Here is a recording of last weeks webinar on "The clinical conundrum of exercise and pain"

ENJOY

Yeah controversial I know……..dragged you in though : )

But hang on, hear me out.

Self-efficacy is another one of these fancy terms that can now gets used to justify why the things that health care professionals do ‘work’….....

“oh it probably improves self efficacy”

This coincides with the emergence of self-efficacy as a important prognostic factor for recovery as we see here and here. Firstly, it is important to highlight prognostic data is often not interventional, so improving self-efficacy to improve outcomes makes sense but not yet fully supported by interventional data.

But is self efficacy actually a thing that can be low, high or improved? No!

WHY????

The point of self-efficacy is that it relates to something SPECIFIC.

"There is no all-purpose measure of perceived self-efficacy. The “one measure fits all” approach usually has limited explanatory and predictive value because most of the items in an all-purpose test may have little or no relevance to the domain of functioning” - Bandura HERE

So self-efficacy for what exactly, rather than just ‘self-efficacy’ is a really important question and one that is consistently missed out when discussing self-efficacy.

"self-efficacy is a judgment of capability to execute GIVEN types of performances

Bandura also makes some distinctions on some common terms that are often not well defined

"Perceived efficacy is a judgment of capability”

"Self-esteem is a judgment of self- worth”

"Locus of control is concerned, not with perceived capability, but with belief about outcome contingencies—whether outcomes are determined by one’s actions or by forces outside one’s control”

So essentially self-efficacy is simply not a stand-alone ‘thing’, it has to actually relate to something and I am going to use an example from Adam Meakins who made a good point to me in a recent discussion

"How much self-efficacy do you have around repairing your car?”

Now I might consider myself to have pretty high self-efficacy when it comes to most things using my body such as playing sports or general daily activities but take me outside of those and ask me to tile a bathroom or fix my car and suddenly it drops, significantly

Self efficacy for what?

We have so many self efficacy scales because they relate to different things.

The most common used is the PSEQ (pain self efficacy scale). This relates specifically to doing things WITH PAIN. So it’s not just self efficacy for anything….its moving IN pain!

Still fit with your narrative?

The PSEQ HERE

“assesses the confidence people with ongoing pain have in performing activities while in pain”

We also have the SEE which is the self efficacy for exercise scale, guess what that relates to? Um yeah….exercise.

Now because I am a critical B****** we could say that this whilst being DOMAIN specific to pain, it is still not activity or movement specific and if used without further questioning could miss the actual things that are actually bothering people.

Bandura's scale for pain management is really quite specific to controlling pain in comparison to the more general PSEQ.

 

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Perhaps it is more low pain CONFIDENCE as a general measure?

Bandura himself distinguished the difference between self efficacy and self confidence as one being a more general measure (self confidence) and one a more specific (Self efficacy) measure. Perhaps it is best seen as a spectrum rather than simply one or the other, but it still relates to a domain or a specific within that domain rather than just simply SELF EFFICACY as a stand-alone thing.

Is the way we often discuss self-efficacy more a proxy for self-confidence, general functioning or coping? Is that important? I think it is if we start looking at self-efficacy from an interventional standpoint using the theory put forward by Bandura to justify ways of building self-efficacy as they relate specifically, well to the specifics!

Most questionnaires lack specifics and often need a proper conversation around them to tease out more specific movements, activities etc, the Fear Avoidance Belief Questionnaire suffers from this issue as well IMO. This is a common criticism of PROMS.

And this bring us onto the next point…..

General versus specific

Always a big question in therapy is “how specific do we need to be?” and this is no different with self efficacy.

The way I view it is, the more specific the problem then the more specific the answer probably needs to be. Problem is with a more general domain-based scale it’s pretty tough to know how specific we need to be. A specific approach may relate better to something general than a general thing might relate to something specific is a thought I often have.

So if the problem is a one of more general low confidence of using our bodies then doing general exercise or loading will probably have good results.

Is that confusing? Yeah probably : )

Exposure therapy

The most common way that we interact with self-efficacy or confidence is to simply practice or exposure to doing things we don’t currently or normally do. Clinically I think we often expose people to things that build their confidence in their bodies rather than change any physical measures.

Perhaps we are really helping keep the persons pain expectations more in line with the probable reality, that the current situation is bothersome but not inherently dangerous, and therefore normal life can resume. This helps avoid exaggerated cognitive responses that can limit engagement in activities and create disability and increased pain.

This is not really the true ‘exposure therapy’ that we may see around psychopathology such as the fears or phobias that we see in literature such as Craske et al as an example, but a ‘soft’ exposure I suspect can have a positive effect on confidence, violate expectancies and improve clinical outcomes. We should not confuse this though with more specific situations were general confidence building probably won’t make a huge difference.

‘Soft exposure’

I think this process happens a bunch in rehab.

We expose people to different things such as lifting weights, that are pretty general interventions and can have a really good effect on peoples levels of general belief and confidence in their bodies. But they might not have the same effect on someone who has very low self-efficacy around a specific task involving lifting say, in this case a deadlift might not cut it if I need to be contextually specific as we see in true exposure therapy.

So if a general thing helped then perhaps the problem was not that specific?

Many years ago in the 90’s I worked as a gym instructor. That pretty much was using exposure to improve the self-efficacy of people who had never come to the gym before. It involved relationship building, coaching and doing the thing they wanted to gain more confidence in, in this case a basic gym routine. Guess what? After a few weeks of doing I with a bit of support and getting comfortable in the surroundings and building a bit of a habit they improved their self efficacy!

Is it normal anyway?

If I have pain or have never done something before such as weight lifting then having low self-efficacy for this might be completely normal. I don’t see this as a clinically significant low self-efficacy, say under 30, as has been discussed, on the PSEQ and rarely gets measured anyway clinically.

People are a bit worried, their confidence has dropped, they are often more cautious of experiencing pain and using their bodies. Rather than an abnormal response it might be something quite normal. Perhaps it is the duration of these beliefs beyond what might be considered normal that is the problem?

