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The University Of Utah
Department of Physical Therapy
The Biopsychosocial Approach to
Functional Improvement
Julie M. Fritz
“Pain represents a national
challenge. A cultural
transformation is necessary
to better prevent, assess,
treat, and understand pain of
all types.”
Professor, University of Utah
Clinical Outcomes Research Scientist
Intermountain Healthcare
Salt Lake City, Utah, USA
The University of Utah
Department of Physical Therapy
Pain as a Public Health Challenge
The BIOMEDICAL Model
• Affects at least 116 million American adults
• Significant reductions in quality of life
• Costs to society $560–$635 billion annually
Pain as a sensory event reflecting
underlying disease or tissue damage
• For many pain prevention, assessment, and
treatment are inadequate.
• Need to improve provider education in a
manner consistent with current pain science.
Injury/
Nocioception
Tissue
damage
Pain
The University of Utah
Department of Physical Therapy
The BIOMEDICAL Model
 Pain is solely explainable in biological or
medical terms
 Mental or emotional problems may result from
chronic pain,
p
but the pain
p
itself is biological
g
in
origin
 Effective treatments for pain involve medical
approaches (ie, address the pathoanatomical
source of the pain)
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
Cognitive/
Behavioral
Consequences
The University of Utah
Department of Physical Therapy
The BIOMEDICAL Model
TREATMENT IMPLICATIONS
 Signs and symptoms are directly proportional to
the underlying pathology
 Identifying the underlying pathology is critical for
guiding treatment
 Signs and symptoms should disappear when
pathology is corrected
The University of Utah
Department of Physical Therapy
1
Increasing Rates of Back Injections
The incidence of common symptoms in primary care
and the proportion found to be due to organic disease.
Friedly J. Spine 2007;1754-1760
Adapted from Kroenke and Mangelsdorff, 2001)
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Chronic LBP Prevalence by Age Category
The BIOPSYCHOSOCIAL Model
18
16
Clinical expression of pain
encompasses numerous
aspects besides physical
dysfunction:
14
percentage
12
10
8
Over 70% increase in medical
di
i d
expenditures over same period
1992
2006
Social & Vocational Environment
Behaviour
Emotional
Distress
Emotional distress
Attitudes
& Beliefs
Attitudes and beliefs
6
The social environment
4
Illness behavior of patient
PAIN
2
0
>65
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Evidence for the Biopsychosocial Model
The BIOPSYCHOSOCIAL Model
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
No disability
Henschke et al. BMJ (2008)
0.4
ye
ar
1
on
th
s
m
6
m
on
th
s
0.2
w
ee
k
m s
on
th
s
1
ye
ar
0.2
0.6
3
Cumulative probability of
still having pain
0.4
0.8
6
0.6
m
on
th
s
 Outcomes of treatment depend on management
across domains of the model
0.8
m
on
th
s
 Knowledge of cause of pain is not sufficient to
determine its impact (or legitimacy).
1.0
1.0
9
 Pain (particularly when chronic) is rarely the only
presenting symptom (although may be the only
one recognized).
 Follow up at 6 weeks, 3 months, and 12 months
Cumulative probability of still having disability
 The relationship between tissue damage and pain
is variable and unpredictable
 Inception cohort study of 973 patients presenting to
primary care with LBP < 2 weeks duration
6
MANAGEMENT IMPLICATIONS
9
55-64
6
45-54
w
ee
k
m s
on
th
s
35-44
3
21-34
Freburger et al, Arch Int Med, 2009
Pain-free
The University of Utah
Department of Physical Therapy
2
Yellow flags
Yellow Flags
(adverse prognostic factors)
 Inappropriate attitudes and beliefs about back pain
 Older age
(e.g, belief that back pain is harmful or potentially severely
disabling or high expectation of passive treatments rather than a
belief that active participation will help)
 More intense pain
 Longer
g duration of low back pain
p
 Patient reports feeling depressed
 Patient believes pain is likely to persist
 Work related problems or compensation issues
(e.g., poor work satisfaction)
 Emotional problems
(e.g, depression, anxiety, stress, tendency to low mood and
withdrawal from social interaction).
