It seems like there is a never-ending debate over the biomedical and psycho-social aspect of Physiotherapy. Honestly, I didn’t know such a debate even existed until very recently, and now I find myself to be just another victim like many others. Well, if you were to ask me, there is a clear difference between the two terms. When we talk about biomedical focus, we are clearly talking about the tissue damage, joint congruency and movement, biomechanics as well as explanation of several pain mechanisms. Psycho-social on the other hand explains nothing about the above jibber-jabber, it’s about how a patient deals or feels about his/her pain. It could be their fear, anxiety, perspective or a form of belief related to the experience of their injury or problem. This raises a question, how do you bridge the gap between these two and POOF, you have the answer – Biopsychosocial model.

This recent concept (at least to me it was) called Biopsychosocial model talks about moving ahead of the fear that limits you from movement, it’s more about goal setting and encouraging the patient to do and get better. This model is more of an approach rather than a focus.  Let’s just say, Biopsychosocial approach is the moderator for the debate between the other two focuses!

Clinically,

As a Therapist, I always believed in having a structured protocol as a part of my treatment plan. It included a lot of Passive and Assisted handling, a lot of recently learned and totally exciting mobilizations and ‘over the top’ exercises. My advice to the patients would be on the following lines:

  • If bending your knee gives you pain, then don’t do it
  • Mobilizing the joint is the only way I can fix you
  • You are young you can do 10 repetitions/ you are old you shouldn’t be doing 10 repetitions
  • Stay fit and active, try to be stress free and so on

While referring to the available literature on this subject, I read an article by Paul Ingraham about Central Sensitization. He makes it a point to mention that this is a phenomenon where pain can alter the Nervous System, due to which the patient becomes more sensitive to the nociceptive stimuli and experiences more pain with less provocation. So, when I think about it now, if I have a patient who walks in with a painful knee and I am going to go all passive aggressive on him, there is a high chance that in the hope of making him better I am making his condition worse with every little forced movement. On the contrary, on what basis have I decided that the patient is a victim to central sensitization? Isn’t there a possibility that the pain is arising from an underlying tissue or pathology? There is no specific clinical test to determine presence of sensitization. And the only explanation or proof that I have of the patient’s pain is his own experience and previous memories with it. This gets me to a dead end. What next?

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Next step would be getting to know more about pain, and its pathways to support and act as a backup in our decision making. I will be talking more about the pain and its pathways in general in my next blog.

For now, let’s talk about a patient suffering from chronic pain. Assume he is a case of osteoarthritis of the knee. Now we know that chronic OA is characterized by pain and local tissue damage. It’s the wear and tear of the joint most of the time because of old age. Historically, cartilage was believed to be the root cause of pain but recent research material tells us otherwise. Cartilage is an avascular aneural tissue and hence cannot be the root cause1. Pain is likely to be more complex and arise from the surrounding structures such as the bone, tissues, ligaments or synovium which influence the activation of central pain pathway2. Hence it is of utmost importance that as clinicians we know more and study more in detail about the central pain mechanism that may form the major outline for the patients complains regarding persistent pain.

In recent studies, the use of functional MRI (fMRI) has increased in investigating how the brain processes noxious stimuli in OA and the cortical location to which perception of pain is mapped3. The schematic representation below shows the central pain processing pathway in OA knee:

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Talking about evidence, a recent work carried out by Baliki et al has reported that movement causing pain at the knee joint in an Osteoarthritic Knee was associated with activity in different areas of the brain such as, Thalamus and the Cortex. This suggests that nociceptive stimulation at the knee engages with the brain leading to Central activation of the Nervous System causing pain in OA4. Keeping this in mind, if we are going to treat the patient at the local area there will be no reduction in the symptoms, pain will persist and there might be chance that he/she might expericence more discomfort due to repetitive input of nociceptive stimuli which are given as treatment because of the dearth in our knowldge.

Conclusion:

Let me start framing the last bit of this blog. When we talk about the clinical reasoning and the recent development in the field of Physiotherapy, I think some things remain the same and some don’t. According to me, the most crucial part in diagnosing and decision making is listening to the patients. The best content that you will need is always in there. The Biopsychosocial approach tells us to look at a patient in a more broader way, by including the good from the past experiences and practices and incorporate the new ways such as clinical reasoning, evidence based practice and combine this to get the maximum out of your patient. As mentioned earlier since there is no specific tests to determine the presence of central sensitization, a detailed evaluation and knowledge around the area of pain is necessary. As explained by Greg Lehman in his article about treating pain with simple fundamentals, let’s keep the key aspects in mind such as ruling out red flags, and the major stress component.

Another very important point I would like to mention is about the handling and treatment of patients by deconstructing our rigid opinions about “I know what is right and this is the only way I will go ahead with my treatment”. We (specially me) must stop concentrating on the local area and thinking of fixing that one issue. Let’s look at every aspect of the individual. Let’s split it into the biological the social the psychological aspect and draw a conclusion as to what really is the underlying cause. Let’s not tell our patients to stop doing the activity which gives them pain, instead let’s focus on changing the biomechanics and loading of the joint, simultaneously building tolerance towards the painful activity5. Avoid stimulating the already excited nervous system and cause more pain that there already is. Instead try and make the patients more comfortable with the idea of pain and the reasons for its cause and direct them as well as ourselves towards being more gentle in our treatment ways.

Let’s not try and fix our patients; they aren’t broken objects. Instead, focus towards getting them moving and feeling more safe about and around their pain.

References:

  1. Ejindu, V., Kiely, P., Sofat, N. (2001). What makes Osteoarthritis painful? The evidence for local and central pain processing. Journal of Rheumatology, [Online]. Available at http://rheumatology.oxfordjournals.org/content/early/2011/09/26/rheumatology.ker283
  1. Conaghan PG. Structural correlates of osteoarthritis pain: lessons from magnetic resonance imaging. In: Felson DT Schaible H-G, eds. Pain in osteoarthritis. New Jersey: Wiley-Blackwell, 2009.
  2. Ogawa S, Lee TM, Nayak AS, Glynn P. Oxygenation-sensitive contrast in magnetic resonance image of rodent brain at high magnetic fields. Magn Reson Med 1990;14:6878.
  1. Baliki MN, Geha PY, Jabakhanji R, Harden N, Schnitzer TJ, Apkarian AV. A preliminary fMRI study of analgesic treatment in chronic back pain and knee osteoarthritis. Mol Pain 2008;4:4
  1. Lehman, G., Don’t Freak Out: Treating Pain with Simple Fundamentals A Blog Article. [Online] MedBridge. Available at https://www.medbridgeeducation.com/h/blog-article-greg-lehman-dont-freak-out-treating-pain-n-af

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