Take away’s

 

• Self-efficacy is a not a thing

• The scale used generally relates to the thing

• The scale used to measure the thing can miss the thing

• General interventions work on general things

• Specific interventions work on specific things

• Exposure and confidence go hand in hand

One of the most common questions I get asked, after “which exercise is best to fix back pain?” is....

“How often should my patient do their exercises?”

One of the things we have to remember is that “how often” or FREQUENCY is tied into the INTENSITY and EFFORT and therefore need for REST & RECOVERY, and the one thing underdiscussed and often unreported in studies is intensity!! We could do 3x10 or 5x5 or whatever, but without the accompanying intensity the sets and reps don’t really mean that much.

Intensity and effort often get used interchangeably, if there is a technical difference to discern then intensity is more about the objective measures we make e.g. heart rate whilst running, and effort is more how hard we perceive this to be, so rate of perceived exertion (RPE) would be a subjective measure with the Borg scale designed to relate to current working heart rate. So whilst technically not exactly the same, intensity & effort do have a strong relationship in my opinion and RPE can be used clinically as a simple, rudimentary measure of intensity.

This does not mean that all exercises have to be intense, it might need to fit the current sensitivity of the patient and this lower intensity can often be done more regularly, and for many just moving in a non threatening way might suffice. But there may also need to be progression and this can be where lots of therapeutic exercise programs can fall down as they are looking for a single exercise/dosage.

Based on the current data with exercise my personal belief is that the dosing such as intensity and frequency are probably more important than the TYPE for some people!

I wrote about this a while back -  "Exercise dosing for pain is not he same as exercise doing for fitness"

What is the aim of the exercise?

 

Your clinical reasoning should really determine which exercise, how much, and how OFTEN!

Now there is a fair bit of discussion of whether ‘general exercise’ is better than ‘specific’ exercise whatever those two things are exactly, but my personal belief is we should always have some reasoning around WHY we are doing something. Unfortunately, although it’s a simple answer I just don’t really see “just do some exercise” as being THE answer to back pain for example.

So what is the aim? Well we often have two main types, a more physical adaptation aim or a pain/function focused aim.

Lets start with the physical adaptation side of reasoning.

Strength

So strength and strengthening often get used interchangeably but might be different. Actually increasing force production or strength can require some intense exercise and higher effort levels. Sets and reps are often programmed but not the intensity as previously discussed. You could do strength programming variables but without sufficient intensity, and therefore you may not need the same rest as with more intense training but also might not get the same benefit. The load here should really dictate the reps as stopping at 5 reps with another 5 in the bank because the load is too light isn’t really going to cut it.

Our views of programming are changing with regards to strength and hypertrophy but intensity matters here and therefore frequency does too.

Load/tissue tolerance

This is a common aim, the concept of ‘strengthening’ an area to take a bit more load or activity.  A common mistake is to assume painful movement or being intolerant to an activity or load is CAUSED by excess load. Load is a very catch all term and ANY painful movement or joint could be described as being load ‘intolerant’ if it causes pain, this would be a basic correlation NOT causation mistake.

Generally heavier loads are advocated and therefore higher intensities and lower frequencies although we really don’t know that much here, load tolerance I doubt is a solely tissue phenomenon.

In some cases a load tolerance approach might work by actually taking away load as much as a stimulus to increase tolerance, so addition by subtraction. We simply keep the body moving whilst taking away an aggravating load is a plausible rationale especially with exercises of limited intensity.

How does your exercise prescription also fit in with the other stuff the person is doing? This also should tie into your reasoning around frequency. With very active people, where volume might be an issue, sometimes LOWER intensity exercise performed more FREQUENTLY can also be of benefit.

The spanner in the works & graded approaches

 

It would all be so easy if therapeutic exercise was just about physical variables such as strengh, but unfortunately it’s not. We all know it’s great to get parameters to work with but anyone who has been in clinic knows that the real test is in how the person RESPONDS.

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It’s the interplay between intensity, frequency and PAIN that’s that really should guide us rather than theoretical parameters for fitness. And it’s not just pain as a sensation but the persons beliefs and behaviours in response to and around pain in general that also need to be considered.

Graded activity and exercise are concepts that relate a bit more to habituating to pain and graded exposure to cognitive factors such as fear or catastrophising. Here we don’t have ANY real parameters apart from those that are based around physical ability and pain tolerance. So frequency is really a thing that is tough to set BEFORE you work with someone. This is part of the inherent uncertainty in therapy that we have to get used too but ca be guided by a thorough history of pain and exercise participation.

Graded activity & exercise

These are approaches that originally looked at improving chronic fatigue but are equally applicable to pain too. Again the intensity is important, if we are pushing the level of grading towards the more intense then longer rests and decreased frequency might be important. If more about building a movement HABIT then less intense and more frequent.

Graded exposure

Graded exposure is slightly different in that it is more about cognitive factor such as fear and anxiety around moving than pain or actually than a physical change. But frequency is NO LESS important. True exposure sessions are mentally fatiguing and because of this physically and emotionally tiring. If we want to reinforce this with additional work at home we would have to consider this in terms of frequency and individual levels of fatigue.

Reasoning in action

 

Here is how my reasoning might work with the two different aims. I like to use effort level as a guide to intensity as it is a simple subjective measure that is easy to use clinically across a variety of exercises/activities and I find rate of perceived exertion (RPE) is good for this. Now intensity and effort are NOT the same thing but generally the more intense an exercise the more effort is required especially the more of it you do.

Physical

Although the data around adaptation and reps/sets/intensity is definitely changing compared with what I was taught back in the 90’s, I still think that intensity is key for physical adaptation. With more intensity we need more rest so frequency might only be 2/3 times per week. Bodybuilders were smart at training regions of the body on different days to maximise recovery whilst also getting in their overall training needs.

So we probably need at least a 7/10 RPE.  If you are looking for strength (force production) then I would say we should probably bias heavier mass to create that intensity too.

