24. april 2017
An overview of three recent biopsychosocial treatment models for musculoskeletal pain disorders
Yngve Roe1 and Daniel Major2
- Associated professor, Institute of Physiotherapy, Oslo University College of Applied Sciences (HIOA) and clinical physiotherapist; e-mail: Yngve.firstname.lastname@example.org
- PhD Research Fellow, Institute of Physiotherapy, Oslo University College of Applied Sciences (HIOA) and clinical physiotherapist; e-mail: email@example.com
The increasing disability caused by musculoskeletal pain disorders such as back-, neck- and shoulder pain is a global challenge (Vos et al., 2012). This development put strain on health care systems, as they need to address rising numbers of patients with conditions that largely cause disability but not mortality (Vos et al., 2012).
Within rehabilitation, common treatments for persistent musculoskeletal pain disorders are surgery, injections, physiotherapy and/or medication. Among physiotherapists, exercises alone, or in combination with manual therapy is the most common treatment intervention. Often exercise treatment for patients with musculoskeletal disorders are based on a structural model, aiming to increase strength and load tolerance in local tissue, such as muscles, tendons and ligaments. In these types of treatment models, thoughts and experiences of the patients about pain and movement, are redundant. The role of the physiotherapist is to teach and educate the patient in exercises and physical activity. Actually, this professional role can be quite pleasant for both sides; the patient may have an experience of getting clear answers about their condition and the physiotherapist thinks their knowledge and skills, are utilized. In other words, both parts are satisfied! But the question remains; does it work? At the societal level, based on the high and increasing burden of musculoskeletal disorders, the answer is no. At the level of the patients, a number of systematic reviews have found low to moderate short term benefits on pain, but not long term effect on disability. The dominant pathoanatomical treatment model for persistent musculoskeletal pain, is increasingly challenged among researchers in physiotherapy, in particular within the field of back pain (P. O’Sullivan, 2012).
With the growth of the biopsychosocial model of disability and recent advances in pain research, several new exercise treatment models for persistent pain conditions, have been developed. According to the International Association for the Study of Pain (IASP) pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Patients with persistent musculoskeletal pain can have remarkably similar pathology but dissimilar clinical presentations encompassing different thoughts, beliefs, behaviours and expectations which require different exercise treatment approaches (Booth et al., 2017). This has led to an increased attention on screening for psychological factors (yellow flags) (George & Stryker, 2011; Main & George, 2011; Nicholas & George, 2011). However, physiotherapist does not always provide treatments that underpin this definition and many focus solely on the biomedical model biased by their professional backgrounds, beliefs and training, and remain in their “comfort zone”, without exploring other domains (K. O’Sullivan, O’Sullivan, Vibe Fersum, & Kent, 2016).
As a result of the introduction of the International Classification of Functioning, disability and Health in 2001, a new biopsychosocial framework for functioning, is available. Following this, a number of condition-specific ICF categories, which describes common impairments, limitations and restrictions in musculoskeletal disorders, has been identified. This most rapid development, again, is within low back pain, were a comprehensive ICF core set, is available (Cieza et al., 2004). However, also within shoulder pain, patient experiences within the ICF framework, has been investigated (Roe, Bautz-Holter, Juel, & Soberg, 2013). This research confirms that there are large commonalities in relation to the disability, across conditions (Schwarzkopf et al., 2008).
Based on the developments within pain and disability research on persistent musculoskeletal disorders, we believe it is unfortunate that much of the research still is divided in separate fields, such as back-, knee- and shoulder research. Advance within one of these fields, seems to have little or no impact in another. An explanation for this, can be that among health professionals, there are beliefs that these conditions should be treated differently. For example, in discussions of pain in relation to exercise performance, among some physiotherapists it is believed that pain in the lower extremities is more acceptable than shoulder and elbow pain during exercises. This opinion (by a leading physiotherapist in elbow rehabilitation) was justified by arguing that the motor performance of the upper-extremity is different. In our opinion, such beliefs, that whatsoever have no theoretical foundations, contribute to consolidate the barriers between rehabilitation fields.
Recent, biopsychosocial treatment models for physiotherapy have the potential to enhance rehabilitation for patients with persistent pain. In this development, researchers such as Peter O’Sullivan and Kieran O’Sullivan have made major contributions, with the development of Cognitive Functional Therapy for back pain. Their impact has both been due to the quality of their research and their willingness to engage on social media. In shoulder pain rehabilitation, Chris Littlewood has made similar contributions, with the development of a self-management model. Within the field of pain research, Jo Nijs, has established a framework for cognition-targeted exercise therapy, hereafter referred to as the pain memory model. As mentioned, knowledge-transferal across rehabilitation fields, are limited. The purpose of this paper was to investigate similarities and differences between these three exercise models for persistent musculoskeletal pain. The more specific aim was to investigate the theoretical underpinnings of these models and how they deal with symptoms during treatment.
