Biopsychosocial aspect of pain

The biopsychosocial (BPS) model proposes examining patients from a lens that incorporates the biological (physical or chemical alterations) and psychological (mental health and personal factors), in the context of the social determinants of health for each individual.

The purpose of this commentary was to summarize the BPS model and provide the authors’ recommendations for integrating it into chiropractic education and practice.

Chiropractors and other manual medicine providers are well suited to engage in positive psychosocial interventions, which may help to reduce the risk of developing chronic pain and disability. Clinicians may assist patients with the development of active coping techniques by encouraging positive thinking, helping patients learn to redirect negative self-thoughts, engage in activities which distract from pain and continue with physical activity within pacing parameters.  

As a recent example, Monticone et al. conducted a RCT to examine the effect of group-based rehabilitation with cognitive behavioural therapy (CBT) compared to general physiotherapy exercises in patients with chronic neck pain. Following treatment and at 12-month follow-up, the rehab and CBT group showed a reduction in kinesiophobia and catastrophizing.

In another important example, the clinical guidelines recently published by the American College of Physicians recommend interventions such as mindfulness-based stress reduction, progressive relaxation, CBT, exercise, yoga, tai chi, manipulation and rehabilitation as initial treatment options for patients with acute, subacute and chronic low back pain.

It is important to recognize that clinicians may inadvertently justify a patient’s maladaptive thoughts and beliefs if messages overemphasize pathoanatomy or the need for indefinite, long-term, passive care. If the patient perceives that missing appointments will result in the worsening or persistence of their condition, they may become reliant on passive care, lose a sense of self-efficacy and believe s/he has no control over her/his health. Clinicians should be aware of the potentially negative consequences of their words, and aim to frame messages in a positive light that emphasizes the benefits and gains of treatment.

Techniques such as motivational interviewing, CBT and acceptance and commitment therapy can serve as doctor-patient communication strategies to identify targeted behavioural changes, and understand a patient’s motivations and barriers to making change. These techniques assist patients in the development of constructive alternatives to problematic thoughts.

Motivational interviewing is a technique intended to target behavioural changes. It focuses on a patient-centered discussion to identify motivators and barriers to change. This technique is based on four principles: expressing empathy; developing discrepancy between what needs to occur for positive change and what the patient is willing to do; “rolling with resistance” if the patient expresses negativity, and; supporting the patient’s self-efficacy so the patient understands the doctor is ready to support him/her when s/he is ready to make change.

Cognitive behavioural therapy is an approach that focuses on the relationship between thoughts, emotions and behaviours. It attempts to nurture the patient’s development and use of active problem-solving skills to assist him/her in managing the challenges associated with chronic pain.

Acceptance and commitment therapy intends to help a patient shift his/her perspective in order to deal positively with experiences. It aims to change problematic thoughts and feelings to constructive alternatives such as acceptance, mindfulness, cognitive defusion, and committed action.

Applications, conclusions
The authors recommend that clinical communications should focus on maximizing positive messages to foster self-efficacy and self-reliance, while minimizing negative communication that encourages reliance on passive care. The authors further suggest that research regarding the implementation of the BPS model in practice is required, along with research investigating outcomes of BPS and integrated care. Finally, the authors recommend increased emphasis of the BPS model in chiropractic education and continuing education courses.

Dr. SHAWN THISTLE is the founder and CEO of RRS Education, providing weekly research reviews, online courses and seminars to help busy clinicians integrate current research evidence rationally into practice. For more information, visit: www.rrseducation.com. Shawn can be reached by email at shawn@rrseducation.com