The bio psychosocial model is now widely accepted for the diagnosis and the management of multifaceted nature of pain. The bio psychosocial model of pain presents an integrated view of biological, psychological and socio cultural factors, which could occur in pain (Jull and Sterling 2009). Seventy-five percentages of individuals in the western world during their lifetime affected with acute or chronic low back pain, which leads to major cause of disability (Kirk et al.2005). " Low back pain must be considered as a bio-psycho-social syndrome that consequently requires a multidisciplinary bio-psycho-social treatment approach." (Negrini et al .2008, p.55). The result of a dynamic interaction between psychological, social and patho- physiological factors of chronic pain makes difficulty for the individual patient to determine the pre-eminent factor in his experience of chronic pain, which emphases the importance of bio-psycho-social treatment approach (Kirk et al. 2005). European guidelines also recommend the bio-psycho-social treatment approach for the treatment of chronic low back pain (Balague et al .2007).
Rationale behind investigating this topic
In clinical area of practice, low back pain is a common health problem for both healthcare professionals and patients, which reflect the thought to find out the role of bio psychosocial perspective in assessment, diagnosis and treatment of chronic low back pain. This would lead us to better understanding of low back pain and pain in general. The aim of this assignment is to critically evaluate the available evidence regarding bio psychosocial model in relation to chronic low back pain. It will also reflect on clinical practice, taking into account the principles of evidence based practice.
All major databases including Psychinfo, Ovid, Medline and Cochrane databases and Goggle scholar search engine will be searched for available evidence in the last 5 years. The search was extended to ten years, as the initial search did not yield enough results. Keywords; bio psychosocial model, Low back pain, fear avoidance behaviour, depression, psychological factors, and their combinations were used. Search criteria were limited to clinical studies in humans and in the English language only. Backs chaining to identify and include other relevant articles were also undertaken. The strength of evidence will be graded using Sackets's hierarchy of evidence (1997). (Please see appendix 1). Each of the papers were analysed for validity and rigour according to the framework given by (Rees 1997, cited in Taylor 2009)
Case history to relate to bio psychosocial model into clinical practise
Mrs smith 35 year old mother of one child, a health professional has been suffering from chronic back pain since 2006 to2008, who feels so depressed as she has some family problems (son was sick with heart problem) and problems with her manager at work (never agreeing with shift adaptation to look after the child). She went to see her GP and complete medical assessment was negative, started on analgesics .The conflict existed, which lead her into severe depression. In 2009 she went see a psychotherapist. The manger agreed with her job flexibility to look after the child, by the time child's condition improved lead her to less frequent and less intense episodes of pain. Like many other patients the patient had never considered the possibility of psychological or social factors for two years, which could contribute to her chronic pain. Mrs smith she was told by psychotherapist that any biological reason together with psychosocial concerns can exacerbate the experience of pain and she realized the contributing psychosocial factors to her pain gradually. As she was a health care professional she started to use coping mechanism effectively with the help of psychotherapist, which helped her to control her stress with subsequent less intense episodes of pain. In the light of the above case, one of the reasons that her medical treatment had failed to respond is because of the underlying psychosocial factors have been left un-addressed. The health care professionals should understand and exploit the bio psychosocial approach to the management of chronic pain will provide effective treatment modality for patients
The bio psychosocial model relates to chronic low back pain: Evidence from studies
Mitchell et al.(2009) conducted a cross sectional study to evaluate the bio psychosocial factors that can contribute to low back pain in nursing students. The results proved that modifiable personal factors play an important role in low back pain. One hundred and seventy undergraduate nursing students from two university nursing schools of western Australia were enrolled for this study. Study gives the evidence for sufficient statistical power and ethical consideration. The researcher used triangulation in data collection, which overcome the limitations of a single method of collecting data and hence increased the validity of the results. The results of this study were based on self-reported (questionnaire) outcomes that were collected from patients. It can contribute to validity of the results, because they are more subjective and most likely true. Another important feature of the study is that it had good inclusion and exclusion criteria on sample selection (Patients who had back pain as a result of inflammatory disorders, neurological or