Physiotherapy: A Process Based Approach

Physiotherapy has been going through some significant changes in the last 20-30 years. Probably one of the most significant is the paradigm shift from the biomedical to the biopsychosocial (BPS) model. The BPS model shifting the emphasis from tissue pathology to a systems based approach capturing biological, psychological and sociological components.

Despite the argument that it is reductive and has its own limitations (Eriksen, Kerry, Mumford, Lie, & Anjum, 2013), the BPS model has given clinician’s an appreciation for wider contextual factors (personal and environmental) and the reciprocal influence behaviours, sensitivity and neuroplasticity can play in human suffering. In addition, the research base has slowly revealed that the biomedical model has failed to provide adequate explanations for ongoing disability and pain (Stilwell & Harman, 2019).

In particular, 1) the divide between nociception and pain – one being the term given to the transmission of noxious information from the tissue, the other an inherent human experience.

2) Advances in research has shown that pain related disability is more associated with Psychosocial (PS) factors over physical factors in back, knee, shoulder and a host of other conditions (Costa, Maher, McAuley, Hancock, & Smeets, 2011; Menendez, Baker, & Oladeji, 2015; Piva, Fitzgerald, Wisniewski, & Delitto, 2009).

3) The lack of effectiveness of biomedical treatments to address pain and disability and that biomedical reasoning models in isolation are focused more on addressing the disease and less about treating the person (Low, 2017). 

Compounded by the lack of effectiveness biomedical treatments have on treating chronic disease, Low Back Pain being the number one cause of disability worldwide (James et al., 2018), things needed to change.

As mentioned, the BPS model is not the absolute answer. It too has failed to escape criticism either due to categorization of the person into Biological, Psychological and Social categories (Eriksen, Kerry, Mumford, Lie, & Anjum, 2013), or due to the failure of the BPS model unable to capture the combination of subjective description of symptoms and objective observation of them. This has resulted in a similar Cartesian mind/body split as with the biomedical model (Davidsen, Guassora, & Reventlow, 2016). A counter argument postulated by Pincus et al., (2013) is that the model has been misrepresented and until fully adopted in clinical practice and research, can it only then be assessed.

Eriksen et al’s (2013) paper is a particularly interesting read as it highlights the challenges of medical reasoning within the context of disease and “medically unexplained symptoms”. Therefore, due to the increasing rate of chronic disease and disability worldwide,  the lack of theoretical links between mind/body and the lack of effectiveness in treatment outcomes, alternative models of reasoning have been proposed in an attempt to capture a true sense of, “why does this person present in this way at this time?”


Dispositional Philosophy

I admire the Cause Health group that have posited this approach. Dispositional philosophy or Dispositionalism, is a philosophical theory of causation. The theory infers that causality is context-sensitive and the empirical science lacks the ability to capture this component of causality. Hence the failings of the biomedical model and associated reasoning models (Anjum, 2020). Incidentally, what else is contextually sensitive? That’s right, you guessed it. Pain is.

What is Process Based Therapy?

Simply, Process Based Therapy (PBT) is a method to capture evidence-based BPS processes of change that intends to ease suffering and support a person towards a life that is rich and fulfilling (Hayes et al., 2019). PBT asks the question, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?” (Hayes, Hofmann, & Ciarrochi, 2020). In some ways, we can already see how influential context is in PBT.

Mediating factors

In much of the pain research, we read about specific factors mediating relationships between variables and how they are found to impact outcome (Miles et al., 2011). For example, self-efficacy being a mediator between pain intensity, disability and depression (Arnstein, Caudill, Mandle, Norris, & Beasley, 1999; Martinez-Calderon, Zamora-Campos, Navarro-Ledesma, & Luque-Suarez, 2018) or pain catstrophising mediating work disability following acute back pain onset (Besen, Gaines, Linton, & Shaw, 2017) or mediating physical and cognitive treatment in Chronic Low Back Pain (Smeets, Vlaeyen, Kester, & Knottnerus, 2006). Now not being an academic, my interpretation might be a bit off the mark, but what I understand is that a particular mediating factor can  be a generative mechanism on the independent variable influencing the dependent variable of interest (let’s say an outcome).

The problem is that the research tends to focus on one mediating factor and so this is deemed to be linear and unidirectional, see figure 1 (Hofmann, Curtiss, & Hayes, 2020).

Figure.1. Mechanism of mediating factors on variables

If I’m honest, you need to be a bit of an academic to understand the statistics and jargon behind mediational analyses. If I were to summarise it into one word, it would have to be causation – why did what happened, happen?

To sum up

What Dispositionalism and PBT propose is that in order to provide quality of care to people living with illness or disease, using a model of reasoning that is linear or unidirectional is insufficient. I think with the two combined (one a philosophical reasoning model, the other determining dynamic processes of change) we can focus more on the individual, working towards impacting outcomes of interest and for who or what matters to the person (put simply think about what people yearn for in their lives? Is it coherence, meaning, feeling, a sense of belonging?).

It is also reasonable to suggest that favouring one treatment approach over another as the “evidence suggests” hasn’t really given clarity on what is most effective. Therefore, advocating for methods, terms, “the best treatment” is merely peddling the practice of the practitioner.

By targeting processes of change we can tailor specific outcomes of interest (to person and practitioner) rather than using a best treatment approach  (McCracken, 2020).

Why the clouds? Don’t be afraid to dream a little broader.

Thanks for having a read.