Tolerance might be different in that intensity could be created by a lighter load but you have to get in more reps to make the intensity. If we think about all the different activities and types of loads coupled with access to loading equipment then adjusting load and reps for intensity helps us a bunch. Remember that all this also ties in with their current level of sensitivity too and we often have to adjust this based on responses.

Graded

My reasoning here would be how can we build a HABIT of moving. HABITS are built more by frequency than intensity.

So let’s identify something that is going to be valued or ties into the values. We don’t always have to enjoy things but we do have to see a worth in doing them to continue to do them. Based on how someone’s pain behaves in terms of types of activities that trigger, severity of pain and how much it takes to do so (irritability) we can start to build a picture and reason a  dose of that activity.

So although we still have to be guided by the persons RESPONSE, I would aim for intensity lower (3-5 RPE) and a frequency of daily or every other day, remember it does not have to be the SAME activity/exercise that is performed each time.

It is important to remember where you start with frequency and intensity should not be where you finish with it, but sometimes we need to start lower to get higher!

Key points

 

  • Just go do some exercise might be why lots of exercise programs ultimately fail
  • Sets and reps also need intensity/effort
  • Intensity is relative to what you want to achieve and intensity dictates frequency
  • It’s often about trial and error
  • Get used to it!

The biopsychosocial (BPS) model is one of those things you probably feel like you should be doing but maybe don’t know exactly how or you don’t have the skills? There does seem to be a fair amount of uncertainty and a bit of anxiety associated with the BPS model HERE and even the papers that discuss it rarely seem to actually define it!

This take on the Dan Ariely "big data" quote sums it up quite nicely (kudos to the author!)

Biopsychosocial management of back pain

Is like teenage sex;

Everybody talks about it;

Nobody really knows how to do it;

Everyone thinks everyone is doing it;

So everybody claims to be doing it.

But maybe we don’t need to FULLY define or understand the BPS to start to implement it in some way. The first thing we need to do is actually know MORE about it. I was told recently that the BPS model is “old and we should move on” in a twitter discussion. A little bit further into the discussion it turned out the other party had not read much about it, I think this happens a lot. We all seem to have our own interpretations around what BPS is and is not, so this is my attempt!

What is it?

 

There seem to be two main perspectives that are summed up in these quite differing quotes:

“The centre of interest in biopsychosocial model is not the disease but a sick individual” Havelka  

 “The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person's medical condition it is not simply the biological factors to consider, but also the psychological and social factors” Physiopedia

The first is focused more on the person we are treating and the second more focused on the condition or problem, so no wonder we have a bunch of confusion and NEITHER really give much guidance about what to do next.

One of the perspectives that I feel gets lost in some views of the BPS model is the focus on the ‘humanisation’ of healthcare which is a feature of Engel's writing. To understand the biopsychosocial model we also have to understand why we needed it in the first place and this was to come away from the reduction of healthcare to pathology and numbers that was the biomedical model.

Isn’t it fascinating we now quantify the success of a BPS approach simply by an outcome measure!?

Philosophy of care and person focus

 

Maybe this is the real spirit of the BPS? A ‘philosophy of care’ and a person focus.

The cool thing is it does not require extensive training to implement, instead it simply requires us to appreciate there is another person who is more than a disc or a tendon or whatever issue they have. They also will have a history and experiences that shape their emotions, perspectives and ultimately behaviours.

This for me is summed up nicely in this quote.

“Look at the world through the patients eyes and walk through the world in the patients shoes” -   

 This quote from Joanne Bourke also sums up how we can focus more on the pain than the person who has it.

‘Pain’, rather than a person-in-pain, is given agency. A pain-event always belongs to the individual’s life; it is a part of her life story”  

When it comes to the human side of the BPS perhaps we can get stuck on the idea that everything we do has to result in a better outcome e.g. a change in pain. So this interaction is measured and judged via change in pain, empathy is measured via change in pain, you get the idea. This is exactly the positivist/empirical perspective Engel seemed to be arguing against, reducing everything to a hyperfocus on the problem and then measuring its change! We should be being aware of how we interact NOT just to get a better outcome measure but also because its the RIGHT THING TO DO!

Evidence based medicine is important but not at the expense of a person. We really need to zoom out to the whole often rather than separating into smaller parts and descending DOWN Engel's hierarchy of systems.

The aspect of the BPS model that is probably most important is our own self reflection on how we think, act and interact but I have rarely seen this discussed. Just reflecting on how we communicate or care for the other party or conduct ourselves is enormously valuable.

The thing is that if we want the BPS to be an effective treatment tool then it probably requires the human aspect that is being discussed here. Many psychosocial factors that relate to pain require changes in behaviour. These changes also require trust and belief in what we are saying and this can be tough when it is contrary to all the other concepts and ideas around pain that people get exposed to.

There are a number of points that we can appreciate to implement a more person focused version of the BPS model that are NOT directly treatment focused but might have an effect on the process.

  • Having pain can affect our emotions as much as our emotions might affect pain. It is a BI DIRECTIONAL model.
  • Socioeconomic status and health literacy directly affect the entire therapeutic process
  • Appreciate how beliefs are in part formed at a societal level and this can make them pretty sticky. They often don’t simply change in a session
  • Having pain is HARD and can limit motivation and belief in recovery
  • This person may have had to tell their story multiple times and this can be very frustrating
  • A constant search for the answer can be frustrating and tiring. Modern medicine can paint the picture there is one to be found
  • Uncertainty and the worry it brings makes people feel worse. Not just their pain but also their well being
  • Hope, motivation, optimism and instilling confidence are important not just for pain but also for LIFE and the person

None of these things are treatments but do help us understand the person and their levels of engagement, optimism and outlook for the future. The appreciation of these points also does not require a huge amount of training to impliment.

Causes and Treatment focus

 

A more traditional diagnostic and treatment focused use of the BPS seems to be the most popular way it is interpreted and implemented and perhaps this can cause a bunch of the issues for both clinicians and patients. To treat thing’s specifically the thought is we have to kind of know what the problem IS first and we can get hyper focused on finding the CAUSE of the problem, but now we have way more potential problems across lots more areas to confuse us! Sticking to traditional pathologies can be hard enough and this is without having to be an expert in other fields too!