Similarities and differences between three exercise treatment models for persistent musculoskeletal pain
All three treatment models have in common that they are underpinned by psychological theory. Both the cognitive functional therapy- and the pain memory models, have referral to Cognitive Behavioural Therapy (CBT); however the pain memory model have more explicit referrals to acceptance, commitment theory, which has gained increasing popularity in a number of fields in the last years. In contrast, Self-Managed Exercises have referral to Social Cognitive Theory (SCT). SCT has been closely linked to behavioural change, based on the work of psychologists such as Albert Bandura (Bandura, 1977). The principles of SCT has been applied on different educational situations such as increasing fruit and vegetable intake, increasing physical activity, HIV education, and breastfeeding. Enhancing patient’s self-efficacy, which is seen as a mediating factor, is considered a premise for behavioural change. Principles for how this can be operationalized within a treatment context, has been provided by Lorig & Holman, who has suggested five core self-management skills that should be addressed: problem solving, decision-making, how to utilize resources, forming partnerships with health care providers and taking action (Lorig & Holman, 2003).
Physical activities and exercises can be painful and it is often difficult to advice patients in relation to these symptoms. For patellofemoral pain syndrome it has been suggested that VAS pain level up to 5 during exercise, is acceptable (Thomee, 1997). In line with this, Silbernagel & Crossley proposed a pain monitoring model where 0-2 was “safe zone”, 2-5 “acceptable zone” and 5-10 “high risk zone” (Silbernagel & Crossley, 2015). Another common pain monitoring model presented by Moseley, suggest that some pain during activity is acceptable, but it should stay under the point of a «flare up» (Moseley, 2003). None of the three treatment models we analysed, use a rigid VAS- or numerical pain monitoring model. However, some interesting differences between the models, were identified: the pain memory model emphasizes that exercises should be time contingent. This can be interpreted as acceptance of higher levels of pain, where pain shall not determine the number of repetitions or exercise duration. According to the model, the emotional response (fear) of the exercise, is the deciding factor. The cognitive functional therapy model emphasizes that exercises should aim at normalising maladaptive and provocative postural movement behaviours as directed by the patient’s individual presentation. Thus, the focus rather is on the quality of the motor performance. This is a view that is probably recognized by a majority of physiotherapists – sometimes pronounced as relearning of normal movement patterns. Nevertheless, the concept of normal, adaptive, non-normal or maladaptive is based on empirical, rather than theoretical evidence. In addition, there is always a balance in patient communication between enhancing patients’ self-efficacy and introducing concepts of normal and maladaptive movement. The last model, self-managed exercises, has a slightly different approach to pain-management, as it enables the patient to judge what is tolerable in terms of symptom response, although the pain should be no worse upon cessation.
All three models seem to have in common that pain during exercises not only is something that should be controlled, but also actively approached. For example, in the self-management model, exercises are chosen, because they trigger pain. Furthermore, if the pain response abates this is the stimulus to progress the exercise. In our view, several topics should be discussed in relation to the pain monitoring in the three models, such as: Are there no limits for pain intensity during exercising as long as there is little emotional response? What is the evidence for maladaptive movements and is it different between body parts? Is it beneficial to use pain as the deciding factor in selecting and progressing exercises?
Behavioural change in relation to increased physical activity should be a long term aim of interventions for patients with persistent musculoskeletal pain. Both the Cognitive Functional Therapy model and the self-managed exercises have explicitly outlined this. However, in the Cognitive Functional Therapy model, there is little referral to a methodological approach to behavioural changes. Instead, physical activity and lifestyle training is a step, following cognitive training, movement training and functional integration. In contrast, change in behaviour is a major focus in the self-management model. As earlier discussed, change in behaviour is underpinned by Social Cognitive Theory and decades of empirical evidence. However, in the self-managed exercise model, goal-setting is linked to patient-reported limitations in performing activities and not to physical activities and lifestyle changes. This is consistent with the functional integration step in the Cognitive Functional Therapy model. It is reasonable to question whether the self-managed exercise intervention sufficiently fills the gap between activity performance and changes in lifestyle behaviour. Progression in this model is rather linked to pain intensity than lifestyle behaviour. The latter model, pain memory, does not cope with physical activity and lifestyle behaviour. In our view, this point at an important issue within physiotherapy; what is the ultimate aim for interventions? To increase patients’ capabilities or actual performance to execute activities, or physical activity? There is no straight forward answer to this question, but in our opinion physiotherapy as a profession historically has been little focused on discussing these questions.
The three treatment models we have presented, represent important progress within the field of physical therapy. Biopsychosocial models for treatment will hopefully progress in the forthcoming years, with further refinement of existing models and introduction of new. To achieve this, in our view three factors are crucial: Firstly, transition of knowledge between clinical fields. Why do back- and shoulder pain researchers go to different congresses? Secondly, we think there is a potential to improve how treatment interventions are anchored to theory and empirical research. Thirdly, there still is a potential to tailor interventions to the patients experiences of living with persistent pain.
Patients with persistent musculoskeletal disorders need high quality health care. It is our hope and belief that physiotherapy as a profession will contribute to enhance treatment interventions which systematically addresses patients’ fear, worries, hopes for the future, self-efficacy and helps them to become more active and resilient. In the wise words of the late, great Louis Gifford: «Physiotherapy is about the restoration of thoughtless, fearless and painless movement».
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