Musculoskeletal Physiotherapy Consultants

Biopsychosocial – getting the balance right

By on February 11, 2016 in General with 0 Comments

biopsychosocialAdopting a biopsychosocial approach to managing musculoskeletal disorders is a sound and fundamental principle of the Clinical Framework . It has almost become a mantra repeated by all and sundry and presumed to signify that the best, most evidence based and up to date approach is being used.

Consideration of the multidimensional (biological+psychological+social) nature of back pain in particular, is essential but a not new concept. Many decades ago the impact of psychosocial factors was recognised and over 30 years ago Waddell developed some tests to help identify when this was the case. In recent times there have been a number of studies that have shown that scores on various psychosocial scales are in fact the strongest determinant of outcome with respect to return to work and functional status.1

This raises the risk that the original intention in coining the phrase (recognising the influence of all aspects) will become lost or at least unbalanced. To avoid this we must step back and take a broad view to decide what the priorities are for each individual and not assume all to come under the umbrella of psychosocial. A propensity to place undue emphasis on relatively small psychosocial issues often results in inappropriate and ineffective treatment. In general Physiotherapists feel they are not properly equipped to identify or deal with such issues1 yet increasingly it is being touted as contemporary practice that practitioners are expected to embrace.

Physiotherapy has a history of following fads and fashions, often to the exclusion of proven methods and despite being warned against doing so –

“With our enthusiasm for new trends to seem smart and stylish in our therapeutic practice, we must be careful that we don’t fall into the trap of not adhering to recognised and established practices” (Moore and Jull, 2000)

Unquestioningly following such new trends as presented by charismatic and well-meaning ‘gurus’, can be at the expense of having a balanced, objective view in each individual case and can lead to a misguided but well-meaning focus. There have been documented cases where a predilection for a psychosocial based approach resulted in missing a clear biological diagnosis and significant delay in receiving the right treatment2. Others have also called for the ‘bio’ not to be disregarded3, 4.

While there has been a past history of perhaps over- emphasis on the ‘bio’, the swing to psychosocial is risking an overcorrection. It is typical of physiotherapy to embrace new approaches even before the verdict is in on the research. On top of this, many extrapolations are being made from e.g. lumbar spine to peripheral joints, chronic situations to acute situations when there is actually no evidence that there are valid comparisons. Almost every new treatment approach has eventually been shown to have far less efficacy than initially expected, claimed and hoped for. There is a strong lesson in that.

In our experience, as in all things, the truth is usually somewhere in the middle.

In the physiotherapy community there are both extremes – those that persist with physical treatment when no benefit is demonstrated and those that shy away from physical treatment too readily in the face of minor psychosocial issues. The truth can best be arrived at via a proper assessment that includes all aspects of a physical examination as well as incorporating some well-chosen and appropriate questionnaires to help determine the true degree of psychosocial influence (see previous blog re outcome measures).

  1. O’Sullivan, P. (2011) Its time for change with the management of chronic non specific low back pain. British Journal of Sports Medicine. doi:10.1136/bjsm.2010.081638
  2. Singla M, Jones M, Edwards I, Kumar S. (2015) Physiotherapists’ assessment of patients’ psychosocial status: are we standing on thin ice? A qualitative descriptive study. Manual Therapy;20:328-34.
  3. Monie AP, Fazey PJ, Singer KP, (2015) Low back pain misdiagnosis or missed diagnosis: Core principles. Manual Therapy doi: 10.1016/j.math.2015.10.003
  4. Hancock M, Maher C, Laslett M, Hay E, Koes B. (2011) Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain? European Spine Journal;20:2105-10.

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