Implementing the BPS Model Into Patient Care

[AJ Lievre]

At this point in the residency program and course series, we have hopefully emphasized that musculoskeletal pain is a complex experience that cannot be reduced to biological factors. However, being aware of this, and knowing what to do about it can be two very different things. Many therapists are aware of the BPS components of the pain experience but do not know how to address the psych and social factors. So rather than learn how to address them, they ignore them. Here are several qualitative articles that discuss therapists’ experiences in implementing the BPSM into care or how they make decisions when a pathoanatomical diagnosis cannot be made. Read one or more articles and see what resonates with you. I cannot attach the articles, and most are not open access. If you cannot find a pdf of the article you want to read, please email me and I will send you a copy.
Consider these questions as a guide:
1. Do you hear yourself in some of these experiences?
2. What struggles do you have addressing psychological or social factors?
3. How do you plan to improve your weaknesses?
4. Were you reminded of a patient experience after reading one of these articles?

Cowell, I., O’Sullivan, P., O’Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskeletal Science & Practice, 38, 113–119. https://doi.org/10.1016/j.msksp.2018.10.006

Josephson, I., Hedberg, B., & Bülow, P. (2013). Problem-solving in physiotherapy—Physiotherapists’ talk about encounters with patients with non-specific low back pain. Disability and Rehabilitation, 35(8), 668–677. https://doi.org/10.3109/09638288.2012.705221

Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558–569. https://doi.org/10.1177/0269215511420179

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016

[Sarah Frunzi]

“The ability to act in spite of uncertainty requires appropriate vocabulary and a deliberate manner of speaking without anxiety.20 Geller et al. argue that tolerance for ambiguity is a prerequisite characteristic for effective healthcare provision.21 Physiotherapist ‘disposition’ for accepting and working with uncertainty may have impact on care-seekers and students/ novice physiotherapists and has not been adequately researched22,23” (Slade et al, 2012). This paragraph in particular from the article written by Slade et al resonated with me the most and is something I have been actively working on improving. As a new physical therapist, displaying confidence in the face of uncertainty and limited experience can be a challenge for me. Having a background in evidence-based practice from a PT school who taught on the topics of BSP model, non-specific LBP, and pain science, I am aware of the complexity of pain in these populations. “Experience is the real teacher” (Slade et al, 2012). Even with this background knowledge of all that goes into treating these patients, experience is where I feel like I will learn the most and have the least. Actively working on identifying and developing clinical patterns is one way to help improve this weakness.

Another method to improve this is by observing and modeling the actions of my mentor and experienced colleagues around me who demonstrate this ability to address concerns in the face of uncertainty with the confidence and demeanor needed. “Theme 5: Physiotherapists seek ‘certainty’ from experienced colleagues.” I am very blessed to be surrounded by such knowledgeable and experienced physical therapists that I can learn from in the clinic each day. Some of the most valuable parts from residency so far have been in the moments talking with my mentor about difficult patient cases, reflections, and discussion on ideas/topics; specifically, the moments of past experience, expertise, and advice given.

Many patient experiences come to mind when thinking about patients who had elements of the biopsychosocial model involved in their presentation. I believe building rapport and a therapeutic relationship is essential before diving deep into these topics. Some parts may be able to be addressed during initial evaluation, however, I have found the most benefit in addressing BSPM aspects during the subsequent follow up visits once the patient has developed trust and a bond with their therapist. The aspects that I have personally struggled with is finding the right amount to discuss with the patient before overloading them with information, as well as finding the right time to discuss the contributing factors to their pain that may not be related to an anatomical diagnosis; I know this will also come with experience and practice. I have made it a personal challenge to not shy away from addressing these parts of patient care, to address them to my best ability, and to always seek advice and literature when I don’t have an immediate answer.

Reference:
Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558–569. https://doi.org/10.1177/0269215511420179

[David Brown]

As always, I thought your take on this subject was very well put! I agree with you a great deal when it comes to knowing how to dose this information and creating a solid rapport with the patient before diving too deep into BPS talks. I like to “plant the seed” so to speak at the eval with maybe a few min of these kinds of talks depending on the personality and receptiveness of the patient and then chip away at it little by little as time goes on. I find it is difficult to have these conversations and knowing the best way to navigate them when you do not know the person that well and there is a bit of uncertainty as to how the patient will interpret what you are trying to convey. I think this topic is one of the more difficult ones to discuss with patients and colleagues alike. Great thoughts!

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