An apology to the Australasian Faculty of Musculoskeletal Medicine


Some months ago I wrote a blog post about fibromyalgia, and mentioned that a group of clinicians seem to believe that psychosocial issues are not important when nociception can be abolished.  A commentator took issue with my comment, and I very quickly amended the post. You can read the amended version here.

I also offered an invitation to the people who were offended by my statement that : if you’re able to demonstrate HOW you integrate biopsychosocial approaches in your practice, I’ll publish it. 

Today, however, I found out that the AFMM has written to the University and wishes me to be censured, and that I should apologise for that blog post.

I wrote that post pointing the finger at a specific group of clinicians, and I apologise for causing them offence.  I sincerely do not want to point the finger at any clinician who integrates biopsychosocial aspects of pain and pain management into their practice.

As I stated in my amendment to that post, it’s simplistic to suggest a single discipline is at fault, but any profession that does not address the person as a whole (person-in-context) and particularly the psychosocial factors (because they’re so strongly associated with longterm disability associated with pain), needs to take a good look at the broad pain literature.

The AFMM is aware that the post was immediately amended. The invitation to publish a post showing how the psychosocial factors are addressed by this group of clinicians remains open – I welcome open discussion because the practicalities of HOW to incorporate all three elements of the model needs to be discussed widely to help reduce the risk to people with pain, especially those who are at risk of developing ongoing disability associated with their pain.

That’s the beauty of social media – we can ALL contribute to the discussions, clinicians, academics and patients alike.  I’ve had a wonderful response to posts I’ve written over the years I’ve been blogging (since 2007). Over 1 million hits from all around the world in that time, many from patients but even more from clinicians.  I see blogging as a really useful way to extend the conversations beyond the closed doors of the clinic, and the offices in the ivory towers, and the associations and faculties and other regulatory bodies.  Some people don’t like what I post, others welcome what I write – whatever reaction in response to a blog post means people are thinking about chronic pain. And that is a good thing.

 

24 comments

  1. Bronnie, I cannot see any reason for your university, or for any other academic body, to censure you. Bravo!

    1. Thank you SO much John, that really makes my day. I hope they join the conversation as you have, it’s one way to come to grips with the problem of musculoskeletal pain before it becomes chronic pain.

      1. Bronnie, if my colleague Dr Victor Wilk happens to be their spokesperson on Fibromyalgia, this organization did indeed enter the discussion.

  2. Hi John, you are quite right, Dr Wilk did comment on that post and thus has been part of the conversation. I’m not sure that he’s their spokesperson though.
    My worry is that while I’ve opened the door for Musculoskeletal physicians to give me a post showing how they incorporate the biopsychosocial model in their management of pain, there has not yet been a response. Of course, this could just reflect a certain reluctance to participate in social media, but I’d love to be able to post something because as I said, I think it’s an important area for dialogue.
    I have also had offers of various blocks (diagnostic and therapeutic) to help “manage” my fibromyalgia pain from MSK physicians, on the basis that there are likely to be nociceptive drivers underpinning it. This doesn’t seem to be supported by the literature.

    1. Continue the good fight, Bronnie. Many (I did at one time) will have a problem with the truth that science has revealed to us in regards to pain and the neuroscience that underlies it. Many of our past treatment approaches may have “worked” but not for reasons that we thought, and unfortunately many of our treatment approaches did not work at all and may have made things worse.

      1. Thanks Kory. I know it took me a few years to come to grips with it too. The thing is that it’s not easy to change practice but when you do, it opens up a world of positive change for your clients. That’s why I do what I do, because it shouldn’t take years of getting inadequate treatment before someone decides that it’s not the right thing. And because cognitive biases are very difficult to change even when you know about them. How much more difficult when you don’t take the time to look closely at unintended consequences of your approach.

  3. So the AFMM’s feelings were hurt because you had a critical opinion about the prevalence of certain views and practices amongst their members? So much so that they demanded your CENSURE? Wow. That seems like a petulant over-reaction. Apparently they AFFM is unaware that free and open debate is an important part of science and medicine. And that such debate often gets pretty testy. And that’s fine.
    I’ve read your original post, and strongly agree with it. It’s unthinkable that any editorial variation on that article would constitute cause for censure — even if you’d been extremely rude about it. Which seems rather unlikely, for anyone familiar with your style!
    Interesting story. Please keep us updated.

    1. I think my main error was in specifying one group out of the many that seem to think about psychosocial issues as way over the Cartesian divide. When psychosocial isn’t seen as integral to biopsychosocial, and when it’s relegated to being a reaction to what occurs in nociceptive pathways, or only viewed as being a set of risk factors, then I think people with pain are short changed. I should have been clear that practitioners of all stripes can continue thinking this way. It comes back to whether, as Diane Jacobs puts it, you recognise that you’re an interacter or an operator. Even when you think you’re operating, really you’re interacting so that everything you say and do is actively processed by the patient. That means that inadvertently relegating psychosocial to a lesser place than biological is likely to misfire.
      I sincerely hope I get a flood of stories showing how the biopsychosocial model is integrated into practice. We need this discussion so that more practitioners learn to do it well. I hope to see some exemplars to act as models of really good practice.

