I posted last week on some of the basic domains of knowledge that I personally think are important when you’re new to pain management. For more detailed curricula, the best place to go is IASP, where you can see some older but still relevant examples of curricula such as this one for occupational therapy and physiotherapy.
To break the area down a bit, because it really is quite a daunting list of topics, I thought about some of the basic conceptual material as being quite helpful to organise learning. The first topic that I think is fundamental to understanding pain is the biopsychosocial model, and a quite nice summary of the model is this one by Dr Shaheen Lakhan. A lightly longer, albeit older couple of papers are here. A much more recent paper is briefly summarised here, and the paper referenced in this new item is Fava, G.A. and Sonino, N. The Biopsychosocial Model Thirty Years Later. Psychother Psychosom 2008;77:1-2
The biopsychosocial model helps explain not just the system-level dysfunction or impairment (eg the broken bone, the nerve damage, the inflammation) but more importantly, helps to explain why this person is presenting for help in this setting today.
Let’s unpack that a little:
Aunty Maude has an arthritic hip, she has a family history of osteoarthritis and all her family have had rusty, crusty old hips and ended up using walking sticks or eventually needing a hip replacement. When she starts to get a niggle in her hip when she gets up off a low chair, or crouches down to pull the weeds from her garden, she is generally aware of what the pain is about (‘oh my aching bones, I’m getting old’), and doesn’t do anything to get it looked at. When she sees her daughter Trixie, Trixie tells her to stop being so stubborn and go and see a good orthopaedic surgeon and get it looked at. Problem is, Aunty Maude doesn’t have health insurance, and she knows she is going to go onto a public waiting list and probably be told her problem isn’t serious enough for it to be seen by a specialist, so she decides to wait and perhaps take some arnica.
The model would look a wee bit like this: biomedical/biophysical – osteoarthritis around the articular surfaces of the head of femur and acetabulum, weak hip flexors and extensors, reducing range of movement on internal and external rotation and flexion. (Note: tissue and system-based changes and effects of these changes on movement patterns and tissues)
Psychological – believes it is osteoarthritis, nothing much can be done about it without surgery, it will inevitably mean giving up activities and using a walking stick or walker, and having hip surgery. In the meantime, carry on doing as much as possible. Getting a bit fed up with people telling her to go and see a surgeon because she knows she’s not ‘too disabled yet’. (Note: beliefs, attitudes, motivation, emotions etc)
Social – her daughter is urging her to seek more help, and not settle for what she has, but she’s in a health system that can’t respond to her level of disability. She can obtain arnica locally and this satisfies her daughter’s distress and keeps her from fussing. (Note: the influence of others in both a micro and macro way – if this had been an accident, she would have lodged a claim in New Zealand for ACC, and received immediate and abundant support)
So, the biopsychosocial model can help us understand why some people are stoic and don’t demonstrate disability or ask for help, and why others are frequent fliers. It’s an organising model rather than a specific treatment model – but it’s helpful to structure learning about pain and pain management, because it helps break down the territory, and it’s one way of framing the equal importance of biophysical elements alongside the psychosocial.
There are other models such as the ‘Onion ring’ model that I’ll introduce tomorrow.