metastasis disease, pregnancy or less than 6 months postpartum were excluded) this enables to examine the study with more relevance to bio psychosocial model more closely. The study was conducted as cross sectional study, which has less power against longitudinal studies because of the time constraint, there were no experiments and control group involved, it can be classified into Class 3c on level of evidence. The result cannot be generalized in other population types, as it conducted on healthy professional youngsters and included age between 18-35,and researcher failed to include other factors like fear avoidance and genetic factors. Application of these results into clinical practise: This study was carried out in the Australia and their standard of clinical practice may differ from standard of clinical practice in UK, decreasing the accuracy of reproducing these results to UK practice. The study result proved that the modifiable personnel factors can contribute to the low back pain and it also showed that no link between low back pain and social measures such as household income, smoking and alcoholism .The accuracy of the second part of this result needs to consider before it reflect on clinical practice with general population as healthy university sample may not be much influenced by social factors. The researcher failed to explain the relation between personnel factors and social factors before the conclusion of this result. In the area of practice psychosocial factors has significant role on experiencing low back pain among healthcare professionals and potential candidates, which reflects the necessity of education related to stress management such as relaxation techniques and meditation. Physical factors can control by mandatory manual handling training. The high prevalence rate of low back pain highlights the importance of targeting prevention interventions among healthcare professionals and patients. The case study of patient discussed has not had much benefit from the conventional treatment pattern and showed clear evidence of personnel factors that can contribute to pain. The understanding of bio psychosocial factors helps to find out cause diagnosis treatment and prevention of chronic back pain
Suprina (2003) conducted a case study to discuss the efficacy of bio psychosocial model.
The sample for this study was a 32-year-old woman who suffers from chronic back pain for almost ten years and study reported that bio psychosocial model helps the women for successful reduction of symptoms. This study also proves that single practitioner also can plan bio psychosocial model for the treatment of chronic back pain. The researcher reports that the treatment can be more effective when implementing one person integration model than multidisciplinary approach as it has easy access to patient also saves money and time. This study classified under level 3d as this is a study of only one individual. There is chance of bias through hawthrown effect because subject can make her own changes in response to the fact that she is being studied, which can affects the rigour of the study. Application of these results into clinical practise: Even though it is individual case study it agrees with widely accepted bio psychosocial model. The study reveals that all health professional should consider individual patient as one with complex behaviours and emotions and not just organism with physiological changes .The researcher who conducted this study in US is supporting the one-person integration model, practicability of this one- person integration model in UK clinical practise questionable because the way of clinical practise vary different countries. The current trouble within heath care system in European countries is relegate mainly to biomedical perspective and not considering psychosocial aspects because of time constrict and inadequate training. Mauksch (2005) compared the current state of bio psychosocial approach to a dormant seed, which is sitting on the shelf, which need to be watered with bio psychosocial education by health care professionals and placed in an environment fertile with bio psychosocial practise. The knowledge about bio psychosocial approach helps healthcare professionals for better assessment and treatment of patients, which also agrees with case study discussed
Tang et al. (2008) did an experimental study on the effects of mood on pain responses and pain tolerance in chronic back pain patients
The recruited sample was 55 patients suffering from chronic back pain and experimentally induced depressed and happy mood to study different effects on pain and pain ratings. The patients were asked to perform a clinically relevant active task (holding a heavy bag) to elicit pain responses and tolerance. The duration of bag holding time was recorded for the three groups studied was 86.7 seconds (depressed group, n=18), 120.3 seconds (neutral group, n=19) and 101.6 seconds for elated group (n=18). The results of the study indicate that the induction of depressed mood resulted in significantly higher pain ratings at rest and lower pain tolerance and happy mood resulted in lower pain ratings at rest and greater pain tolerance. The mood was induced by making the participants listen to different types of music to induce the desired mood .The induced 'depression' and 'happiness' may not truly reflect moods experienced by patients