I think there is a case that we could see this as a biomedical application of the BPS as we could treat multiple BPS 'factors' WITHOUT actually treating the person in the spirit of the BPS and with a focus on person-centred care. A real aim would be to successfully implement a person AND pain focused model.  Many of the factors we need to identify to implement a pain focused model actually need the person-centred model to make them work anyway. Without a good therapeutic relationship and trust and rapport how do we get people to tell us the information we need? How do we help implement the behaviour changes that are often required? The simple answer is we don’t.

Triggers not causes

 

Maybe a better way to see this all would be factors/behaviours that TRIGGER pain not always viewing it through a causation lens. Many things might trigger, exacerbate or modulate a painful state. Is this semantics? Potentially, but maybe less focus on CAUSE might take the pressure off clinicians to pin point a cause and does not feed people’s desire to find the one thing that they need to fix their pain. We might swap disc/nerve/alignment for stress/sleep/job and a triggers perspective may help people make sense of their pain situation rather than search for the cure or fix in the same way that can often prove frustrating and demoralising.

As we can see HERE 9, yes 9 psychological factors were identified as being involved with rotator cuff tendinopathy pain, function and quality of life. No wonder a BPS find and fix it model is seriously daunting for most clinicians.

A good analogy might be that of a cut that is grumbling away in the background. Sometimes I am unaware of it, others it is giving a slight twinge. But get something in it that irritates it and it’s a whole other story. This added element has interacted with the cut and triggered a response. Without the cut it might not have done so perhaps on its own we might not see it as a casual element. There is a sometimes a danger we simply swap biomechanical impairments for psychosocial ones.

The interaction of BPS factors is inherently messy. Humans are a complex web of interrelating systems that display non linear responses between things acting on the system and the responses it makes. This can mean we could have huge changes in a variable such as stress but only minor changes in how it affects a target variable such as pain. We also might target one variable, that may not change significantly, but another mediating variable changes and this changes a target variable. This maybe different to the sometimes linear approaches that we can see in research and clinical models that involve a primary outcome measure and intervention.

If we approach the BPS model as a simple view of linear causation and impairment fixing this kind of goes straight back to a biomedical perspective.

 

Positives not negatives?

 

There are positives and negatives to this messy non linearity of the BPS with treatment. Positive in that treatments can have wide ranging effects across many variables and the negative that they also might not! Exercise can have implications for general health, mental health and pain through a whole bunch of different mediating variables. One way to start to approach the BPS model is not in trying to fix an impairment but improve aspects we know are beneficial and may provide an overall effect. This would fit with Antonoskys salutogenic model of focusing on wellness rather than illness.

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Perhaps an issue is we now see it as “just do some exercise” and the person will be ok.

Exercise ‘works’ is a common perspective but this really does not tell the story of the data. It is not so much if it ‘works’ at a population level but how much effect does it have for this person in front of me. For all this potential to have wide ranging effects we still don’t see dramatic benefits in the research and often clinically too on the outcome measure of pain. Maybe this is because we expect exercise to automatically transfer to whatever the issues are? Effects on strength, sleep, mental health and ultimately pain are all potential effects/mediators that we see in the research base but we are not GUARANTEED these effects. This paper found HERE found that strength and power scores did not make people feel automatically ready to return to play. Although physical conditioning MIGHT make people FEEL mentally stronger it is not an automatic and linear relationship.

Summing up

 

We probably need a bit of both perspectives to make things work effectively.

If we put this into a context, firstly we need to consider the effects we might want from exercise based on finding out more about the person we are working with. Do we want to improve health? Wellbeing? Function? Exposure? We might have to set up exercise in some different ways to achieve these different aims. Secondly our deeper knowledge of this person and their journey might help use frame, explain and implement the exercise in some different ways that could have a better potential to have the desired effect.

If a BPS approach just ends up in do some exercise because it CAN have wide ranging effects I think we have lost sight of what the BPS just might be!

 

 

 

 

 

 

 

 

 

 

 

 

This is going to be a series of blogs looking at a number of topics under this umbrella title as it would turn into more of a book than a blog and although we are on lockdown, ain’t nobody got time for that sh**!

Exercise has become a popular treatment for many musculoskeletal issues over the past few years but surprisingly little is actually understood, even after tons of research, about how to use it in clinical practice and maybe even if it’s worth using?

In this blog we will look the actual question of “does exercise ‘work’ for pain” as ‘works’ tends to be a phrase that gets banded about a lot without much clarity. Similar to “the research shows” when often the deeper you dive into the research the LESS clear it often becomes, especially around pain.

I will write a few more posts on the “everything works/nothing works” perspective, how it might work and how specific we may need to be in future posts.

Well does it work?

 

Well it depends on what you mean by work? Which condition? What are you comparing it against? Do you mean pain? Do you mean disability? Did it have an effect on physical function or some biomotor variable? All of these things are quite different questions that often get lumped into the catch all term ‘works’.

We need to think as well about WHY we might come to a conclusion on if it ‘works’ or does not. Is it because I have read widely in this area? Is it because who I follow on twitter tells me it does or doesn’t or am I simply following my biases? A little bit of epistemology perhaps.

Like ANY intervention, exercise should be thoroughly scrutinised and the basic reality is we have to be prepared that exercise will not work for everybody, it is not a magic bullet or panacea and a lot of what we do is a bunch of informed trial and error really, but we will come back to that later in another post. We have to remember we are dealing with HUMANS who tend to be wonderfully variable in their responses as most biological organisms are.

We now discuss pain as being a complex, multifactorial experience (blah blah blah) so why do we expect one thing to come along and solve it all for everybody? For some it will be revelatory, for some it will do very little and for others even flair them up, so we need a bit of perspective but as a standalone treatment I think there is a lot to like here especially with the benefits for our health and well-being

Just hurry up and tell me…..

