on a persistent pain state. If pain is deemed an emergent process of complex interactions between the self and environment we inhabit (Thacker, 2015), it is necessary to look beyond the state of the tissues. The yellow flag system (Kendall, N. A, Linton, S.J, Main, 2004) is a validated screening tool to identify psychosocial risk factors or barriers that could result in long-term disability and work loss.

Yellow flags can be sub-grouped into:

• Attitude and beliefs
• Behaviours
• Compensation
• Diagnosis and treatment
• Emotions
• Family
• Work

In addition to screening for sinister pathology, I consider three aspects of the clinical interview as fundamental to my practice. This includes the individual’s perception of what they believe the cause of their problem is, what concerns they have about the ongoing problem and the future, and finally their expectations of physiotherapy, their injury and the future. These questions allow me to cover yellow flags in an indirect manner, whilst being able to understand the individual’s story.

Method and Process of Assessment

Thoroughly covering the domains of the biopsychosocial framework provides an opportunity to establish a more comprehensive clinical picture of the individual, as opposed to considering the pathology in isolation as the biomedical framework is more suited to.

My assessment is pragmatically based upon observing and testing how the individual moves in order to confirm my hypothetical thinking ascertained from the clinical history. Baseline scores either through use of measurement tools (i.e. sensorimotor two-point discrimination, goniometer, tape measure or functional testing) pertinent to established goals are important to give an objective measure of movement and tolerance. The pain scale, which I still use, is a popular assessment tool but can cause much frustration for patients as they are often unable to provide a definitive score because of the subjective nature of the scale. In addition, it is becoming more widely accepted that having no pain is not the goal (Lee, 2016).

In recent years the use of Photograph of Daily Activities (PHODA) has shown promise in providing an alternative means of measuring perceived harmfulness of activity  (Leeuw et al., 2007). It was originally developed to help people living with pain identify a hierarchy of activities that maybe avoided. Beginning with mild discomfort it would progress to activities that would be beyond the person’s current abilities (Kugler et al, 1999). The only issue here is the sheer volume of pictures (100 in total) and the lack of contextual specificity of the images.

During assessment I observe for specific behaviours such as breath holding, tensing, grimacing, movement behaviours to determine the habits that an individual has adopted, that are either associated with or related to movement. The observation of movement may lead to questions of a motivational interviewing nature such as, “That movement looks really difficult for you, what does it feel like when you perform the movement?” This may be followed by “What do you think might happen?” A challenging question for the individual may be “What would make you feel more comfortable about doing this movement?”

Finally, a screening questionnaire(s) aims to ascertain an overall picture of the perception of movement and also the level of disability experienced by the individual.  Common outcome measures would include the Pain Disability Index (Pollard, 1984; Tait, C.R. Pollard, C.A. Margolis, R.B. Duckro, P.N. Krause, 1987), the Orebro musculoskeletal pain questionnaire short form (Linton, Nicholas, & MacDonald, 2011). If specific factors such as catastrophizing or fear avoidance were identified during the history taking, I may consider outcome measures such as the Pain Catastrophizing Scale (Sullivan, Bishop, & Pivik, 1995) or Tampa Scale of Kinesophobia (Vlaeyen, Kole-Snijders, Boeren, & van Eek, 1995). (See Appendix 2 for Outcome measures).

Use of Assessment

The assessment helps to guide my course of treatment and identify barriers that may surface along the course of the individual’s rehabilitation plan. I adopt a continual assessment process, allowing an ongoing reflection of the overall progress of the rehabilitation program and assessment of when appropriate changes can be made. Moreover, it provides progressive objective markers to show the person living with pain their continual improvement in mobility, independence and internal locus of control. I note here that (previously stated) that zero pain is not the goal and that the focus is on movement improvement not pain elimination so to speak. I advocate a living well with pain approach and it is important to gain the trust and co-operation of the person living with pain to buy in to this approach.

Conclusion

The degree to which a patient believes that they are disabled by their pain is a powerful factor in the extent of their physiological impairment, and links have been demonstrated in cross-sectional studies between individuals who have long term pain and the presence of psychological tendencies such as catastrophizing, depression, anxiety disorders, hyper-vigilance, avoidance behaviours, and the belief that pain signifies harm (Walsh and Radcliffe 2002, Linton 2000, Linton and Boersma 2003). Thus, it is important to understand that a multidimensional problem such as pain requires a multidimensional approach. When members of an MDT have a shared knowledge and work ethic surrounding the BPS model, this facilitates an integrated approach that involves the patient throughout the pain management programme.

 

Thanks for having a read. As always your comments are welcome.

 

TNP

 

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