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.

IMG_0151CfpxMnzUkAATtvc.jpg-large

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).

pain_rating

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.

Courtesy of Mike Stewart
Courtesy of Mike Stewart

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

 

References part 1 & 2

Barker, K. L., Reid, M., & Minns Lowe, C. J. (2009). Divided by a lack of common language? A qualitative study exploring the use of language by health professionals treating back pain. BMC Musculoskeletal Disorders, 10, 123. http://doi.org/10.1186/1471-2474-10-123

Bruehl, S. (2010). An update on the pathophysiology of complex regional pain syndrome. Anesthesiology, 113(3), 713–725. http://doi.org/10.1097/ALN.0b013e3181e3db38

Darlow, B., Perry, M., Stanley, J., Mathieson, F., Melloh, M., Baxter, G. D., & Dowell, A. (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. BMJ Open, 4(5), e004725–e004725. http://doi.org/10.1136/bmjopen-2013-004725

Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W. J. G., de Vet, H. C. W., … Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical Research Ed.), 347(January), f7095. http://doi.org/10.1136/bmj.f7095

Eccleston, C., & Crombez, G. (2007). Worry and chronic pain : A misdirected problem solving model. Pain, 132(3), 233–236. http://doi.org/10.1016/j.pain.2007.09.014

Engel, G. L. (1980). The clinical application of the biopsychosocial model. The American Journal of Psychiatry, 137(5), 535–544. http://doi.org/10.1176/ajp.137.5.535

Gifford, L. (2014). Aches and Pains. CNS Press. Aches & Pains Ltd. United Kingdom.

Hengeveld, E., & Banks, K. (2005). Maitland’s Peripheral Manipulation. 4th ed. Elsevier: London.

Henschke, N., Maher, C. G., Refshauge, K. M., Herbert, R. D., Cumming, R. G., Bleasel, J., … McAuley, J. H. (2009). Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis and Rheumatism, 60(10), 3072–3080. http://doi.org/10.1002/art.24853

Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., … Buchbinder, R. (2012). A systematic review of the global prevalence of low back pain. Arthritis and Rheumatism, 64(6), 2028–2037. http://doi.org/10.1002/art.34347

Hoy, D., March, L., Brooks, P., Blyth, F., Woolf, A., Bain, C., … Buchbinder, R. (2014). The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases, 73(6), 968–974. http://doi.org/10.1136/annrheumdis-2013-204428

Hunt, K., Adamson, J., Hewitt, C., & Nazareth, I. (2011). Do women consult more than men? A review of gender and consultation for back pain and headache. Journal of Health Services Research & Policy, 16(2), 108–17. http://doi.org/10.1258/jhsrp.2010.009131

Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J. E. M., Ostelo, R. W. J. G., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ (Clinical Research Ed.), 350(February), h444. http://doi.org/10.1136/bmj.h444

Kendall, N. A, Linton, S.J, Main, C. J. (2004). New Zealand Acute Low Back Pain Guide. New Zealand Guidelines Group.

Lee, T. H. (2016). Zero Pain Is Not the Goal, 1–2. http://doi.org/10.1001/jama.2016.1464.2

Linton, S. J., Nicholas, M., & MacDonald, S. (2011). Development of a Short Form of the Örebro Musculoskeletal Pain Screening Questionnaire. Spine, 36(22), 1891–1895. http://doi.org/10.1097/BRS.0b013e3181f8f775

Linton S. J, Boersma K, (2003). Early identification of patients at risk of developing a persistent back problem: The predictive validity of the Orebro Musculoskeletal Pain Questionnaire. Clinical Journal of Pain, 19:80-86.

Linton S. J., (2000). A review of psychological risk factors in back and neck pain. Spine, 25:1148-1156.

Loeser, J. D., & Melzack, R. (1999). Pain: an overview. The Lancet (London, England), 353(9164), 1607–9. http://doi.org/10.1016/S0140-6736(99)01311-2

Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), 2041–2056. http://doi.org/10.1016/j.apmr.2011.07.198

Louw, A., & Puentedura, E. J. (2013) Therapeutic Neuroscience Education. Teaching Patients about Pain. International Spain and Pain Institute. OPTP. USA

Main, C. J., Foster, N., & Buchbinder, R. (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice and Research: Clinical Rheumatology, 24(2), 205–217. http://doi.org/10.1016/j.berh.2009.12.012

Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378–1382.

