There are times when it seems the biopsyschosocial model is given lipservice amongst people working in the pain medicine field. Yes, I do hear them say ‘the biopsychosocial model is important but you’ve got to remember Engel’s model starts with the bio…’
I’ve often wondered if it’s worthwhile pursuing the idea that if we can abolish the pain, then all this psychosocial ‘stuff’ will disappear – after all, once a hip joint is replaced in someone with an arthritic hip, you don’t hear of people complaining about their hip pain any more! Surely if we can get rid of the back pain through nerve blocks or similar means, then with the pain gone the person will simply get on with life.
Several papers I’ve read recently suggest to me that there’s something important about why person might ask for treatment for their back pain. Many people get a sore back – some studies suggest up to 90% of us will have an episode of back pain during our life. And many studies suggest that back pain settles down quickly within about 6 weeks, but might ‘grumble’ away periodically after that (NHMRC, 2003). Yet for some people, getting treatment for each episode is unthinkable, while others persist in looking for ‘something to take it away’.
One study especially relevant in New Zealand is written by Karen Grimmer-Somers from the University of South Australia, and colleagues Mathew Prior and Jim Robertson (the latter from ACC). In this study, (and I won’t go into the details of the design) a group of around 900 people seeing their GP for a first visit for acute low back pain under ACC funding, provided their responses to the Orebro Musculoskeletal Pain Questionnaire. This is a widely used questionnaire designed to identify those people at risk of developing ongoing problems with their back pain, and has been used in New Zealand (and many other places in the world) as a screening tool to determine the need for early intervention.
In this study, the findings showed that the factors present at the time of the first visit for back pain, as identified in the scores on the OMPQ, were associated with the eventual overall cost of the claim. Now the association wasn’t a linear one, there was some variability between low scores and low costs, and high scores and high costs, but the overall picture is one of increasing costs of claim with increasing scores on the OMPQ.
Some points to ponder – this questionnaire does not identify ‘physical’ features of back pain, it simply looks at the person’s self report of pain intensity, their beliefs about how their pain is affecting them, their current difficulties with everyday activities, and their beliefs about whether they their pain was a sign they should or should not do things. There was no ‘diagnostic’ anything – these people were considered to be experiencing nonspecific low back pain.
About 60% of the 900 people who attended the GP reported their pain had subsided within 5 visits to the GP. I’m guessing that this may be one reason GP’s rarely refer patients on to psychologically-based services, even when the clinical pathway strongly suggests this. If a GP sees most people making good progress, the occasional person who doesn’t may be quite hard to differentiate.
Another interesting finding from this study was that of the 30% who were referred for these services, few actually completed their treatment with psychologists. Could this be because psychologists in New Zealand are
(a) rarely trained in pain management, whether acute or chronic
(b) not seen by the general public as working with people with ‘genuine’ back pain – which is commonly viewed as a physical problem ‘in my back’ rather than a problem that could benefit from psychological input and
(c) rarely involved in a subacute or acute physical rehabilitation setting
Whatever the reason, two studies (this one and the previous one by Crawford, Ryan & Shipton (2007)) now show that GP’s don’t commonly consider the ‘psychosocial’ part of managing low back pain. I’m sure many GP’s identify people with psychosocial factors – but their sense of what to do about it seems less clear.
This suggests maintaining the focus on the psychosocial aspect needs to occur. It also suggests that perhaps, rather than sending people to psychologists, perhaps broadening the range of people who commonly use a cognitive behavioural approach in subactue pain management such as occupational therapists, physiotherapists and so on, might be helpful. At least this group of clinicians is an acceptable ‘face’ of treatment for low back pain.
Of course, this raises the question as to whether occupational therapists, physiotherapists and others areconsistently trained to view low back pain in a biopsychosocial model, whether especially experienced or senior clinicians have effective skills in a cognitive behavioural approach, and whether GP’s would think to refer to them.
My thoughts? I’d love to see an increased emphasis on routine inclusion of allied health in the primary care setting – not in separate clinics away from the GP practice, but right beside the GP. I’d love to see interdisciplinary teams working in the community alongside the GP, to routinely screen and work with the patients who can be identified as having a number of risk factors present.
I’d love this teamwork to occur without the need to focus exclusively on increasing the number of psychologists, but rather, to upskill and support the occupational therapists and physiotherapists who are already working in the community.
And wouldn’t it be great to see adequate funding so that clinicians could spend the time they need with people?
Finally, I’d love to see postgraduate education in musculoskeletal pain (and other pain problems too) have a much more focused approach to the importance of recognising and managing psychosocial risk factors. They seem to be more important in terms of outcome than the biomedical part.
Grimmer-Somers, K., Prior, M., Robertson, J. (2008). Yellow flag scores in a compensable New Zealand cohort suffering acute low back pain Journal of Pain Research :1 15–25
Crawford C, Ryan K, Shipton E. 2007. Exploring general practitioner identifi cation and management of psychosocial Yellow Flags in acute low back pain. N Z Med J, 120:U2536
National Health and Medical Research Council. 2003.Evidence-based management of acute musculoskeletal pain [online]. Accessed September 1, 2007. URL: ttp://www.nhmrc.gov.au/publications/synopses/_fi les/cp94.pdf