Re-examining the ‘bio’ in a biopsychosocial approach to the management of pain

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Contemporary knowledge and thinking advocates an integrated biopsychosocial model for the more effective management of spino-pelvic pain disorders.
However, the ‘bio’ aspect seems to be the poor relation to the psychosocial at the moment. ‘Bio’ also appears to mean different things to different people and risks being misunderstood. The ‘bio’ element is big – and its complexities appear to be underappreciated.

My last post: “Axial dysfunction: Are you missing the real criminal driving many ‘Central Sensitisation’ and/or ‘Peripheral Pain’ syndromes?” provoked a lot of interest and frankly, a somewhat unexpected response.

It was most illuminating in that it showed how, in attempting to adopt a biopsychosocial approach, we risk developing an ‘either/ or’ attitude around a particular facet of the model according to our interest, level of understanding and clinical experience. An integrated approach fully appreciates each element and can variously apply them in management as indicated in each particular case.

The recent surge in behavioural and neuroscience research has greatly helped us better understand pain science and the influence of experience, understanding, beliefs and emotions around the pain experience. But what about what is going on in the body? It would appear that there is a camp of staunch neuroscience followers who pretty much see the ‘bio’ as limited to the well demonstrated CNS changes that occur in pain states.

‘Bio’ has been defined in the past by the medical biological model which led us thinking down the path of patho-anatomical structures such as ‘the disc’ or the facet joint as the cause of pain. Looking for structural pathology alone limits our understanding – and outcomes.

It is well documented that while many show radiological ‘pathology’, they don’t necessarily have pain. If they do, the pathology should not be ignored but rather understood as a component within a wider context of changed neuro-musculo-skeletal function throughout the body.

Coming to grips with the ‘bio’ in back pain represents a big challenge for professional care.

As a physiotherapist, I’m interested in trying to contribute towards a better understanding of the ‘bio’ in terms of how the integrated function between the nervous (CNS and PNS), myo-fascial and joint systems changes in back pain and many other spino-pelvic disorders (i). In particular, to explore the relationship between changed control of movement and pain. As ‘physical therapists’, this should be our strong suit.

A recent editorial (ii) addressed the pendulum swing in musculoskeletal physiotherapy practice behaviours from the ‘solely passive’ and ‘hands on’ treatment approaches of the past to the more recent ‘solely active’ or ‘hands off’ treatment approaches. Has the pendulum swung too far such that direct manual and specific motor control interventions are seen as ‘almost sinful’? These authors advocate a multimodal treatment approach within a bio-psych-social context reminding us of the ample available research to support the effectiveness of both appropriate manipulative therapy interventions and specific motor control exercise.

We can only properly address the ‘bio’ when we can appreciate how changes in one part of the neuro-myo-articular system will affect the functioning in the other interdependent systems and have repercussions throughout the whole body. ‘Knowing what is wrong helps you to right it’ – by appropriate manual intervention, exercise prescription and sound education and advice.

Spino-pelvic pain disorders are multifaceted in nature. We need to ensure we don’t only address one dimension, but adopt a balanced biopsychosocial approach.

Refrences

  1. Key J 2010. Back pain; A movement problem. A clinical approach incorporating relevant research and practice. Elsevier Edinburgh 2010
  2.  Jull G, Moore A. 2012. Hands on, hands off? The swings in musculoskeletal physiotherapy practice” Manual Therapy 17(3):199-200

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