      1. Bronnie, at the risk of repeating myself, “biopsychosocial” is NOT a scientific model. Engel advocated an approach to patient management whereby both parties, clinician and patient, considered a range of factors that might be relevant to the clinical presentation. In practice, this approach too easily defaults to medical reductionism. One consequence is that a fruitless search for nociceptive drivers takes place when the problem at hand is persistent pain, often spinal in location. As a result, all too many pain sufferers are prescribed interventional procedures that are based on irrational theory and/or lack of evidence. Another unfortunate consequence is that patients can be dismissed as having a problem that is primarily psychological.

  4. I have been a practising occupational therapist for 45 years now.I can’t tell you how often I have encountered patients who receive treatment in recognized pain managment clinics that are unable to tell me what the practioners have offered within the model you have suggested. As an OT, the biopsychoscoial model has been important my entire career. The most frequent complaint I hear is, ” all they do is throw more medications at me. They don’t understand how the pain is affecting my life.” I believe that if the model were applied, these patients would not be saying this. Keep up yuor convictions. And shame for a group of health professionals who will not enter a dalogue so critical to people.

  5. I concur that it’s not a scientific model – it’s a conceptual model, and can be a heuristic for developing a holistic view of the what may be contributing to the person’s experience. I think it helps to remind people to look beyond simplistic biological mechanisms, but as you so rightly point out, often it’s not well-understood, and there are plenty of occasions where I’ve seen the search for nociceptive drivers becoming the overarching goal – leaving the person and his or her experience relegated to a by-product.
    I’m not sure how else to encourage biomedical practitioners (in particular, though they’re not alone!) to get out of the “issues in the tissues” and into looking at other factors.

    One thing that’s nice to see, however, is the AFMM/NZAMM meeting in Rotorua this year is looking at the brain. Above the thalamus even! But the risk is that this once again relegates the person to simply being a piece of tissue. A very important and complex piece of tissue, but still a piece of tissue. I hope Paul Hodges and Malcolm Johnson can help persuade them that “psychosocial” issues are not just risk factors, but integral to the experience.

    1. Bronnie, the conference programme looks very impressive. I was delighted not to find there any mention of dry or wet needling as subjects worthy of discussion. There are important “issues in the tissues” that cannot be ignored if one is wedded to the scientific method. But this does include assessing the outcomes of one’s treatment. The evidence base for many modalities of treatment is now quite comprehensive and has informed us that much treatment that is on offer to our patients is ineffective.

      1. Yes, there are issues in the tissues, but beliefs, attitudes, self efficacy, social constructs and all manner of lived experience need to be concurrently considered. Because people live in a context and always interpret what is going on with a lens that is shaped by experience and expectancies. And I certainly am wedded to scientific method (there’s more than one!) and outcomes from a range of perspectives provided that functional and disability reducing outcomes are prioritised.

      2. Bronnie, you will hear no counter-argument from me. But I wonder who amongst us is adequately trained and equipped to concurrently consider each and every one of these issues? This is tough territory!

      3. And that is why interprofessional teams were born. Exactly the same realisation that the pioneers in pain management (Fordyce, Loeser, Waddell) had when they made interdisciplinary and interprofessional teams the mainstay of pain management.

      4. Bronnie, but as you know the demand for these services has well outstripped the available resources.

      5. That’s true, but is there a stepped care approach that could apply? So far I’ve seen biomedical and biophysical (medical and PT) then bring on the bigger teams, but what about an OT/PT front line approach, with a functional restoration focus, then bring on a larger team if these don’t do the trick. Just a thought.

  6. Just for the record, Bronwyn, I find your blogs well researched, informative and inspiring – very welcome for informing work in an often difficult area of practice. Keep up the great work, and a bit of controversy can always be a helpful thing for provoking thoughtfulness and the unpacking of ideas.

      1. Bronnie, welcome to the foot-in-the-mouth club. Don’t forget the funds for unnecessary investigations, particularly imaging, as well as those being paid to health professionals who administer CIA (counter-irritation analgesia).

  7. Interesting debate, however I think it is simplistic to assume that different professions will take on similar models of practice, especially if time and energy is spent on social media as opposed to evidence-based research (which provides much better arguments). Strategically I think more of this research is required in order to convince health care funders to follow alternative approaches. Until then, professions that have been trained and paid to follow certain treatment protocols will not have the inclination to look broader. In a sense, the biopsychosocial model does not scream specialisation, which therefore is interpreted by specialists as vague underpinnings. So, whereas I respect your candor, I would say that the approach to sway others should be looked at. Can we compare how many hours worth of intervention is required to bring patients to the same or better level of pain management than the original approaches? That, as an example, may get clinicians, researchers and funders to show interest.

    1. Oddly though, there has been considerable research looking at approaches that mitigate disability as opposed to simply reducing pain. If we’re looking at time spent with a client, and the cost of that, I think diagnostic blocks leading to the possibility of radiofrequency neurotomy would work out at roughly double the cost of a three week cognitive behavioural programme, based on my knowledge of costs in New Zealand. Not only this, but the outcomes from cognitive behavioural approaches continue for at least 12 months, with some effects lasting longer, while RF and other injection procedures need to be repeated roughly every three to six months. Self management approaches have been researched since the mid-1980’s at least, probably longer. The move towards a biopsychosocial model has been present since the 1970’s. I think the hard and crunchy RCT’s have been done. What may not be so evident amongst health funders is the distinction between reducing pain and reducing disability. And the political influence that certain groups have with funders by comparison with allied health clinicians who have, by and large, been lacking in political clout.
      You might have it quite correct: “professions that have been trained and paid to follow certain treatment protocols will not have the inclination to look broader” – payment is a potent reinforcement strategy.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s