We have heard so much about the Biopsychosocial model in the physio world over the last few years. In my Undergraduate Physiotherapy Program, we were taught a bit of a mixture of both the Postural Structural and Biomechanical, and the Biopsychosocial models. A mixture of both, but probably leaning toward the Biopsychosocial model- at least when it comes to it’s benefits anyway, but probably not the implementation of it. I came out of college thinking my hands-on skills were not up to scratch. And they were not. But I also came out thinking my ability to implement the Biopsychosocial model was inadequate. I knew its importance. But how do I apply it to the individual who walks through my door?
After college I began trying to improve on my “hands-on” skills. But what happened to the Biopsychosocial model? Did I stop using it? Did it fall to the wayside? Probably to an extent. Living in a different country for a few years probably made it a little harder for me to implement it. Not an excuse but it happens. The culture was totally different, and you find yourself telling “stories” about the biomechanics, postures and damaged structures. Buy-in was hard enough to get when the therapist was a from a completely different country and background. Things often got lost in translation. So, you do what you can to get them on board. But this meant that psychosocial factors were neglected.
As I say this, I realise, what was the barrier to getting “buy in”? Social Factors. Client and therapist’s culture and beliefs systems. What are they? Do they differ? Barriers and facilitators to treatment affected by social factors. Where does that fall into the model if it is solely postural, structural and biomechanical?
A few years ago, I had a little bang to my own wrist. It was small and seemingly innoxious. But I had had a fracture in that wrist 10 years previous. This small bang required splinting followed by a bit of rehab, and after a few weeks there was no improvement. The impact such a small injury can have on your life is phenomenal. Unable to play my sport, unable to do my job, unable to cook for myself, tie up my hair.
I eventually got an MRI revealing a “small TFCC tear” (Triangular Fibrocartilaginous Complex). More conservative treatment. No improvement, until a few months later (all the while being out of work on sick-leave) we opted for surgery.
Intra-op the surgeon found “Masses of scar tissue”, told me I had been “Repeatedly tearing it over the 10 years since the initial fracture.” He reinforced that I “Definitely needed the surgery.” Telling me I “made the right decision, you would have needed the surgery in a years’ time regardless”. Apparently, it was “One of the worst I have seen”. He told me not to injure it again because if I did, there was not enough good healthy tissue for a second repair. These were just some of the things my surgeon said to me.
At the time I was delighted. Thank God I made the right decision. Until I reflected on the treatment I received. Did anyone ask me how I was feeling, how I was coping with being off work in a foreign country, with limited social support, with no family around to help. Did they ask me how I was getting on at work, how I was coping at home? About the high stress job that I was in at the time? Did they ask about the support structures in place for me? About how I spent all this new spare time I had? Did anyone ask about my general health at the time, or how well I was sleeping? Or did everyone assume it was fantastic to have a few weeks off without realising or acknowledging the impact it has on you as a human and as an individual?
I say the impact on you as an individual because an injury does not happen to a wrist, or a hamstring or an ACL. It happens to the individual. It happens to the person and so it effects the person in their entirety.
Working by the Structural Postural and Biomechanical Model, I surely would have been getting pain for the last 10 years as, according to the surgeon, I had been tearing and re-tearing the cartilage and ligaments all along unbeknownst to myself.
But the model is flawed.
If the model was flawed for me, how can I expect to treat my clients based on such a model.
How can I ensure that I do better with my clients? Did I need the surgery? Maybe. Maybe not. Is my wrist all the better for it? Well it is better, but I am also in a much lower stress job than I was previously, my general health is better, I have improved social support, life seems to be going a lot smoother recently.
This isn’t to say that there is no merit in the postural, structural and biomechanical model at all. The Biopsychosocial model includes it. But it also includes other things that the individual is currently experiencing.
I suppose as physiotherapists we are experts in movement and it can be easier to hone in on movement specifics. We need biomechanics to generate locomotion. We know this. But do we need to strive for perfection with these movements? What even is perfection? Can we compensate in a pain free way? Is compensation not the most powerful thing a body can do? You tear a muscle in your leg, but yet you can still walk. You can have torn ligaments in your wrist and not even know about it.
Our bodies are adaptable and resilient.
I will say that again. Our bodies are adaptable and resilient.
Trust in our own body’s resilience often goes a long way. Trust. Trust in your body. Trust in yourself. Trust in your healthcare professional.
How can we promote this resilience and trust? Through language. I will never forget those things the surgeon said to me. What if someone had said to me “Yes, there is some slight damage in the wrist but why don’t we try getting you into a better environment for recovery? What can we do to manage your work stress a little better? How can we optimise your potential for recovery by looking outside of your wrist? Your exercise levels, your sleep pattern, your diet?” What if someone took 5 minutes to actually talk to me about me? Maybe I still would have needed the surgery, but maybe not.
We know that nociceptors are not pain receptors. They are threat detectors and nociception is neither sufficient nor necessary for pain. Threat is interpreted by the nervous system. What if the brain is really busy dealing with all the emotional and psychological stressors you have going on at the moment and it misinterprets that threat? Is that particular stimulus actually threatening and dangerous? How many times has our brain gotten things wrong before and misinterpreted things? Particularly when we are distracted, busy and fatigued. Should this potential threat always be avoided if our nervous system misinterpreted it in the first instance? How can we show the system it might have been a mistake? Maybe by trying again in a safe and controlled way allowing system to come to terms with this scary movement, exercise, stimulus, idea; whatever it may be.
The nervous system and the brain are powerful. Our bodies are powerful.
Sometimes I think the biopsychosocial model is a lot harder to justify to clients and implement because they’re expectations have been set by a long tradition of physiotherapy being mainly a hands-on treatment approach. Sometimes it’s a lot easier to be able to blame a specific structure being “out”. Sometimes I myself wish it was as easy as just being able to blame the “anterior pelvic tilt” or the “rounded shoulders”. Sometimes we want the easier option. So do our clients. But again, is that right? Is that going to get them better?
So how do I as a physio address the psychosocial aspects of pain? Do I just offer a listening ear? Or do I promote movement and empower my clients to help themselves and to move? I need to get to know them, their motivations and what makes them tick. I need to know their fears and their beliefs to empower them to tackle the obstacles in their paths- physical obstacles, psychological stressors and social influences. I need to ask questions, decide what pushes them, but equally as importantly, what holds them back. Knowing these things won’t help me fix anyone. But that isn’t what I do. It helps me to facilitate people on the road to maximise potential, maximise movement and maximise quality of life. Maybe physiotherapy is as much about the journey as the destination?Leave a reply
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