Pain Science (Part 4/4): Treating Under BioPsychoSocial Framework

In the first three parts of this series I put forth a lot of research and criticized traditional thought on pain, orthopedics, posture and physical therapy. But what does all this information mean for us as practicing clinicians?

Above all, we need to reframe how we think about a patient in pain

We know from part one (*see here*) that while it may contribute, pain does not directly occur from tissue damage, degeneration or dysfunction as traditionally thought. Reframing our view on pain in this manner changes everything from how we view the patient’s condition to the way we explain things and even the prognoses we set. The framework has major ramifications for how we evaluate and treat.

We need to evaluate and treat more than biomechanics, strength and posture

We know (*see part one here*) the brain determines threat and produces pain in response based upon information from more than just the Bio domain. While the Bio domain may be contributing we are doing our patients and ourselves a disservice if we limit treatment to movement patterns, posture, or strength and ignore contributions from the Psycho & Social domains. How do we identify and treat those other contributions? Great question!

Evaluation of the Psycho & Social domains begins at first contact. I recommend a paper by Diener in 2016 for more thorough coverage on evaluation under the BPS framework than is within the scope of this post.¹ However, in general we are assessing for relevant beliefs, expectations and environmental drivers. I feel this can be done well through the combination of three things: Subjective questionnaires, targeted questioning and clinical judgement.

Questionnaires like the Pain Catastrophizing Scale and Orebro provide a standardized way to assess a variety of psychosocial constructs. Careful questioning can be used to further identify those beliefs and expectations. My favorite are two questions I picked up from a previous CI – “Why do you think you have pain?” and “What do you think it will take to get better?” as they are a short, sweet way to identify pertinent maladaptive beliefs and how to tailor treatment to patient expectations. The remainder simply comes down to clinical judgment based upon the questioning as well as patient’s non-verbal behavior, response to activities, appearance of family environment, etc.

Treatment of Psycho and Social drivers will vary on presentation. If the patient’s fear, worry about work, or avoidance behavior stem from knowledge of a disc herniation or fear of worsening the herniation with movement then it’s easy to address – educate them about the prevalence of asymptomatic herniations and sprinkle in PNE/BPS education. If the patient presents with severe anxiety or stress, then consider recommending something like meditation (we have some limited evidence of its effectiveness for chronic pain.)² On the expectation side – if the patient thinks PT won’t work then educate them on research supporting its effectiveness for their condition or find a way to frame your treatment under what they have positive expectations for. With that said, there are situations where the psycho and social drivers are beyond what we can or should treat (like complex family life, clinical depression, etc.) and a referral out may be warranted.

We need to be cognizant of how we explain our assessments and treatments

We know a person’s beliefs and expectations influence both their pain experience and treatment effectiveness. Practitioners constantly shape patient beliefs and expectations through their interactions which is awesome! However… practitioners can also shape harmful beliefs and expectations. For an easy look at how words matter – We know PNE education in isolation can improve pain and physical performance while telling a patient a movement may aggravate pain can worsen both pain and performance!^3,4 We also know using a PNE/BPS based explanation of manual interventions results in better outcomes than the typical biomechanical explanation (*see here for more on this in my manual therapy series.*)⁵

A practitioner can help guide a patient with a disc herniation to stop seeing spinal motion as a threat where pain is produced -OR- the practitioner can exacerbate threat perception by stating spinal flexion is inherently bad or dangerous. A practitioner can instill hope by educating a patient with a meniscal tear about asymptomatic tears -OR- they can instill hopeless by pinpointing the tear as the source of the patient’s pain, stating it must be vigorously protected or even surgically repaired (which may be the case in very select cases for function) to improve the pain.  A practitioner can calm a patient’s fear and anxiety through some PNE education -OR- they can exacerbate fear, anxiety and feelings of fragility by stating the patient’s spine is unstable and at risk.

