Biopsychosocial Approach: Mistakes I’ve Made – Part 1

In the last 10 years, the scientific evidence (along with better knowledge translation) has helped to move rehabilitation from a biomedical model, which focuses solely on biological health factors, to more of a biopsychosocial (BPS) model. This considers the role of psychological and sociological factors in addition to biological factors on a client’s health. While this has progressed our understanding of pain and rehab by leaps and bounds, translating it into practice isn’t easy. A few years ago, it hit me that we are the first generation of therapists to be using the BPS model on a wide scale and as such, mistakes will be made.

In this two-part series, I share mistakes that I’ve made (and have seen other clinicians make) in implementing the BPS model in practice. This was a tough series to write, and something I debated for a while, but it’s important to share these to allow clinicians and students to not make these mistakes in the future.

A person that helped me apply the BPS model into practice was Dr. Mike Stewart. I took his Know Pain course a few years ago and it is still one of the best courses I’ve ever attended. He also has a Masterclass on A Practical Guide to Persistent Pain Therapy.

With that out of the way, here are some of the mistakes I’ve made and have seen other clinicians make.

1 – Trying to do it All During Assessment & Treatment

If you read enough about assessments you’re supposed to listen to the patient’s story; explore beliefs, behaviours and the impact of pain on a patient’s life; build rapport; take vitals; do a thorough psychosocial and physical assessment; set SMART goals; do hands-on treatment; give exercises; have the client repeat consultation findings back to you; and map out an entire treatment plan. Sigh. I don’t know about you but that seems like a lot to do in an hour. Especially if you work with clients who may have complex presentations, multiple comorbidities or injuries, major mobility limitations, and/or language barriers.

Don’t get me wrong – you need to rule out red flags, get a diagnosis, get treatment started and build a reasonably good therapeutic alliance with your patient. While an hour is fine for “non-complex” clients who speak good English, if you bite off more than you can chew you can run into such problems as:

• Patients feeling rushed through an assessment
• Clients feeling very sore afterwards from too much testing and not wanting to book back
• Multiple areas being assessed and treated at the time but not done very well
• Clients feeling upset that they didn’t get any hands-on treatment during the first sessio

However, I use a different approach now. With every assessment, I like to set expectations for what the session will be like right from the get go. Where I work, clients fill out an online intake questionnaire in advance which helps to highlight their areas of concern.

• If it’s a client who has 1 area or 2 neighbouring areas (i.e. neck/shoulder, back/hip) affected then it’s no big deal.
• If it’s 2 “non-neighbouring” body parts and/or a client who may have a bit of a language barrier, I will give them the option of either:
  • A: I assess 1 area (2 if connected) and have time for treatment on that area (tackling the other stuff later) OR
  • B: I assess both areas but state that there might not be much time for hands on treatment afterwards.
• If it’s a client who has 2+ “non-neighbouring” body parts affected I just state that I can’t effectively assess and treat them all in one session.

If it’s a “whole body” condition like Rheumatoid Arthritis or Fibromyalgia, I will often use a Selective Functional Movement Assessment style of testing. This includes a few total body strength tests, and whatever specific detailed assessments are relevant to my clients’ concerns and needs during the physical exam. Unfortunately, in these situations I don’t always have the luxury of taking 2-3 appointments to do a detailed active/passive/resisted/special tests exam for every joint in the body while getting all the other stuff I need done. In addition, I don’t want these highly sensitized clients to feel too intolerably sore afterwards.

• I also pick and choose what needs to be done the first day and what can be left for later sessions. For instance: if your client strained his calf and hamstring playing soccer do you need to do a max calf raise test on Day 1?

Some clients may want a plethora of body parts assessed and treated in the same session and some (particularly ones who may have had this before from a previous provider) may just expect to be on the treatment table for 5-10 minutes without much of an assessment. In those situations, I educate clients on the importance of appropriate assessment and diagnosis. But ultimately if they still want a slip shot assessment and treatment approach, I’m not the therapist for them.

2 – Going Too Far in One Direction or The Other

I’ve made the mistake of going too far in either the biomechanics or the psychosocial direction. Sometimes, even when I haven’t, it may be misinterpreted that I’m going too far one way or the other. Unfortunately, clients may think “oh, it’s all psychosocial factors” or “oh, it’s all my weak muscles.” This illustrates the importance of having a thorough assessment and clinical reasoning process AND making sure the client understands what is going on.

This is also where a trick like the “Kieran O’Sullivan test” of getting the patient to explain the findings to you can make a big difference in confirming understanding.

3 – Underbooking

This is one that gets less attention. Sometimes us BPS clinicians can be concerned about overbooking patients as:

• We don’t want patients to be dependent on us
• We don’t want to use up all of a client’s benefits
• We don’t want to be seen as being more concerned about money than patient care

In reality, as with many patient care situations, the answer doesn’t need to be black and white and is case by case dependent. Don’t get me wrong, booking a routine sprained ankle or an acute back pain case that’s going to likely recover on its own for 3 sessions a week for 12 weeks is likely overkill. Unless you are working with a client who is starting at a low level and/or a client who is working towards very high activity demands.

That said, I will admit that sometimes I was so concerned about making a plan fit within a patient’s insurance that I underbooked them and didn’t have enough consistent follow-up in the early stages to ensure they progressed appropriately. This was especially the case with clients who were paying and I only saw them once every 2-3 weeks leading to inconsistent progress. In hindsight, getting them in more regularly on the front end would have helped them progress faster and may have even saved them money in the long term. Their recovery would have been maximized quickly and effectively rather than drawing it out over a prolonged period.

I tell patients and practitioners that I always recommend the treatment frequency that I feel is ideal. This frequency depends on the below factors:

• Is your patient getting better or not?
  • If she’s 90% recovered, I don’t mind following up once every 3-4 weeks. But if her shoulder pain is up and down, I don’t feel comfortable going down to that low of a frequency until things are more stable.
• Is your patient the type that could go either in a way in a hurry?
  • Sometimes clients with a symptomatic disc herniation can get better or worse very easily and need to focus on posture and movement in those early stages. Or on the flipside, a young lady who’s fresh out of a MVA, highly sensitized and fearful, may need a lot of consistent reinforcement to ensure she doesn’t completely “shut down” and avoid activity whenever her pain comes on. By contrast, an easy going client who just has a bit of back pain after running too much doesn’t need much treatment frequency.
• Is there an indicated need for manual therapy?
  • Your post-op ACL client, which is late starting therapy, has hamstring guarding and limited knee extension ROM will need multiple times per week in-person therapy to regain that lost ROM. Conversely, a non-operative client who has full ROM may not urgently need much manual therapy and can be booked less frequently.
  • As for the old debated topic of patient dependence on manual therapy, that needs to be looked at on a case by case basis.
• How fast are you progressing exercises?
  • A healthy 16 year old who sprained his ankle last week and is getting off crutches can probably progress exercises multiple times per week. Conversely, a 70 year old who has osteoporosis and is so sedentary and deconditioned that she lacks Grade 3 quad strength may need to work on those exercises for a while before she can progress further.

Ultimately, patients may not be able to book at your recommended frequency because of time, financial ability and individual differences. This requires flexibility from the therapist as well. Treatment frequency can also be adjusted based on client progress and needs. However, I’ve found it very liberating to forget about insurance and focus on recommending what I think is right.

Conclusion

In this piece, we’ve covered three of the biggest mistakes I’ve made within a BPS model of physiotherapy. In the next piece, we’ll cover the remaining four!