 

The whole idea of “it works” could stem from how we have traditionally looked at research. To show a difference between two interventions or ‘usual care’ it has been common to use a significance level of p = 0.05 to indicate something ‘works’, so the observed difference in effect between two groups is likely to be at least as big as reported and this then is used to reject or accept the hypothesis of a study. Generally something like “treatment A WORKS better than treatment B” or something along those lines. Is exercise better than manual therapy? Is it better than usual care? You get the picture. I am no statistician or researcher, only a humble clinician so bear with me here.

So we might say exercise is better than usual care or whatever else, but the real question should be HOW MUCH better or the actual magnitude/size of the difference. The p value is a statistical tool and not a measure of the actual average size of the effect. Something can be statistically significant without really making a difference to our patients and this is where minimal clinical important difference comes in (MCID).

A clinically meaningful change for pain has been discussed as being somewhere between 1-2 points on an 11 point VAS/NPRS dependent on what it is being tested against such as ‘usual care’ or another specific intervention. Other magnitudes of clinical significance have pointed a 20% or 30% change from the baseline and this makes sense as a 2 point change for a baseline of 4 is far more significant than a 2 point change on a baseline of 8 for example.

We have to be aware that these cut off values such as 0.05 are also a bit arbitrary. If we critique the significance of p = 0.05 then we probably have to do the same for MCID too. The real value of any effect may only really be possible via subjective evaluation by the person experiencing them and their expectations of what that change should be.

We may also have to consider how we view the ‘mean effect’ as this may not actually reflect THE effect that MY patient gets (for a whole load of potential reasons). The mean represents the average response and is sensitive to those that respond very highly and also people who respond lowly or even negatively. In trials with small sample sizes, as much of exercise & pain related research is these more extreme values can significantly alter the mean.

We should also take into account the standard deviation of the mean response and this is a measure of the variation within the group of participants being studied. This could mean (get it…) that the variation in response when applying the treatment in clinic could also be pretty wide too. A confidence interval (CI) is another measure of uncertainty/variability around the potential treatment effect on a wider population. The CI reflects the inherent variability/error in the process of sampling taking into account the size and variation within the sample.

The last question here is does exercise research always reflect clinical practice? Personally, I tinker with type of exercise, intensity, frequency, volume etc to ‘optimise’ for the person whether that’s in relation to their response or ability to achieve the program. If I am not getting the desired response then I feel quite at home playing with the variables. Is this right or wrong? I have no idea but standardised programs used to study exercise often don’t do this.

You really didn’t answer the question…..

 

So what was the point of all this, well we can start to see that “it works” is a pretty nebulous term really. It’s the classic clinical conundrum of applying the world of research to our patients and how we should expect them to respond. Predicting the future is always tough and worlds of research and clinical practice is definitely not a game of certainties.

We have to consider the actual size of what ‘works’ and how likely is my patient to actually respond in this way and I see it as a bit of a “probability wrapped up in a probability”. This often makes clinicians feel uncomfortable as we tend to like certainties and sometimes research can be portrayed as more certain than it really is IMO.  But we really have to look at the trials, who they are studying, how many people, what exercise/dosage and what’s the spread of responses amongst other things to even get close to answering the question.

 

Next time we might actually answer the question ; )

 

We probably have to face the fact that most common treatments that we learn such as manual therapy, exercise (yes even exercise) etc are often little more than hugs and kisses for the most costly and burdensome issue in musculoskeletal health today, Lower Back Pain (LBP). Something that is pretty clear however in the murky world of therapy, when it comes to back pain something people suffering from it value one thing highly, INFORMATION!

Before many people even come to see a therapist they search the problem on the internet and consult the medical sage that is DR GOOGLE (and we know how good that often is).

This 2018 paper “What matters most to people in musculoskeletal physiotherapy consultations? A qualitative study” found some clear themes. Firstly that people often have some clear questions they want to ask. Secondly that people required information about their problem and third was the need for collaboration with their therapist.

“In this study the people frequently reported lack of understanding, such that information and an explanation of their condition and a diagnosis was one of the main issues of importance that emerged for all but one participant”

This makes complete sense! People want to know what this is and if it’s a big problem? Is it medically serious? How long might it take to go?  Now rather than 'fancy pants' explanations of neurobiology, load capacity and other poorly define buzz words it might just be basic epidemiology delivered in a reassuring and non-threatening way. The current trend of 'simplicity' in rehab probably applies here to! This can take practice and knowledge and like most simple sounding things can be tough to actually do.

Perhaps if we can satisfy the people engaging our services needs then they might be more likely to trust and engage with the messages that we feel are important? Just a thought!

Why is this important info?

 

We should really see the data around what people want from us as market research for therapists! This makes it worth taking notice of what the end user actually wants without just guessing or assuming, which can happen. Rather than meeting and satisfying the needs of those seeking help some of the current approaches actually probably fuel more uptake of the product (smart from a business sense)!

Education forms a key part of the current LBP treatment guidelines and papers such as the recent Lancet series "Prevention and treatment of low back pain: evidence, challenges, and promising directions" but like another guideline staple, exercise, what exactly does ‘education’ mean? Education about what exactly? This is why guidelines are often not followed, they are just too vague. But low and behold we have a lot of research to guide us here on what people would like to know.

What is treatment anyways?

 

We also have to ask ourselves what actually IS treatment when it comes to back pain? Is education really seen as treatment? Often not, but it really should be. The therapists role may shift from DOING treatments to people to helping people understand and navigate their painful situation BETTER.

This recent paper looked at examination as treatment “Evaluation is treatment for low back pain” the authors stated.

“Participants showed a significant reduction in pain through just the history taking and physical exam for both the back with an NPRS reduction of 1.23 and the leg showing a 0.95 NPRS reduction”

It is important to note that this was for first time back pain sufferers and also the pain reduction was in a small timeframe with no longer term follow up but interesting none the less!