TNP

References

Anjum, R. L. (2020). Dispositions and the Unique Patient. In R. L. Anjum, S. Copeland, & E. Rocca (Eds.), Rethinking Causality, Complexity and Evidence for the Unique Patient. Gewerbestrasse: Springer Open.

Arnstein, P., Caudill, M., Mandle, C. L., Norris,  a, & Beasley, R. (1999). Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain, 80(3), 483–491. https://doi.org/10.1016/s0304-3959(98)00220-6

Besen, E., Gaines, B., Linton, S. J., & Shaw, W. S. (2017). The role of pain catastrophizing as a mediator in the work disability process following acute low back pain. Journal of Applied Biobehavioral Research. https://doi.org/10.1111/jabr.12085

Costa, L. D. C. M., Maher, C. G., McAuley, J. H., Hancock, M. J., & Smeets, R. J. E. M. (2011). Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. European Journal of Pain, 15(2), 213–219. https://doi.org/10.1016/j.ejpain.2010.06.014

Davidsen, A. S., Guassora, A. D., & Reventlow, S. (2016). Understanding the body–mind in primary care. Medicine, Health Care and Philosophy, 19(4), 581–594. https://doi.org/10.1007/s11019-016-9710-9

Eriksen, T. E., Kerry, R., Mumford, S., Lie, S. A. N., & Anjum, R. L. (2013). At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms. Philosophy, Ethics, and Humanities in Medicine : PEHM, 8(1), 11. https://doi.org/10.1186/1747-5341-8-11

Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 82(August), 101908. https://doi.org/10.1016/j.cpr.2020.101908

Hayes, S. C., Hofmann, S. G., Stanton, C. E., Carpenter, J. K., Sanford, B. T., Curtiss, J. E., & Ciarrochi, J. (2019). The role of the individual in the coming era of process-based therapy. Behaviour Research and Therapy, 117(September), 40–53. https://doi.org/10.1016/j.brat.2018.10.005

Hofmann, S. G., Curtiss, J. E., & Hayes, S. C. (2020). Beyond linear mediation: Toward a dynamic network approach to study treatment processes. Clinical Psychology Review, 76(April 2019), 101824. https://doi.org/10.1016/j.cpr.2020.101824

James, S. L., Abate, D., Abate, K. H., Abay, S. M., Abbafati, C., Abbasi, N., … Murray, C. J. L. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet, 392(10159), 1789–1858. https://doi.org/10.1016/S0140-6736(18)32279-7

Low, M. (2017). A novel clinical framework: The use of dispositions in clinical practice. A person centred approach. Journal of Evaluation in Clinical Practice, 1–9. https://doi.org/10.1111/jep.12713

Martinez-Calderon, J., Zamora-Campos, C., Navarro-Ledesma, S., & Luque-Suarez, A. (2018). The Role of Self-Efficacy on the Prognosis of Chronic Musculoskeletal Pain: A Systematic Review. Journal of Pain (Vol. 19). Elsevier Inc. https://doi.org/10.1016/j.jpain.2017.08.008

McCracken, L. M. (2020, July 1). Necessary components of psychological treatment for chronic pain: More packages for groups or process-based therapy for individuals? European Journal of Pain (United Kingdom). Blackwell Publishing Ltd. https://doi.org/10.1002/ejp.1568

Menendez, M. E., Baker, D. K., & Oladeji, L. O. (2015). Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic. Journal of Bone and Joint Surgery, 97(24), 1999–2003. https://doi.org/10.2106/JBJS.O.00387

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. https://doi.org/10.1016/j.ejpain.2011.01.016

Mumford, S., & Anjum, R. L. (2013). Causation: A Very Short Introduction. Oxford: Oxford University Press.

Pincus, T., Kent, P., Bronfort, G., Loisel, P., Pransky, G., & Hartvigsen, J. (2013). Twenty-five years with the biopsychosocial model of low back pain – Is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain. Spine, 38(24), 2118–2123. https://doi.org/10.1097/BRS.0b013e3182a8c5d6

Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of Rehabilitation Medicine, 41(8), 604–612. https://doi.org/10.2340/16501977-0372

Smeets, R. J. E. M., Vlaeyen, J. W. S., Kester, A. D. M., & Knottnerus, J. A. (2006). Reduction of Pain Catastrophizing Mediates the Outcome of Both Physical and Cognitive-Behavioral Treatment in Chronic Low Back Pain. Journal of Pain. https://doi.org/10.1016/j.jpain.2005.10.011

Stilwell, P., & Harman, K. (2019). An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences. https://doi.org/10.1007/s11097-019-09624-7

1 Comment

  1. Paul, to me the clouds represent the “noise” that characterizes the endless discussions about the usefulness of the biopsychosocial model of illness, as proposed by George Engel.

    In my opinion, that biomedical approaches to treatment of many people with ongoing and disabling pain simply reflects the need for more basic research to help us understand the underlying neurobiology.

    We tend to forget or ignore the fact that the sensory dimension of pain reflects activation of a nociceptive apparatus which has reached the level of our consciousness.

    Such activation can occur even without ongoing nociception.

    In such a situation, we now have good reason to believe that the underlying neurobiological process is an excessive increase in the products of neuroinflammation, which can sensitize the neuronal components of the apparatus. This would explain the protean nature of the clinical phenomena that we see in the clinic, the most disabling of which is ongoing pain.

    It is therefore not beyond the realms of possibility that molecular biologists will eventually uncover mechanisms that can be specifically targeted with the appropriate biological agents. The central senstization of nociception will then be reduced, resulting in significant clinical benefits.

    The clouds will then start to disappear.

    Like

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