 Compensable low back pain
The University of Utah
Department of Physical Therapy
Henschke et al. BMJ (2008)
 Inappropriate pain behaviour
(e.g., fear-avoidance behaviour and reduced activity levels)
 More days of reduced activity
MANAGEMENT IMPLICATIONS
SCREENING
From van Tulder et al, 2006: European guidelines for the management of acute nonspecific
The University of Utah
low back pain in primary care
Department of Physical Therapy
 Early identification of patients more likely to develop
persistent disabling symptoms could help guide decisions
regarding follow-up and management.
 Because individual risk factors are relatively weak, risk
prediction instruments could be more helpful than
individual yellow flags for predicting outcomes.
 More research is needed to understand the clinical
usefulness of risk prediction instruments for identifying
high-risk patients and the optimal strategies to decrease
the likelihood of chronic disabling back pain.
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Multi‐Construct Screening Tools for Individuals at Risk of Persistent LBP
 Distress and Risk Assessment Method
 Vermont Disability Prediction Questionnaire
 Örebro Musculoskeletal Pain Questionnaire
(Acute Low Back Pain Screening Questionnaire)
 StartBack Screening Tool
 9-item tool comprising modifiable prognostic factors of
both physical and psychosocial constructs
 Stratifies risk for developing future disabling LBP
–Low Risk (few barriers to recovery)
–Medium Risk (predominantly physical barriers to recovery)
–High Risk (psychological barriers to recovery)
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
The University of Utah
Department of Physical Therapy
3
FEAR AVOIDANCE
ANXIETY
Psychological Barriers to Recovery
CATASTROPHIZING
High
Risk Psychologically-Informed Therapy
DEPRESSION
Physical Barriers to Recovery
BOTHERSOMENESS
Medium Risk
Physical Therapy
Minimal Barriers to Recovery
Low Risk
Advice and Reassurance
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Clinical Journal of Pain
Clinical Journal of Pain
Objective
– Evaluate agreement between clinicians and the SBST’s risk
allocation
ll
ti
Methods:
– 12 patients: video recorded clinical exam including SBST
– Video reviewed and independent risk allocation
3 General Practitioners
3 Physical Therapists
Results
– Interrater agreement: Fair (k = .28)
– Observed agreement with SBST 17/36 (weighted k = .22)
Conclusion
– Clinicians make inconsistent risk estimates
– Little agreement with formal tool
3 Pain Management Specialists
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
 858 patients with LBP in primary care
 Randomized to receive:
– Stratified management based on SBT
– Usual Care (control)
High
Enhanced Physiotherapy
Medium risk
Physiotherapy
Low risk
GP/best practice care
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
4
average lost work days
14
12
10
8
6
4
2
0
Control
Intervention
Low Risk
Medium Risk
High Risk
From an economics perspective, the stratified management approach was
associated with improvements in health-related quality of life (QALYs), a
reduction in health-care use, and fewer days off work related to back pain.
What is Psychologically‐Informed Practice?
Main C J , George S Z PHYS THER 2011;91:820-824
 Educational Interventions
Proposed theoretical framework for the management of low back pain by
physical therapists
– Advantages of remaining active
– Favorable expectations
– Problem-solving/coping strategies
 Cognitive Behavioral Strategies:
–Graded Exposure to worrisome activities
–Graded Activity
Goal setting
Positive reinforcement
The University of Utah
Department of Physical Therapy
MESSAGES MATTER
“Back Pain: Don’t Take It Lying Down”
 Disability from LBP is a public health problem
 In Victoria, Australia back pain accounted for…
25% of all claims account for workers
–25%
workers’ compensation
–40% of long-term disability claims
–Nearly 50% of the total costs of all claims
 Compensation costs for LBP had tripled in the past 10
years
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
The University of Utah
Department of Physical Therapy
“Back Pain: Don’t Take It Lying Down”
 Attitudes and beliefs about LBP influence the
development of long-term disability
 Societal beliefs may perpetuate maladaptive attitudes
towards LBP
– Both provider and patient beliefs contribute to the problem
 SOLUTION – public media campaign
– Campaign was designed to alter the public’s beliefs about
back pain, influence medical management, and ultimately
reduce disability and compensation claims.
The University of Utah
Department of Physical Therapy
5
“Back Pain: Don’t Take It Lying Down”
“Back Pain: Don’t Take It Lying Down”
 Campaign was based on the messages of The Back
Book.