So we could suggest that information & assessment IS treatment not just things that we add TO or do BEFORE treatment. I have had therapists suggest to me in the past that this is NOT what people want, they want to be ‘treated’ (in a more traditional sense of stuff being done to them) and certainly for some this is the case but interestingly, when we actually ASK them (I know right, madness!), understanding what is happening does actually seem to be what people want!

What do people want?

 

From looking at the qualitative literature there are theme's that clearly emerge, people want to makes sense of their painful condition, people want to be reassured that its nothing serious and people want to increase their ability to self-manage (we could call this locus of control if we were being fancy)

The nicely titled systematic review “People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies” looked at 41 papers and identified the type of information people are really after.

“Participants were keen to learn about simple and basic information regarding LBP”

“patients wanted clear, trustworthy, consistent information about the nature of LBP, its benign prognosis, and advice on both pharmacological and non- pharmacological management strategies”

One thing that was also apparent in this a paper and others was the need for a patient to get a diagnosis. This obviously is extremely challenging currently, but I believe a way to approach this is not to say we don’t know as this is often unhelpful. Instead tell people what it is NOT (99% of the time serious pathology), potential causes of MSK origin, the prognosis (generally good) and what they can do about it, which kind of fits the title of the paper : )

People also want to legitimise and validate their symptoms. Perhaps this is hard to do in the medical system without a clear diagnosis, this may also drive the clear need for imaging that was identified by patients, paradoxically it can make things worse. I feel it is an important message that we let people know that it is entirely plausible to have high levels of pain without an identifiable structural issue and this is inability to give a clear diagnosis is our fault not theirs. Learning to manage diagnostic uncertainty is a emerging challenge.

Is there an 'information' disconnect here?

 

A recent paper looked at the information that experts thought were important to inform people about LBP “Essential key messages about diagnosis, imaging, and self-care for people with low back pain: a modified Delphi study of consumer and expert opinions”.

The authors found that messages that he experts felt were important such as “carrying on with normal activities” ranked 2nd (out of 30) by experts. In comparison this was seen as 24th most important message by consumers, quite a disparity I am sure you will agree. So, what did people see as important? The first three messages ranked by consumers all related to red flags and identification of serious pathology. Other things that were important to people were self management and reassurance information and this was ranked much lower in importance by the experts. It does seem there is a bit of a disconnect between the two groups here. Perhaps with a bit of acknowledgment of people’s needs we can make them more receptive to what WE feel is important too.

How do we use this information?

 

How does this inform us?

Well it certainly means that information on occurrence of serious pathology, screening and a thorough explanation of findings is not an unimportant thing to many people and probably provides a large chunk of reassurance. If we accept that having pain can be a scary scenario for our physical, emotional and functional well being then it’s not so hard to connect the dots. Also helping people answer the question of “what can I do about it myself” seems to be important. Maybe treatment is often seen as something that happens INSIDE the treatment room (it’s even in the name; ) not what happens outside. As life mostly happens outside perhaps this is where 99% of treatment probably really occurs and helping people with this is really important (a future piece me thinks).

This is a great quote from what I feel is a hugely insightful and underrated paper “How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury”

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis”

This sums up a bunch of what we deal with on a daily basis with so many non specific painful conditions such as low back pain.

 “What Do Patients with Chronic Spinal Pain Expect from Their Physiotherapist?” again found that people want DIAGNOSIS and information about their problem and this is pretty consistent with the previous papers that have looked at this subject. Interestingly, a reduction in symptoms actually came BEHIND improving quality of life as being important in the responses. Not by a huge amount, 68% found it important versus 66% for pain reduction but this shows the importance people actually put on life and not just pain. Clinical implications here again are the importance of examination and the information that we give alongside finding out what quality of life means to people.

A 2008 paper "Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain" highlighted the tension that exists between people wanting information but also wanting the opportunity to tell their story and this is an important balancing act. Allowing time and creating a safe space to let someone’s story emerge whilst also providing relevant information is again a tough thing to do, especially in the limited time frame many operate within.

To make sure we can get key informationacross perhaps this is where the use of good open questions come in.

“What is most concerning you that you would like me to answer today?”

“Its important we really address your concerns so what would you really like to know?”

“What is worrying you that you would like to talk about?”

Effective reassurance is much more effective if it actually addresses the things people are worried about.

What better way to find that out than to ask?

Next time - How to go about creating a positive narrative around back pain!

Conclusion

 

  • People want simple information about their problem (so you need to know it)
  • People want a good assessment
  • They want a clear diagnosis to validate their symptoms
  • This is REALLY hard!
  • But we can replace it with a clear and concise NARRATIVE around LBP
  • The potential causes, prognosis and management options
  • Effective reassurance targets the problem or worry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.

There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.

We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?

We are humans!

Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.

We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.

The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!

We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.

So a simple guideline turns into a much greater clinical problem.

Providing a path

Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.

How can you guide someone in something of you have no idea how to do it yourself?

Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.

You have all the pieces of the puzzle, but the problem is putting them together!

Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.

In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.

Support

Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.

The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.

Takeaways

 

• Behaviour change is no different for HCPs than it is for patients

• If we want change we have to provide a path to change and support along the way

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient centred care’ or PCC for short.

Now for a buzzword it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient or person?

Most of the available literature in this area discusses “patient centred care” but I much prefer “person” centred care as it turns the patient well ….into a person and a much more ‘real’ entity in a two way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlights the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What actually is PCC?

Maybe by definition PCC is tough to define for all? What is person centred for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centred care has previously been defined as:

"willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems" – Stewart 1995

"the physician tries to enter the patient's world, to see the illness through the patient's eyes'' McWhinney 1989

Two person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient centredness”

  • The biopsychosocial perspective (the patients life)
  • The patient as a person
  • Shared power and responsibility
  • Therapeutic alliance
  • The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC is NOT

There are some criticisms of PCC that seem to centre around the idea of consumer driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

  • Define or explain problem
  • Present options
  • Discuss pros and cons (benefits/risks/costs)
  • Assess patients’ values or preferences
  • Discuss patient ability or self- efficacy
  • Provide doctor knowledge or recommendations
  • Check or clarify understanding
  • Make or explicitly defer decision
  • Arrange follow-up

 

What do people really want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel and ultimately need.

