What's The Best Approach? BioPsychoSocial vs Biomedical. Part 2

Part 2: What should we be learning from Psychologists

Although we are not aiming to become psychologists, we can likely learn a lot from the psychological approach to patients.  For decades, psychologists (and increasingly physiotherapists) have recognized that building a therapeutic alliance should be at the core of every patient-provider interaction. This develops from having good “soft skills”:  being empathic, having good eye contact and other non-verbal skills, focused listening while allowing patients to tell their story, limited interruptions, summative statements and reflective questioning based on what the patient is telling us.

Having this strong alliance has been shown to have drastic effects on treatment outcomes in pain populations (paper here). Interestingly, in this study and others that evaluate the effects of the therapeutic alliance, many of the outcomes measured are not physical, but rather functional and psychosocial related (i.e. depression, global rating of health, treatment satisfaction). So it appears that building this strong therapeutic alliance can affect psychosocial outcomes in a positive manner. Guidelines now exist that recommend a 2-phase process with a clinical interview (incorporating the above soft skills) and questionnaires to appraise the contribution of psychosocial factors in our patients with painful conditions.

Which questionnaires can we use in a physiotherapy setting?

With so many options out there, it’s difficult to pick out measures that fit into our daily practices. Delving into the reliability, validity, and suitability of all of these is beyond the scope of this article, however there are a few that stand out for use in a clinical physiotherapy setting.

  1. Pain Catastrophizing Scale (PCS) – short, easy to use, gives an idea of 3 different patient reported symptom domains (rumination, magnification, helplessness)
  2. Neurophysiology of Pain Questionnaire – very short and easy to use, can be used as pain education tool
  3. Orebro MSK Pain Questionnaire – longer but more complete measure, has functional measures, items can be used for goal setting, yellow flag screening tool
  4. Tampa Scale of Kinesiophobia (TSK) – will help identify fear avoidance types of behaviours and barriers to movement and exercise, short and easy to administer
  5. Pain Disability Index (PDI) – for chronic pain clients, helps measure the impact pain has on the ability to perform essential functions, can be used for goal setting

So just how important are these psychosocial factors?

A 2016 review published in Physical Therapy found that “taken as a whole, the evidence shows a clear relationship between psychological yellow flags and future clinical and occupational outcomes.” They go on to say that many non-physical factors such as depression, catastrophizing, negative pain coping behaviours, and maladaptive pain beliefs are consistently associated with adverse outcomes. Furthermore, research from prominent UK physiotherapist Jeremy Lewis found that in predicting outcomes for patients with shoulder pain, psychological and social factors influenced outcomes more than physical factors.

The past 10 years of research on non-specific low back pain has shown that the main predictors of poor outcomes are psychosocial factors. Dr. Peter O’Sullivan, alongside his group of researchers in Australia have identified the importance of including psychosocial factors into assessment and treatment of painful conditions and notably low back pain. To combat this, they developed a system called classification based cognitive functional therapy. As the NOI blog puts it, this is: “a clinical reasoning process that considers the contribution of: patho-anatomical factors where present, neurophysiological mechanisms, cognitive and psychosocial, lifestyle and physical factors, such as maladaptive movement behaviours, body schema distortions and muscle conditioning”. Thus, the emerging theme of moving away from biomedical and pathoanatomical approaches continues.

In sum, although we likely aren’t there yet as a profession that strongly utilizes a BPS approach, the good news is that it appears as if we’re headed in the right direction. We are perfectly suited to be incorporating some of the above screening tools, techniques, and strategies into clinical practice to hopefully screen for, and appropriately address, some of the psychosocial factors that impact physical functioning and rehabilitation - especially for people in pain!

As physiotherapists we are always seeking actionable clinical tidbits, so here’s the bottom line on screening and addressing psychosocial factors in clinical interactions:

  1. Focus your efforts on building a strong therapeutic alliance with clients.
  2. Seek out educational opportunities in “non-physio” arenas, (e.g. motivational interviewing, listening skills, cognitive behavioural training etc) that focus on the non-physical aspects of physiotherapy interactions.
  3. Start using questionnaires – pick a few that you like and would be likely to use and start implementing them.
  4. As physiotherapists, we are in a position to address many of the common psychosocial factors that present with pain and other physical ailments that research has identified as important aspects of improved functioning – let’s not ignore this important aspect of our patient’s experience!
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.


  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