– Unambiguous advice to stay active, avoid rest for
prolonged periods and remain at work
– Emphasized that the spine is strong, self-coping is
important, imaging is usually not helpful, and surgery is
usually not the answer.
MEDIA MESSAGES
 Positive advice to stay active and exercise, not to rest
for prolonged periods, and to remain at work;
 Encourage patients to take responsibility for getting
better and coping;
 Advice that physical activity and work won’t cause harm
 Education that imaging may not be helpful and surgery
is usually not the answer
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Maladaptive Provider Beliefs
 Assessed physical therapists on their
biomedical vs biopsychosocial orientations
towards non-specific LBP.
 Therapists with biomedical orientation viewed
daily activities as more harmful for LBP patients
Steeper declines in days and
costs per claim for LBP vs. other
complaints
Absolute reduction in medical
costs was 20% per claim
Houben et al. European J. Pain 9 (2005) 173–183.
The University of Utah
Department of Physical Therapy
Patient Education – Key Considerations
 Encourage maintenance of activity (hurt vs. harm)
 Reassure that serious pathology has been excluded
 Decrease patient’s focus on pain, shift to focus on
function
Cognitive‐Behavioral Therapies
 Integrated therapy that combines cognitive
therapy (changing self-defeating thinking)
with behavior therapy (changing behavior)
 Therapeutic strategies aimed at:
 Avoid “medicalizing” explanations, emphasis on
need for imaging investigations
– reducing maladaptive behaviors and increasing
adaptive behavior
 Specific interviewing skills to identify potential
psychological barrier
– modifying maladaptive beliefs, attitudes, and
expectations
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
The University of Utah
Department of Physical Therapy
6
Cognitive‐Behavioral Therapy
 Goal-setting
Patients with LBP (< 8 wks) Receiving Physical Therapy
– short-term goals
– long-term goals
 Shaping
– Successive approximations
– Gradual exposure to fearful activities
 Reward for goal attainment
The University of Utah
Department of Physical Therapy
Biomedical Group
Biopsychosocial Group
• Classification-based management
• Classification-based management
• Exercise prescription based on
limits of pain
• Exercise prescription based
setting goals and quotas
• Education in anatomy and
pathology of spine (Handy Hints
pamphlet, reinforcement of
message in clinic)
• Education to remain active (Back
Book pamphlet, reinforcement of
message in clinic)
The University of Utah
Department of Physical Therapy
Patient Education
 Biomedical group
–Handy Hints pamphlet
–Reinforce
Reinforce this message in clinic
 Biopsychosocial group
–Back Book pamphlet
–Reinforce this message in clinic
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
7
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Exercise Progression
Exercise Prescription
Biomedical group
Biopsychosocial group
 Specific to individual patient presentation
– Based on pain intensity
– Based on quota
 Exercise program components
– Record initial pain intensity
– Establish initial quota
–Aerobic
A bi
– Perform exercise
prescription
– Perform exercise
prescription
–Flexibility
– Record final pain intensity
–Strength
– Progress when pain
intensity is the same or
decreased
– Progress when patient met
pre-defined exercise quota
 Time limit = 1 hour
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Feedback
Biomedical group
Biopsychosocial group
OSWESTRY SCORES
45
– Base explanations on
anatomical model
– Encourage positive
expectations
– Pain = pathology
– Avoid anatomical
explanations of pain
40
35
– Pain is a sign to limit
activities
– Interventions are a
“progression”
30
25
– Regularly review clinic
performance
20
15
– Positive feedback
10
Traditional
Fear-Avoidance
5
0
Baseline
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
4 weeks
6 months
The University of Utah
Department of Physical Therapy
8
Biopsychosocial
group
Traditional group
Summary
 Movement from Biomedical to Biopsychosocial
Model has been a “revolution”.
 The potential of the Biopsychosocial model to
improve outcomes and reduce suffering has yet to
be recognized.
recognized
 Providers must revolutionize their own thinking and
approach.
 This is a system problem
 Screening and targeting are critical to effective
management.
The University of Utah
Department of Physical Therapy
The University of Utah
Department of Physical Therapy
Thank You
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
9