These negative words and explanations are commonly termed nocebo (the opposite of placebo.) In a 2014 meta-analysis Petersen found nocebo to have a similar magnitude to that of placebo (aka it’s a big deal.)⁵ Not only do words influence outcomes but a variety of contextual factors do as well! We know things like perception of practitioner’s expertise level, attire, perceived cost of a procedure and therapeutic alliance all influence outcomes.^7,8

Whats the big take-away here? — Words matter!

 Beliefs and expectations influence how the brain perceives body parts, movements, activities or interventions and moderate whether threat is perceived or relieved with them. We need to maximize positive expectations and beliefs while minimizing the negative (or nocebo.) This is accomplished by being cognizant of our words and seeking to maximize contextual factors by doing things like dressing well, presenting ourselves in a confident, caring and professional, but approachable manner. For a more in depth look at maximizing these positive factors I recommend a paper by Testa in 2016 titled “Enhance Placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes.”⁷

We need to tailor our treatment to the specific pain type

I won’t go into detail here as it was covered heavily previously (*see here for part 2*) I simply contend PTs should be as big on identifying and treating the correct pain type as they are with identifying and treating the source body region. This is because posture and strength (the bio) aren’t always what matters and may not even matter in some cases which brings me to my last point…

We should only address posture and movement patterns when they are relevant

We know from part 3 (*see here*) that “bad posture” does not cause pain, but when are posture and movement patterns relevant? Great but super hard question! In general, I believe there are four major areas where posture and movement matter:

• When approaching the threshold of tissue tolerance/capacity: According to the Physical Stress Theory by Mueller tissue adapts in response to the specific stimulus by which it is is stressed.⁹ Tissues have a threshold of load they can accept before deformation or injury occurs, but that threshold is constantly increasing or decreasing based upon the load the tissue is stressed with. I believe the closer we get to this load threshold the more movement and posture matter as those variables influence the acceptance and distribution of that load.
  • What the heck do I mean? Posture and movement patterns matter when loaded! – like with weight-lifting or high intensity athletic activities.
  • For example – If a fit 20-year-old male bends over with a flexed lumbar spine to pick up a pencil it’s not concerning. Why? Because that load is way below what the lumbar spine can readily accept! However, if that same individual is maxing out on a dead-lift then maintaining a more neutral spine and moving from the hips becomes more important. Why? Because that load is closer to (or even beyond) the threshold of what the lumbar spine can readily accept! So, distributing the load among the hips (which can handle load better than the spine) as well as the spine helps avoid exceeding that threshold into injury
• When it increases injury risk: Although still in debate, certain movements have been associated with increased injury risk like dynamic valgus in ACL injury.^10,11,12 In those cases I contend it is worth changing the movement pattern even if not symptomatic. There are also select medical conditions where, in my opinion (although I hate to assert without evidence), the movement patterns may set the individual up for a great enough risk to be worth changing. An example of this is a younger, highly active patient I treated with Ehlers Danlos and approximately 20 degree of knee hyper-extension with any weightbearing activity from walking, jumping, to squatting.
• When looking to enhance athletic performance: I believe this is by far where the strongest argument to change posture and movement patterns exists. A compelling argument can be made for various specific postures and movement patterns being ideal in different sports. For example, hip dissociation and thoracic mobility are important for power generation and transfer in golf. Scapular stability is important to provide a firm base for power generation in many sports from swimming to rock-climbing to throwing. The detail is well beyond the scope of this post but there’s ample literature to support the influence of movement patterns and postures on performance
• When the movement or posture is symptomatic: Well… here’s the tricky one. I intend to expand heavily on this point in a future post when I discuss the Sahrmann Movement System Impairment treatment approach taught at my university. In general, I contend that if the movement or posture is symptomatic and those symptoms are predictably improved (based on a test-retest model) when changing the movement or posture to a more biomechanically “ideal” one then it is worth changing the posture (even if only temporarily.) Again, this will likely be applicable most often in nociceptive type pain.