This is a really interesting paper regarding a two person perspective in back pain Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership with practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

'Understand me'

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen to me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   - Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction

Does It matter?

A question I often hear asked about person centred care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an affect on outcomes we don't know if PCC specificaly improves the most common outcome measures , but in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the persons experience in healthcare (which might be an outcome measure in itself).

 

The application of PCC

Maybe we should NOT see a person centred approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting with the end in mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding, is in my opinion the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system"  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” - Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person centred approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared decisions and responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to be have an influence on exercise outcomes "Autonomy: A Missing Ingredient of a Successful Program?" . Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally it is a therapists responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each others responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family and social pressures. One of the best ways to implement a BPS perspective is to realise that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort and sacrificing something else.

People don’t just need a something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from From'Non‐encounters' to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than healer can be really helpful for many!

Support & motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite to walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” - Holopainen 2018

 

Conclusion

 

  • Person centred care is defined by the person
  • PCC is not just giving people what they want
  • People are people not just patients (passive recipients)
  • Think about “walking a mile in someone else’s shoes”
  • Think more about shared decisions (within evidence base)
  • Start with the end in mind, tie into valued activities
  • Help people navigate their ‘world’
  • Build people up rather than knock them down

 

 

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"Functional therapeutic movement is without a doubt one of the most practical, well referenced, clinically relevant, and beneficial continuing education courses I’ve taken. Ben has a lively presentation style that keeps you engaged, a good sense of humor, and clear mastery over his content. The course is relevant and valuable for young and experienced clinicians alike. Be sure to come prepared for discussion and plenty of critical thinking!"

DR Jarod Hall DPT USA

 

Key Learning points

 

• Develop GREAT rehab programs for even the most challenging patients


• Latest evidence and best practice guidelines for treating low back pain using an ACTIVE approach  


• Use a flexible, adaptable and simple to implement clinical framework to help navigate the uncertainty of clinical practice from patients with persistent pain to elite athletes.


A look at pain and exercise through a truly biopsychosocial lens.


• Take the complication and rigidity out of exercise prescription – Make it fun and engaging for YOU and your patient. Forget a physio tools or photocopied exercise sheet approach.


Take the mystery out of exercise prescription- when do you need to be specific? And when less so? Learn a comprehensive view of exercise that is more than just sets and reps.


How to sell your patients on exercise – A key factor in rehab success


Learn what you need to know about the psychology of pain and exercise without needing to become a psychologist.


• Learn about pain and how to talk about it without needing to be a neuroscientist. More patient focus and less biology!


Concise and practical reviews of the latest research into pain and exercise to save you time and energy! Perfect for the busy clinician who doesn’t have the time to wade through every piece of new information coming out


How to improve your subjective assessment. How to get all the information and ‘find the hook’ that guides patient beliefs, emotions and commitment to rehab.

 

This is NOT just another exercise course about sets and reps! It is about applying movement and exercise to people in pain. Exercise and movement are fantastic tools to help our patients but the complexity and uncertainty often present in clinical practice can make its application tough especially with painful problems!

What’s the best exercise? Will my patients enjoy or even do it? What if I underload, overload or even make them worse? What does the evidence say I should do? How do I communicate this with my patients?

Couple this with many of the current concepts in exercise & fitness simply not applying well to people in pain and this can be frustrating for therapists and patients alike. . The amount of information out there on this subject can be overwhelming, confusing and time consuming to process and we need to learn how to cut through the noise quickly to get to what really matters to help our patients.

Functional therapeutic movement enables you to navigate this uncertain environment by guiding you in making sense of the evidence around exercise and its application, in a way that will practically apply to your patients in clinic straight away. This can help discard unhelpful, outdated & often detrimental perspectives around movement that are often pervasive, amongst therapists and clinicians, and enable a streamlined, flexible and evidence based approach that is in line with the latest pain and rehabilitation research.  

One of the most widely discussed topics in healthcare and especially in pain circles of late is the Bio Psycho Social model conceived by George Engel.  The BioPsychoSocial (BPS) model was developed in reaction to the dominant biomedical viewpoint that involves reducing medicine to specific diseases or pathologies that can be identified and treated and this model forms the back bone of most western healthcare systems.

Engel felt the biomedical model:

“does not include the patient and his attributes as a person, a human being”

But the question is, have we misinterpreted the BioPsychoSocial model?

Are we simply applying it in the same way as the biomedical model it was trying to replace? 

Its people not just pathology!

We know that people’s experiences of pain and pathology differ. The same painful problem may manifest as huge issue for one person disabling them from work and reducing dramatically their quality of life, whilst another person may remain relatively unaffected. This has to be taken into account both in treating the problem but also how the person is TREATED by their healthcare professional, their family and social network and the wider healthcare system. 

We can see below from Engel's view that it is a bi-directional model that involves the layers in which we exist rather than discreet treatment targets as we now see.

Download 4

We could perhaps determine this interaction between layers as the wider impact OF the problem rather than just as impacting ON the problem.

Rather than seeing the BPS as a direct treatment model where we dissect the three domains to find new pain ‘drivers’ to treat, the BPS perspective should really be seen as a CLINICAL philosophy and guide that can be used for improved patient care.  

Here is another interpretation from a recent paper ‘How do physiotherapists solicit and explore patients’ concerns in back pain consultations’

"underpinning the bps model is patient-centred care (pcc) which involves incorporating the patient’s perspective as part of the therapeutic process"

One of the issues that is often encountered in healthcare however is that clinicians AND patients want solutions and treatments rather than philosophies and the conversion into a treatment model conforms to the biomedical perspective that dominates healthcare.