in real life situations. On other hand there is a degree of uniformity in different moods of the participants. The music here is very specific and time managed, one would anticipate that it would, to a certain extent induce the same level of depression and happiness. This makes the result of the study more accurate and adds reliability. As it an experimental study it comes under level 1a. Application into clinical practise: As we have seen that the patient under case study have not received any behavioural treatment for her suffering. It's also known that the familial situation and her emotional status at the point of suffering all contribute to the perception of pain. These factors are not taken into account here when considering her line of treatment, which made her life difficult for two years. Fig: 1(Appendix: 4 ) shows the possible interactions of bio psycho social factors after musculoskeletal injury, which might happen in Mrs smiths case. This study result clearly highlights the strong association between psychosocial factors and severity of pain, which empathises the importance of bio psychosocial approach. 2.2d Waxman et al. (2008 ) did an observational study examining the association of chronic low back pain, increased disability, lower quality of life, depression and poor relationship satisfaction. Negative responses by a partner and depression were found to have an impact on pain and relationship satisfaction.(Table 1,Appendix:5). The effect of pain on depression was significant, = .63, p< .01. The study used methods like Multidimensional Pain Inventory-part II (MPI), Short Form McGill Pain Questionnaire (SF-MPG) and Centre for Epidemiological Studies Depression Scale (CES-D) have been used. All the tools used here have high reported internal consistency. This adds to the rigour of the study. Blinding was not done, perhaps, owing to the nature of the study. But no measures have been taken to avoid the bias, which might have crept in because of this. The study can be classified under Class 3c on level of evidence considering the design and methods employed in the study. Reflecting the study back to the case of Mrs smith It's not clear about her partners involvement in her treatment, hence it's difficult to relate the study results into her case. The study result underscores the importance of partner involvement in patient's pain assessment and treatment. The study reaffirms the bio psychosocial model for assessment and treatment of chronic back pain. 2.2e Sheldon et al. (2006) studied the relationship of work, psychological and social factors in the contribution of disability in back pain patients. A cross-sectional design (n=890) was used where patients who had back pain for more than a year ,completed questionnaire about pain, disability, pain related fear, job satisfaction and job stress. Pain intensity was found to be the key factor in functional and social disability. Fear avoidance behaviour and pain were mediators of disability. The study used cross sectional data from employees from Belgium and Netherlands. The selection of population from more than one country makes it more acceptable to apply the results to wider population. The study conducted as interview base, because of the nature of the study, it can be ranked as Level 3d on the hierarchy of evidence. A study of this nature has limitations in relation to a RCT, but a sample size of 890 is large enough to minimize statistical errors. The study result is distinct from other study results, which proved pain intensity as the primary factor that plays a role in the onset of functional disability and also proved about contribution psychosocial factors in to severity of pain. While considering Mrs. Smith case only 'bio' part of model was considered 'psychosocial' part of the model not considered. To identify factors that contributing to chronic back pain health care professionals should use bio psychosocial model for assessment and treatment which always explore the psychological and social dimension as well as biological aspect of pain
Suprina (2003) reported after her case study that bio psychosocial approach for assessment and treatment of chronic back pain can make the successful reduction of symptoms . This study result also agrees with Margalit et al.(2004) which reported that the approach can reduce the health care expenditures and can promote patients satisfaction . Tang et al. (2008) , Currie and Wang (2004) and Waxman et al .(2008)also reported the same fact which explains the relation between depression and pain intensity. Depression can significantly leads to higher pain ratings and higher pain ratings can also leads to severe depression. Sheldon et al. (2006 ) and Waxman et al. (2008) proved that psychosocial factors like fear avoidance behaviour, negative responses by a partner and cognitive factors are contributing to chronic back pain. The cross sectional study conducted by Mitchell et al.(2008) reported that personal factors can contribute to low back pain. After extrapolating the results and considering the nature of the studies, the findings suggest that bio psychosocial factors have important contribution to low back pain. One of these factors could trigger the other and vice versa. In practice, it is difficult, rather impossible, to dissociate one factor from the other, which emphases the importance of bio-psycho-social treatment approach