Surgery Vs Conservative Management of Femoral Acetabular Impingement Syndrome (FAIS) – Part 2

Actual “Best Practice Conservative Care”

The biopsychosocial model

The biomedical model is defined as a model of illness that ignores psychological and social variables, and focuses only on biological pathology. This model has been a catastrophic failure for chronic pain suffers, as outlined below.

The biomedical model fails to capture the true reasons for level of disability in chronic pain suffers, because pain intensity and magnitude of disability are explained better by psychosocial factors than by pathophysiology in patients with musculoskeletal disease [1], and injury [2], particularly in a workers compensation setting [3]. The biopsychosocial model also reveals why the reductionist passive interventions offered early in chronic pain suffers treatment are usually ineffective, and often serve to actually perpetuate the recovery.

For example, experimental studies have shown that negative emotions like depression, anger, and anxiety can increase both pain intensity and unpleasantness [4]. These experimental studies are corroborated with epidemiological data suggesting that musculoskeletal trauma results in self-reported disability and pain [5], which is worsened by such psychosocial factors [6].

In addition to depression [6], both self-efficacy about pain [7]and catastrophic thinking [8]are regarded as significant psychosocial factors that can influence disability and pain intensity, and  a biopsychosocial framework allows appreciation of these influences.

The biopsychosocial model also allows us to appreciate how pain experience itself changes across individuals circumstances. As pain perception is modulated by a variety of social, psychological and demographic factors [9], the biopsychosocial model enables holistic assessment and treatment algorithms, which are crucial for successful management of chronic pain [10].

Interestingly, there is compelling evidence of racial and ethnic differences in pain perception [9], low socioeconomic status is also a risk factor for chronic pain [11], and different meaning is attributed to pain in different cultures [12]. It is clear from these insights that psychological and social factors are instrumental, and a biopsychosocial approach is really the only evidence based way of navigating this terrain.

Furthermore, there is a relationship between traumatic events in childhood and chronic pain [13, 14]. A biopsychosocial approach enables early interdisciplinary management. Mitigation of psychological comorbidities is associated with improved outcomes in chronic pain [15], and a biomedical model approach would fail to consider this variable.

Additionally, injuries often occur in situations where patients assess the situation as “unjust”. Using the biopsychosocial model one can assess whether a client conceptualises the experience as unjust and see themselves as a victim [16]. A sense of ‘perceived injustice’ has been associated with fear of movement, poor rehabilitation and higher pain severity [17], higher self-reported disability [18], pain catastrophizing [19], as well as prolonged absence from work [20] in patients with chronic pain.

Additionally, patients being treated for chronic pain under workers compensation are generally more psychologically distressed, more severely disabled, are less active and have poorer outcomes than non-compensated patients[21]. As noted by Mendelson et al. [22], “If you have to prove that you are ill, not only can you not get well but you are also likely to sink further into the abyss of vulnerability and to learn ‘illness behaviour’ in the process.” An analysis of patients using a biopsychosocial approach enables the necessary multifaceted and multifactorial approach to treatment, subsequently reducing the risk of further iatrogenic insult and ineffective management.

Part IIa

Pain correlates more closely with psychosocial variables than pathology on scans

The graphs below indicate 3 things:

1. On average, musculoskeletal pain peaks in midlife
2. On average, stress peaks in midlife, and wellbeing troughs in midlife
3. Objective degenerative change on scans steadily increases throughout life, and is not reliably correlated with pain.

Therefore, there appears to be a relationship between increasing psychosocial stressors in midlife, and increased prevalence of musculoskeletal pain. This epidemiologic data correlation is reinforced by studies demonstrating that, indeed, pain intensity and magnitude of disability are better correlated with psychosocial factors than with pathophysiology in patients with musculoskeletal disease and injury [2, 3].

Following peak YLD in the 50-54 age bracket, there is a gradual tapering off to 11, 490 YLD in the 60-64 year age bracket. Interestingly, this is followed by a significant decrease over the age of 65 (post retirement age) to 8, 839, falling further over the age of 70 to 7, 123YLD, and paradoxically, falling to the lowest rates since the 15-19 year age bracket at 75-79 years.

Prevalence then spikes again over the age of 80. This spike over 80 could also be explained by the influence of both potentially reduced mobility, and potential psychosocial effects. Given the prevalence of abnormal low back pain pathology on imaging in the 80+ age group (figure 2) [4], we can rationally infer than pathology on imaging is unable to explain pain with any degree of reliability. Both psychosocial stressors and reduced movement are more likely to explain this spike. For example, stress in the over 80 age group on average increases due to negative health expectations, the threatening of personal purpose and reduced autonomy [5]. Anxiety experienced in daily life caused by fear of death in the elderly is also a potential psychosocial stressor that has been examined [6].

In all stages of life these factors and mediated by locus of control, social support, socioeconomic status and other variables [6], all which fall under the purview of the biopsychosocial construct.

Part IIb

The need for biopsychosocial interdisciplinary treatment

Evidence demonstrates that some GP’s make more than five times as many referrals per patient as others do [1], and this variability is based on provider training, years of experience, and experience with the presenting condition [2].

