Mulling over balance in the biopsychosocial…

For some years I’ve taught a postgraduate course in pain and pain management – my responsibility is to teach the psychosocial components, while I coordinate the content of both papers.  Recently I had a discussion with a colleague who suggested that the psychosocial component was over-represented, while the biophysical was under-represented.

At the time I didn’t agree, and on reflection I still don’t agree.

For years undergraduates in most health professions have received information on pain that consists almost entirely of biophysical data, coming from a biomedical model.  There is still minimal information at an undergraduate level in medicine, physiotherapy, occupational therapy, nursing or psychology training that covers pain in any shape or form, and what information there is tends to be about neurophysiology, acute pain, and about ‘injury’ or tissue damage.  When psychosocial material is given any time at all, it’s represented as a ‘response’ to pain (ie physical injury), or referred to in the same breath as chronic pain (ie a confounding factor only in individuals who are having trouble coping with persistent pain).

The definition of pain as given by the International Association for the Study of Pain is “… an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” By definition, people who experience pain are feeling it as an emotional event. ‘Psychosocial factors’ are integral to the experience of pain! We can’t experience pain without it being a psychological event…

The problem is, that while most health professionals gain a grounding in anatomy and physiology, and even in tissue pathology, nerve conduction – and healing… not nearly as many are aware of the fundamentals of pain behaviour, the place of psychosocial factors as both integral to the experience of pain and as factors that may complicate recovery (from acute onset of pain right through to coping with persistent pain and ongoing disability).

So in teaching postgraduate pain and pain management, people like me who teach ‘behavioural medicine’ or psychosocial aspects of pain and pain management to health professionals have to start with the basics of the difference between pain and pain behaviour, health and pain anxiety, measurement concepts, the role of the brain and emotions and attention and cognition, not to mention learning and reinforcement and allied concepts!

So if, in teaching at postgraduate level, I am emphasising the psychosocial, I hope that it’s in an effort to redress the imbalance of undergraduate knowledge that is carried over into professional health care.  Roll on the day when undergraduates receive sufficient training in pain as a complex, multidimensional experience that involves the biophysical, psychological and social aspects of being human.   Until then I think I need to spend a good deal of time just covering the basics…

Postgraduate distance-taught papers in pain and pain management

If you haven’t started planning 2008 postgraduate study yet – there are a couple of ‘down-under’ papers that you can choose from.

University of Otago, Christchurch has the Postgraduate Diploma in Musculoskeletal Medicine (for medical practitioners), which includes a number of papers that can be credited to Masters of Health Sciences. These papers cover a broad range of musculoskeletal topics but the two I want to highlight are Pain and Pain Management.

All papers are distance-taught, using a combination of comprehensive readings (provided), online discussion and fortnightly teleconference calls. Pain and Pain Management are taught in the first semester, and enrolments are being called for now! Students come from around New Zealand, Australia, HongKong, Singapore, UK. A unique feature of these papers is the very strong interdisciplinary approach – students come with backgrounds of medicine, psychology, occupational therapy, physiotherapy, nursing, osteopathy, chiropractic, acupuncture, podiatry… Another strong feature is the emphasis on the biopsychosocial model throughout the papers.

Paper MSMX 704 – Pain

The aim of the paper is to provide an understanding of the broad range of clinical techniques used for the assessment, treatment and management of musculoskeletal pain. The paper is designed to complement MSMX 708 Pain Management.

  1. Biopsychosocial model of pain.
  2. Pain mechanisms.
  3. Neuropathic and spinal cord injury pain and central pain syndromes.
  4. Tissue specific pain entities.
  5. Psychology of pain.
  6. Behavioural aspects of pain
  7. Cognitive aspects of pain.
  8. Pain related fear and avoidance in pain – a model of disability.

Assessment is by completion of a case study of a person experiencing pain and a two hour written examination.

Paper MSMX 708 – Pain Management

The aim of this paper is to provide an understanding of the broad range of clinical techniques used for the assessment, treatment and management of musculoskeletal pain. The paper is designed to complement MSMX 704 Pain.

  1. Pain assessment and outcome
  2. Treatment effects and placebo
  3. Cognitive behavioural treatment – theoretical
  4. a – Clinical intervention – Clinical Techniques.
    b – Multi-disciplinary and interdisciplinary treatment for chronic pain.
  5. Interventional pain management
  6. Primary and secondary analgesia.
  7. Neuromodulation
  8. Psychopathology and chronic pain – assessment and management

Assessment is by completion of a case study applying an evidence-based pain management approach, that is also based on case formulation. A two hour written examination is also required.

For busy clinicians, these papers are a relatively heavy workload – but at the end of the papers most students say they have developed a new awareness of pain as a biopsychosocial phenomenon.

For occupational therapists there is another option – through the Otago Polytechnic Occupational Therapy School, in the second semester, a distance-taught paper in Pain and Pain Management will be offered. This paper can also be credited to Masters of Health Science, and Postgraduate Diploma in Occupational Therapy. More details about this occupational therapy specific paper will come later!