Maybe the BPS asks us, as clinicians to better understand our patients and there subjective experience? And it maybe better defined as a model of care rather than a model of treatment. Now this does not mean we cannot involve a BPS thought process IN specific treatment but remember that this is just not really the major focus of the model, certainly as I understand it anyway.

So it is really treating people and their overall existence, not just treating their painful problem. These differing aspects cannot just be separated and simply targeted without an understanding of the person and the context they exist in, doing that for me is the biopsychosocial model in biomedical clothing.

Other commentators such as Leventhal have looked at concepts such as the disease and the illness *HERE*. The disease being the specific issue and the illness being the wider issues surrounding the problem, in my interpretation this is similar in concept to the BPS. How is this PERSON individually affected by the problem that may even BECOME the problem itself.

Just treat the pain?

I can already hear some readers shouting, “Just treat the pain - then you will not have any more problems”

Well that is the biomedical view in a nutshell!

Firstly we have been attempting top do this for ages, hence why there has been a call for a different model. Often treatments for pain are not successful and people need help in other ways and we treat pathology but pain persists. Perhaps the interaction with healthcare even makes the problem worse!

Can we treat the person and pain? Yes I believe so. We should not forget this, just realize our limitations at doing so and also avoid pain being the only focus.

The question is do we often attempt to treat the person AND the pain? I don’t think this happens as much as we would care to admit.  Maybe treating people rather than their pain can lead to reductions in pain? Maybe we cannot have an impact on people’s pain but affect suffering, disability and quality of life? We may not be able to do this in a pain-focused model and why we end up with repetitive surgeries and the opioid epidemic?

People can still have pain and live a positive life; the BPS model is really well placed to help them do so and does life simply return to normal even after pain has reduced for all? I would hazard a guess that for many people their lives are fundamentally changed even AFTER persistent pain has decreased.

BPS model of PAIN

A pain oriented BPS model has emerged more recently and two examples of this can be found *here* and *here*. These interpretations should NOT be confused with Engel's model I feel, and perhaps misses the essence of what he was reaching for. Maybe an issue with the BPS model is its breadth and how far ranging it is? It is quite easy to place our interpretation anywhere within it.

The pain focused model looks at how Biological Psychological and Social factors can influence pain.

This diagram is a great example with the arrows pointing solely inwards.

Screen Shot 2019 08 21 At 07.34.26

The problem here is that it is a return to a biomedical view in which the person is less of a focus and instead the disease (in this case pain) has returned to becoming the primary focus. Instead of being a comprehensive BI-DIRECTIONAL clinical philosophy, it has in many cases become a uni directional treatment model.  We also have much more evidence for BPS aspects being associated with pain than we do actual data to support treatment for pain using these BPS aspects.

Seeing PsychoSocial factors simply as pain influencing factors is missing the wood for the tree’s I feel. This would be a multi factorial pain treatment model, not the BPS model set out by Engel.

This has drawn critique, and rightly so, of the BPS model and it's interpretations. A recent paper from Stilwell and Harman can be found here called “An enactive approach - Beyond the BPS model” (Thanks to the authors for the full text link!). This critique, I feel and highlighted by the authors, is not really of the Engel's model but instead the pain focused interpretation that has evolved. We may not need to move beyond the BPS model, more just apply it in its intended way. Lets try to do that before we think beyond it.

Stilwell and Harman go on to say

“Pain is…..a process that emerges or unfolds through a whole person who is inseparable from the world”

but we should also consider the BPS perspective already to consider the whole world and our existence within it and not just its effect on pain!

The very essence of the BPS model was NOT to delve further and further into the microscopic components of biology but instead to also zoom out to encompass the other factors that may be at play in both pain and quality of life.  I have written about this *HERE*. But if we consider most of the discussion, theories and dominant messages around pain they focus on the reductionist view that Engel was trying to get away from.

As an example please insert any painful problem here 'XXXXX'. Even the most uni-factorial biological one you can think of…lets say a fracture.

How does their perception and knowledge, sense making, around the issue affect them and their behaviors?

How does the injury affect their work and family life?
What are their perceived implications for the future?
How confident are they to return to sport or activity?

How motivated are they to engage in rehab or treatment?

This is considering the PERSON and heir engagement and embodiment in the world not just breaking down pain ‘drivers’ as the trend seems to have become and accusations of people forgetting the bio (eye roll).

Straight lines & trichotomies

Some of the criticisms of the BPS pain model focus on the division into three distinct components biological, psychological, and social as well as a perceived linear causality between the associated factors and pain.

My view of Engel's work is that he objected to a linear causality model. Emergent properties such as pain NEVER have simple linear relationships with causes (whatever they are?). Again this is a misinterpretation and application specifically to pain of the original work. Linear causality is a criticism of previous Cartesian pain models but appears to be alive and well in the BPS.

The term ‘non linear’ means that small things can give large effects but also large effects in one area may also give rise to no effects in the targeted area.  There are so many interactions occurring that can affect each other that the same treatment may give rise to DIFFERENT positive or NEGATIVE outcomes dependent on the current state of the organism.

We seem to be happier for this to be the case now biomechanically, but less so biopsychosocially. If we are being honest then we have many more associations WITH pain from what are termed BPS factors than actual data from using these factors to treat pain.

The trend of splitting pain into separates categories of Biological, psychological and social to diagnose and treat is another critique that Stilwell and Hartman highlight in their paper and neatly term a tri-chotomy. I feel Engel’s point was not that they exist distinctly as pathologies to treat but in their own right but to consider these things within the wider appreciation of the patient’s experience.

Conclusion

  • We should really see the BPS model as a CLINICAL PHILOSOPHY and way of incorporating the patient into healthcare.
  • It is intended to understand patients, their lives and contexts.
  • The biopsychosocial model COULD be used as a pain treatment model, but this is probably not how it was intended. This maybe better termed a multi dimensional pain treatment model.
  • There is not really much data on outcomes from treatment using a BPS pain model.
  • BPS factors are not simply linear treatment targets.
  • We may need to better apply the BPS model rather than move beyond it.