There is compelling evidence to suggest that a referral to specialists, including orthopaedic surgeons, early in pain management is unnecessary and may be iatrogenic [3]. Evidence for chronic pain clearly indicates that staying active, improving one’s understanding of pain, and identifying risk factors for persistent pain results in improved outcomes for most people [4]. However, given that results for invasive treatments are, on average, no better than conservative interventions [5], plus individuals with high score on psychometric testing typically do not benefit from surgery at all [6], and (dubiously) rates of surgery vary geographically according to the surgeon’s enthusiasm for surgery and the availability of MRI [7], referrals for chronic pain patients to orthopaedic surgeons (in the absence of red flags) is fundamentally put into question.

Notwithstanding, there is also evidence to suggest that the language involved in simply referring someone to an “orthopaedic surgeon” early in management can inflame the perceived threat and sense of danger around their hip (for a vulnerable person) [8]; this is particularly relevant for patients with psychosocial stressors.

Additionally, reductionist passive treatments given in isolation for chronic pain are non-evidence based treatments that completely ignore psychosocial variables, and can serve to make patients more distressed, feel more like a patient and reinforce the passivity of their role [9]. This style of treatment is also demonstrably paternalistic and disempowering; and, there is also strong evidence that passive treatments can actually harm patients [10]. Outlining to patients that passive, instead of active, management strategies are advisable can exacerbate patients fear and anxiety about being physically active, contributing to increased anticipatory anxiety about pain and (potentially) further prolonging recovery [8].

In the case of chronic pain, often many months after the initial injury (a period of time where any actual tissue damage would have long since been healed [11]), CT scans and MRI’s are ordered by treating practitioners. In the absence of suspected red flags, these scans expose patients to risk of unnecessary surgery, as any incidental hip pathology (CAM found in 37% of asymptomatic patients) can be falsely attributed to their pain [12]. Also, given what we know about verbally induced hyperalgesia and allodynia, CT or MRI results containing the words “narrowing”, and “impingement”” can worsen a patients symptoms and further circumscribe their function through fear of movement [13]. CT’s and MRI’s are also expensive, and CT’s can expose patients to unnecessary radiation [14].

How might the early stages of a patient’s management be improved?

The early musculoskeletal pain management can be improved if the patients primary health care provider can refer to one allied health practitioner (physiotherapist etc) who can oversee the management through an evidence based, biopsychosocial, interdisciplinary framework.

Some research supports the efficacy multidisciplinary pain treatment [15]. However, given that research also indicates that early aggressive psychological interventions in the acute phase of injury may actually undermine recovery [16, 17, 18], a well-informed physiotherapist can implement an interdisciplinary approach (such as Stress Inoculation Training), thereby assisting coping and problem-solving strategies to reduce stress-related anxiety [16]. Additionally, a physiotherapist can packaged treatment to provide essential information to the client about the impact of stress on their physical and psychological wellbeing; thus facilitating improved insight, which may subsequently reduce the risk of chronicity [19].

This, combined with a ‘classification-based cognitive functional therapy’ (CFT) approach, (which may include a graduated, mindful movement based approach to exercise that emphasises decreasing fear about movement, increasing self-efficacy, self-understanding and self-empowerment, explaining pain physiology, empathetic patient-centred communication, demystifying beliefs about pain (beliefs which come from interactions with previous health care practitioners), and thus increasing the patients’ health/scientific literacy) is well supported by evidence [20], and may have prevented many chronic pain patients unfortunate slide into chronicity.

For patients with pre-existing chronicity and high degrees of psychological distress, psychological treatments based on the principle of cognitive behavioural therapy are supported by evidence [21], and mitigation of psychological comorbidities is associated with improved outcomes in chronic pain [22].

Yoga and mindfulness within a CFT framework

Honest discussion with patients about the factors outlined above is imperative in sound management FAI.

Mindfulness and yoga therapy can be applied as the graded exercise component within at CFT framework, with its techniques to modulate anxiety. Since pain appears to be amplified by anxiety through the activation of cholecystokininergic systems, strategies to reduce anxiety, such as yoga therapy, can be applied whenever pain has an important anxiety component. According to Streeter et al (2007) [23], a regular practice of yoga releases a neurotransmitter chemical called GABA.  Individuals who exhibit increased anxiety have reduced levels of GABA. The authors believe that these sustained levels of GABA over a period of regular yoga practice may help the brain to rewire itself, reducing anxiety and thereby modulating the pain response. Additionally, Mindfulness Meditation is associated with lower amygdala activation, which is related to perceived threat. Pain is often the brains response perception of threat [24].

Furthermore, chronic pain is known to cause brain anatomy changes and impairments, but yoga can be an important tool for preventing or even reversing the effects of chronic pain on the brain. [25]

One of the problems in the implementation of these techniques is that most physiotherapists don’t even meet the low bar set for recommended physical activity levels that they themselves promote to patients. [26] It would be ideal if physios were able to lead their patients by example. It would likely make them better movement facilitators for their patients.