I do not believe we should be concerned with movement or posture outside of these circumstances. If the movement or posture does not meet these criteria than it is not relevant and change or fixation on it will only serve to provide more nocebo and further sensitize the patient – AKA we should not instill the idea that any movement is posture is inherently bad (even if it is symptomatic at the time.)

Quick Recap:

• We need to reframe how we see pain and why we think it occurs
• We need to identify and treat Psycho and Social domain factors as well as Bio
• We need to be cognizant of our words in order to avoid nocebo and take advantage of contextual factors to maximize positive beliefs and expectations
• We need to tailor our treatment to the patient’s pain type and coinciding drivers
• Movement and posture is only relevant when:
  • Approaching tissue tolerance threshold
  • They increase injury risk
  • Seeking to enhance athletic performance
  • The movement or posture is symptomatic and change predictably improves symptoms

 

This post concludes my initial series on Pain Science. Hopefully it was enjoyable and sparked some thinking.

Hit the Instagram (where I am most active by far) or other social media icons up top and drop me a follow for updates on future blog posts, research reviews, exercise videos and other content.

 

Thanks for reading,

~Adam

 

References:

1. Diener I, Kargela M, Louw A. Listening is therapy: Patient interviewing from a pain science perspective. Physiother Theory Pract. 2016;32(5):356-67. (https://www.ncbi.nlm.nih.gov/pubmed/27351690)
2. Hilton L, Hempel S, Ewing BA, et al. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of Behavioral Medicine. 2017;51(2):199-213. doi:10.1007/s12160-016-9844-2. (https://www.ncbi.nlm.nih.gov/pubmed/276589130
3. Michael Pfingsten, Eric Leibing, Wulf Harter, Birgit Kröner-Herwig, Doreen Hempel, Uta Kronshage, Jan Hildebrandt; Fear-Avoidance Behavior and Anticipation of Pain in Patients With Chronic Low Back Pain: A Randomized Controlled Study, Pain Medicine, Volume 2, Issue 4, 1 December 2001, Pages 259–266, https://doi.org/10.1046/j.1526-4637.2001.01044.x
4. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain. 2004;8(1):39-45.1 (https://www.ncbi.nlm.nih.gov/pubmed/14690673)
5. Louw A, Farrell K, Landers M, et al. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther. 2017;25(5):227-234. (https://www.ncbi.nlm.nih.gov/pubmed/29449764)
6. Petersen GL, Finnerup NB, Colloca L, et al. The magnitude of nocebo effects in pain: A meta-analysis. Pain. 2014;155(8):1426-1434. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4213146/)
7. Testa M, Rossettini G. Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Man Ther. 2016;24:65-74. (https://www.ncbi.nlm.nih.gov/pubmed/27133031)
8. Amanda M. Hall, Paulo H. Ferreira, Christopher G. Maher, Jane Latimer, Manuela L. Ferreira; The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review, Physical Therapy, Volume 90, Issue 8, 1 August 2010, Pages 1099–1110 (https://www.ncbi.nlm.nih.gov/pubmed/20576715)
9. Michael J Mueller, Katrina S Maluf; Tissue Adaptation to Physical Stress: A Proposed “Physical Stress Theory” to Guide Physical Therapist Practice, Education, and Research, Physical Therapy, Volume 82, Issue 4, 1 April 2002, Pages 383–403 (https://doi.org/10.1093/ptj/82.4.383)
10. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. (https://www.ncbi.nlm.nih.gov/pubmed/15722287)
11. Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. Am J Sports Med. 2006;34(2):299-311. (https://www.ncbi.nlm.nih.gov/pubmed/16423913)
12. Willems TM, Witvrouw E, Delbaere K, Mahieu N, De bourdeaudhuij I, De clercq D. Intrinsic risk factors for inversion ankle sprains in male subjects: a prospective study. Am J Sports Med. 2005;33(3):415-23. (https://www.ncbi.nlm.nih.gov/pubmed/15716258)