What fills your cup? A biopsychosocial approach to chronic pain.
- alambert202
- Oct 29, 2019
- 5 min read
Updated: Nov 3, 2019
For as long as I can remember, when I was faced with a difficult problem my first step consisted of going back to the drawing board, identifying common themes and creating some type of flow chart. Graphic representations are commonly used to analyze and simplify complex problems in politics, engineering, finance and in health care. Over the years, healthcare researchers have been using multilevel models to better understand complex health issues. In 1970, the biomedical model dominated health care. At the time, an innovative George Engel believed that ‘’to understand and respond adequately to patients’ suffering—and to give them a sense of being understood—clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness” (Borrell-Carrió, Suchman & Epstein, 2004, p.576). This is when the Biopsychosocial Model (BPSM) was born .
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BPSM was first introduced into the world of psychiatry (Jull, 2017). In 1987, Waddell adapted it as a framework to study chronic low back pain and it soon became more and more accepted in other sphere of musculoskeletal disorders and most certainly in chronic pain (Jull, 2017). Referring to the BPSM, Borrel-Cario et al say: ‘’his model struck a resonant chord with those sectors of the medical profession that wished to bring more empathy and compassion into medical practice’’ (Borrel-Cario et al, 2004, p. 576) . This model not only brings the whole medical community closer together, but it makes the patient even more involved in their own health.
As a physiotherapist, I was introduced to the BPSM early in my training, however I must admit that it took me years to understand how a person’s overall psychosocial well-being could influence the pain they were experiencing. I had no idea how someone could still be in pain two years after a simple ankle sprain with no hard findings on an MRI. I believe that my ‘’awe’’ moment came around 10 years after graduating from physiotherapy school. I met a very ‘’different’’ physiotherapist at The Ottawa Rehabilitation Hospital Center: to be honest, I thought she was crazy. Janet Holly, a veteran physiotherapist and certified pain specialist took the time to explain to me the BPSM and how it could be applied to chronic pain. She was treating some of our military members living with chronic regional pain syndrome in such a brilliant empathic way that I only wanted to learn more from her every chance I had. The few hours I spent discussing treatment options and assessment technique with her open my eyes to a whole new world of possibilities. I became more patient and truly passionate to help the most difficult patients in the rehab world: those suffering from chronic pain.
Chronic pain was recently recognized by the World Health Organization as a disease in its own right (Canadian Pain Task Force Report), 2019). This step is huge as it means that it will also get its own code within the new version (11th) of the International Classification of Diseases (ICD-11) (CPTFR, 2019). This will without a doubt facilitate future research and hopefully create some deeper interest and understanding on the subject. The ICD-11 (CPTFR, 2019) further classifies chronic pain into chronic primary pain or chronic secondary pain:
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Fig 2
As one digs further into its understanding of chronic pain, the BPSM seems like a great tool to use in research but also in patient care. No amount of XRAYs, MRIs and ER visits can account for the chronic low back pain felt by the single mother of two teens, working in a loud and stinky garage, who was assaulted multiple times by her ex-husband before she left him (husband who was, yes you guessed right- a mechanic). If the biopsychosocial model did not yet exist or if her provider did not know or understand its application, this woman would be going for endless tests, may be prescribed opioids to deal with her pain and seen by the ER staff as a ‘’frequent flyer’’. On the other end, if this woman meets a provider who takes the time to get the full picture and knows about the importance of each domain of the BPSM, he/she will spend the extra time to educate the woman on pain management, how it works and refer her to the appropriate resource.
According to the Canadian Pain Task Force Report (2019), one in five Canadians currently lives with chronic pain. This burden is not shared equally amongst the population: older adults, females, Indigenous Peoples, Veterans and populations affected by social inequities and discrimination are more affected by this diagnosis (CPTFR, 2019). These five groups are all fitting within the social determinants of health (SDOH) proposed by Mikkonen and Raphael in their 2010 publication. Indeed, gender, Aboriginal status, social exclusion, social safety net as well as income and income distribution are 5 of the 14 SDOH discussed in their report (Mikkonen & Raphael, 2010). These specific determinants were proven to have strong effects upon the health of Canadians and clearly chronic pain is no exception.
When asking clinicians (doctors, physiotherapist, psychologists, etc.) how to treat a patient with a specific condition, the traditional answer will be ‘’it depends’’. One of the most interesting things with the biopsychosocial model and using it with the chronic pain population is that each patient remains unique. The table and diagram below present three fictitious patients, each of them living with chronic low back pain. This should help clarify how each domain of the BPSM can weigh in differently when dealing with patients.
Fig 3 3 patients- 3 different stories
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Fig 4 Jull, 2017
It may now seem easier for you to look at these stories and diagrams and figure out what to do next with each patient. Belinda might require some help from a dietician and get on an exercise program in order to kick start her road to recovery. Samantha may need further support from her community: in turn you may get her to think to explore what it would take to finish her high school degree. Belinda will likely require some assistance from a psychologist and luckily you have one working in your clinic and you bring her case up at the multidisciplinary rounds. Those three women coming in for the same pain all have different stories hence different paths to follow. These paths may be bumpy and full of turns. However, it all started with someone taking the time to ask questions and get the full picture. Although multilevel models in healthcare are a good commencement, never forget that many other factors may influence your patient’s ability to cope with their symptoms. I hope the BPSM will make you think of chronic health problems differently from now on and get you to wonder what fills your patient's cup.
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Figure 5 Lehman, G. (n.d.)
References
Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Annals of Family Medicine, 2(6), 576–582. https://0-doi-org.aupac.lib.athabascau.ca/10.1370/afm.245
Canadian Pain Task Force Report. (June 2019) Chronic Pain in Canada: Laying a Foundation for Action. Retrieved from: https://www.canada.ca/en/health-canada/corporate/about- health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019.html#a1.5
Jull, G. (2017). Biopsychosocial model of disease: 40?years on. Which way is the pendulum swinging? British Journal of Sports Medicine, (16), 1187. Retrieved from http://0- search.ebscohost.com.aupac.lib.athabascau.ca/login.aspx?direct=true&db=edsgih&AN=edsgcl.505809083&site=eds-live
Lehman, Greg (n.d.) Recovery Strategies Pain Guide Book, Retrieved from : http://www.greglehman.ca/pain-science-workbooks
Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian facts [PDF
File]. Retrieved from https://thecanadianfacts.org/the_canadian_facts.pdf
WCPT. (2017, July 4). How important is the Biopsychosocial Approach when Treating Pain [Video file]. Retrieved from https://youtu.be/_-0hh5E0NRs
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