What's The Best Approach? BioPsychoSocial vs Biomedical. Part 1

One of the more talked about topics in physiotherapy is the Biopsychosocial (BPS) model or approach. While it certainly doesn’t have the same curb appeal as “correcting ring shifts” or “myofascial release”, it seems to be grabbing the attention of physiotherapists worldwide. Lets break down the term to give it a fuller meaning.

The “Bio” part is pretty straight forward: it refers to our muscles, joints, nerves, ligaments, tendons as well as the accompanying physiological processes and systems that keep us moving and ticking.  We all know a fair bit about this stuff, and the biomedical model (still largely used) continues to mostly focus on physiological processes.

The “Psycho” is short for psychological and this lends meaning to the fact that our thoughts, beliefs, emotions, personality traits, and behaviors are a critical component of a conscious person and that they invariably impact how we function.

The social component of the model dictates that our cultures, families, environments, jobs and relationships also tie into how we view the world and medical issues presented to us.  Essentially, it’s a holistic way of looking and interacting with the person in front of us.

All this may sound like a great ideal. But don’t we already look at all of these factors when interacting with our patients?

Perhaps not closely enough.

As early as the late 1970’s a psychiatrist in New York by the name of George Engel was calling on medicine for a change in the way patients were being treated. At the time, medical management was founded on the biomedical model that stated that any disease was a deviation from some kind of normative measurable biological state – thus completely ignoring any psychological or social factors. This reductionist approach was used in medicine for generations but had it’s limits. As H.R. Holman wrote here “reductionism is particularly harmful when it neglects the impact of nonbiological circumstances upon biologic processes”.

To counter this reductionist biomedical paradigm, Engel proposed a biospsychosocial approach to medical interactions. Fast forward to a 2005 paper that expanded on Engel’s thinking: “patient’s experiences and accounts of illness are generally not partitioned into biomedical and psychosocial domains…Starting from an understanding of this unpartitioned overall experience, the clinician can then develop a method for taking those pieces of the whole that are relevant for each case”. It has even been suggested that often our patients will tell us as clinicians which of these elements we need to focus on (ref here) – a call to employ good listening skills.

Perhaps after reading this, many will be thinking: how can we pick out which of these elements are important for helping the individual in front of us? Are we any good at this? How important are the different components in physiotherapy management? Are we effective at managing patients from a BPS approach?

I think we would all agree that most of us are good at detecting the biological parts. For 2-4 years (depending on where you were trained), our undergraduate and graduate-level training hammers the biological pieces into our brains; orthopedic assessments, physiological testing, basic physical functioning measures and fitness assessments are well covered in most Physiotherapy training programs and are strongly addressed and (mostly) well managed in clinic. For the purposes of this article, I am not discussing this piece of clinical interactions, although I want to make it clear that it is always a critical part of any physiotherapy session and cannot be ignored.  

Psychosocial factors appear to be less well covered and assessed by physiotherapists. In a 2015 study published in Manual Therapy, some themes emerged when physiotherapists were asked about assessing a patient’s psychosocial status. Physio’s in the study were “unclear about what psychosocial means”, performed “assessment based on gut feeling” rather than objective measures, identified “limited training and education” around assessing psychosocial factors and they all agreed on a “need for more formal training and additional tools” in this area. Interestingly, all physiotherapists in the study identified the importance of taking a BPS approach to patients, yet their practice did not reflect this. Another interesting sentiment that emerged from this paper was the fact that physiotherapists often saw psychosocial factors as only relevant in two situations – patients with chronic problems and those with a compensable status (e.g., third part claims). While we do know that these two are seen as risk factors for poor psychosocial outcomes, the authors go on to say, “research indicates that psychosocial factors can also influence acute presentations and contribute to the transition from acute to chronic in patients.” Furthermore, this study showed that health care professionals often view psychosocial factors as a negative construct that is separate from a patient’s biomedical presentation.

A lot of us can likely relate to these findings. Imagine this encounter: A client attends a physiotherapy assessment for long-standing low back pain. Over the years, this person has sought out care from multiple different health care professionals with mixed results. She has become worried about moving in certain ways because of painful episodes that have kept her off work for extended periods, which in turn creates financial struggles for her and her family. She has read through countless websites that have led her to believe that there must be something seriously wrong with her back because she has had pain for so long. How do we know what is important for accurately and comprehensively assessing and treating this person? As physiotherapists, we all have good intentions of helping this person with her pain and function, but where do we start and is our training good enough to tackle the (sometimes not-so-apparent) psychosocial factors?

How can we accurately identify these parts and then appropriately manage them?

The ability to detect and manage the various BPS components when working with patients can come from many avenues (not an exhaustive list): strong listening skills and rapport, empathic interactions, reflective questioning, and objective outcome measures.  At this point, I want to insert a blanket statement for the clinicians reading this thinking “but we are not psychologists and we don’t want to become psychologists!” I completely agree with this, however we cannot ignore that psycho-social challenges that have been found to impact physical functioning and associated treatment gains within a physiotherapy setting (Ref). Thus, identifying and addressing those psycho-social issues that are relevant to a patient’s physical functioning is highly relevant to any of us supporting our patient’s to make gains in these areas. Understandably, many physiotherapists may feel uncomfortable assessing and dealing with some of these factors or utilizing cognitive or behavioural techniques within physiotherapy. We currently lack the entry-level (and post-graduate) training in how to identify and deal with these factors. The NOI group postulated in a 2015 blog that “Given the move towards biopsychosocially oriented practice, psychosocial assessment should be considered as an integral part of physiotherapy assessment, and not merely an add-on.” Entry level physiotherapy training programs need to define these psychosocial factors that are approachable in a physiotherapy setting and implement training to screen for and address these factors. Just how good are we at identifying these factors to date? So far, the limited research says we are not great. Three studies showed that therapists in rehab settings often fail to accurately identify relevant psychosocial factors in various pain populations (ref, ref, ref).

 Jeff Jukes BSc MPT. Jeff's a Vancouver based Physio with a love of Pain Science, human behaviour, movement, and exercise.

Jeff Jukes BSc MPT. Jeff's a Vancouver based Physio with a love of Pain Science, human behaviour, movement, and exercise.

References: 

  1. Engel GL. The biopsychosocial model and the education of health professionals. Ann N Y Acad Sci 1978;310:535-44.
  2. Holman, H.R. The Excellence deception in Medicine. Hosp Prac. 1976; 11 (4); 11-21
  3. Bishop A, Foster NE. Do physical therapists in the United Kingdom recognize psychosocial factors in patients with acute low back pain? Spine 2005;30(11): 1316-22
  4. Heneweer H, Aufdemkampe G, Tudler MWV, Kiers H, Stappaerts K, Vanhees L. Psychosocial variables in patients with (sub) acute low back pain. Spine 2007;32(5):586e92.
  5. Haggman S, Maher CG, Refshauge KM. Screening for symptoms of depression by physical therapists managing low back pain. Phys Ther 2004;84:1157-66.
  6. Parker R. Physiotherapy student's assessment of psychosocial yellow flags in low back pain. SA J Physiother 2007;63(1):3-8.
  7. Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With Low Back Pain: A Reappraisal. Phys Ther 2016; 91 (5): 737-753
  8. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicenter longitudinal cohort study. BMJ 2016; 0; 1-8