Merskey, H., & Bogduk, N. (1994). IASP Task Force on Taxonomy Part III: Pain Terms, A Current List with Definitions and Notes on Usage. IASP Task Force on Taxonomy, 209–214. http://doi.org/http://dx.doi.org/10.1016/0304-3959(86)90113-2

Miles, C. L., Pincus, T., Carnes, D., Homer, K. E., Taylor, S. J. C., Bremner, S. A., … Underwood, M. (2011). Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs. European Journal of Pain, 15(8), 775.e1–775.e11. http://doi.org/10.1016/j.ejpain.2011.01.016

Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain, 16(9), 807–813. http://doi.org/10.1016/j.jpain.2015.05.005

Nijs, J., Roussel, N., van Wilgen, P. C., Koke, A., & Smeets, R. (2013). Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy, 18(2), 96–102. http://doi.org/10.1016/j.math.2012.11.001

O’Keeffe, M., Purtill, H., O’Sullivan, P., Dankaerts, W., Conneely, M., Hurley, J., … O’Sullivan, K. (2015). Comparative effectiveness of active interventions for non-specific chronic spinal pain: Physical, behavioural or combined? A systematic review and meta-analysis. Physiotherapy (United Kingdom), 101, eS1131–eS1132. http://doi.org/10.1016/j.jpain.2016.01.473

Pollard, C. a. (1984). Preliminary validity study of the pain disability index. Percept Mot Skills, 59(3), 974. http://doi.org/10.2466/pms.1984.59.3.974

Ratcheva, V. (2009). Integrating diverse knowledge through boundary spanning processes – The case of multidisciplinary project teams. International Journal of Project Management, 27(3), 206–215rat. http://doi.org/10.1016/j.ijproman.2008.02.008

Schneider, S., Randoll, D., & Buchner, M. (2006). Why Do Women Have Back Pain More Than Men? The Clinical Journal of Pain, 22(8), 738–747. http://doi.org/10.1097/01.ajp.0000210920.03289.93

Stewart, M. (2015). The assumption dilemma : do healthcare professionals have the teaching skills to meet the demands of therapeutic neuroscience education ?, 13(1), 40–42.

Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation, 7(4), 524–532. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-0029584617&partnerID=40&md5=7f8615d1b52cbabde152c2e9b9683fff

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy, 61(2), 68–76. http://doi.org/10.1016/j.jphys.2015.02.016

Tait, C.R. Pollard, C.A. Margolis, R.B. Duckro, P.N. Krause, S. J. (1987). The Pain Disability Index: Psychometric and Validity Data. Archives of Physical Medicine and Rehabilitation.

Thacker, M. (2015). Is pain in the brain? Journal of the Physiotherapy Pain Association, 3. http://doi.org/10.1084/jem.20511iti3

Thakur, M., Dickenson, A. H., & Baron, R. (2014). Osteoarthritis pain: nociceptive or neuropathic? Nature Reviews. Rheumatology, 10(6), 374–80. http://doi.org/10.1038/nrrheum.2014.47

Thomas, E. N., Pers, Y. M., Mercier, G., Cambiere, J. P., Frasson, N., Ster, F., … Blotman, F. (2010). The importance of fear, beliefs, catastrophizing and kinesiophobia in chronic low back pain rehabilitation. Annals of Physical and Rehabilitation Medicine, 53(1), 3–14. http://doi.org/10.1016/j.rehab.2009.11.002

Van Wilgen, C. P., & Keizer, D. (2012). The Sensitization Model to Explain How Chronic Pain Exists Without Tissue Damage. Pain Management Nursing, 13(1), 60–65. http://doi.org/10.1016/j.pmn.2010.03.001

Vlaeyen, J. W. S., Kole-Snijders, A. M. J., Boeren, R. G. B., & van Eek, H. (1995). Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain, 62(3), 363–372. http://doi.org/10.1016/0304-3959(94)00279-N

Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., … Moradi-Lakeh, M. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), 2163–2196. http://doi.org/10.1016/S0140-6736(12)61729-2

Waddell, G. (1992). Biopsychosocial analysis of low back pain. Baillière’s Clinical Rheumatology, 6(3), 523–557. http://doi.org/10.1016/S0950-3579(05)80126-8

Walsh, D. A., & Radcliffe, J. C. (2002). Pain beliefs and perceived physical disability of patients with chronic low back pain. Pain, 97(1-2), 23–31. http://doi.org/10.1016/S0304-3959(01)00426-2

Watson, T. (2006). Tissue Repair: The Current State of the Art, 30–34.

World Health Organization. (2013). How to use the ICF: a practical manual for using the International Classification of Functioning, Disability and Health (ICF), (October), 1–127.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s