Understanding the biopsychosocial orientation of pain and it’s incorporation into the clinical reasoning process.

Previously we explored what influence psychosocial factors can have on patients’ pain experience. Initially I believed it was all about how the patient presented, that influenced our clinical outcome, however I now aim to explore what influence clinicians’ beliefs on pain can have on their practice. But first what do clinicians believe pain is all about?

A systematic review by Parsons et al (2007) that explored the influence of patients’ and primary care practitioners’ beliefs and expectations on the process of care for chronic musculoskeletal pain found four common themes; Beliefs about pain, expectations of treatment, trust and patient education.
Within the review there seemed to be conflict in patients’ and general practitioners beliefs and causation of pain. Patients’ beliefs seemed to be focused around their subjective experience in comparison to the beliefs of general practitioners which seemed to be more biomedical orientated. The reviewed papers suggest that this biomedical approach may be due to their lack of training and awareness in how to manage patients with musculoskeletal pain.

In 2009, Overmeer et al found that physiotherapists held similar views on the cause of pain to those of the general practitioners in the review by Parsons et al (2007).
Overmeer et al (2009) evaluated the views of forty-two randomly selected physiotherapists on the cause of pain by the use of the Pain Attitudes and Beliefs scale for Physical Therapists (PABS-PT). The PABS-PT consisted of two factors one measuring the biomedical orientation and the other the orientation of biopsychosocial treatment.
Prior to attending a severn day educational program the results of the physiotherapists PABS -PT scores suggested that they held beliefs that were more biomedical focused. Compared to after the educational program results favoured a more biopsychosocial orientation towards pain. Despite the study showing a change in beliefs following the educational program the results could be flawed as the physiotherapists attending the course applied voluntarily and were already interested in and had knowledge about and already with some degree begun to adopt a biopsychosocial approach before the course.
What I found interesting in this study was that the majority of participating physiotherapists had over ten years experience. I would have expected them to have had a greater understanding of the biopsychosocial orientation of pain. However, clinical practice changes all the time despite despite the fundamentals staying the same and concepts move forward. We don’t know if the practitioners specialised and if so what in and how long for. The fact that participants signed up voluntarily could suggest they were keen to improve their current knowledge. Also most of the therapists worked mainly in private practice perhaps they adopt a more biomedical approach. Is there less biopyschosocial presenting clientele within private practice than within the National Health Service?

Similarly, a study by Latimer et al in 2004 that measured the attitudes and beliefs of third and fourth year physiotherapy students on adults suffering chronic low back pain, found that following a specialised educational program, attitudes and views changed.
Six hundred and eighteen, third and fourth year undergraduate physiotherapy students completed the Health Care Providers’ Pain and Impairment Relationship (HC-PAIRS) scale. Believed by Rainville et al (1995) to be a highly reliable form of assessment with internal consistency when used to measure the attitudes and beliefs of health care providers to chronic back pain.
Three hundred and five students went on to complete a further scale after a 4 week, 16 hour teaching module.
Although therapy students’ attitudes and beliefs were measured through the HC PAIRS scale, unlike the study by Latimer et al (2000) the orientation of their beliefs was difficult to tell. The short term effects of the teaching module was evaluated through assessing students’ beliefs immediately after the teaching module. Long term effects of the module were evaluated a year on when year three students were in their final year. The HC-PAIRS scores of students not exposed to teaching i.e those that completed the scale but did not go on to attend the teaching module and the year four students that received no specialist training were found to be similar to those obtained by Rainville et al (1995) for a group of community health care providers, that included physiotherapists, occupational therapists, physicians, nurses, and psychologists. Rainville et al (1995) compared the views of community health care providers to a group of pain clinic providers. Community health care providers had a significantly higher mean HC-PAIRS score than those working in specialist pain clinics. This suggesting that like the physiotherapy students, health care providers agree more with the notion that chronic low back pain justifies disability and the limiting of activities.

Smart and Doody (2007) assessed the clinical reasoning processes of severn experienced physiotherapists. The study concluded that all severn of the physiotherapists demonstrated extensive and diverse psychosocial oriented reasoning. their clinical reasoning took into account patients’ cognitions, emotions, behaviours, attitudes andcoping strategies as well as sociological factors. In the same sequence, each physiotherapist viewed three separate videotaped patient – therapist interviews describing three different pain presentations. Their thought processes regarding the nature of the patients’ pain presentation were asked to be verbalised. As each physiotherapist viewed each of the case studies, the principle researcher, a senior physiotherapist conducted a semi-structured recorded interview. At set intervals the researcher paused the video recordings at which point open ended questions were asked to prompt each physiotherapist to verbalise their thoughts. Each of the interviews were transcribed. The transcripts were then coded and their inter and intra coder reliability was checked which was found to be excellent and good retrospectively according to Daly and Bourke, (2000). As all therapists had a minimum of ten tears experience in musculosketal physiotherapy and had engaged in formal postgraduate education this study highlights the difference between inexperienced practitioners knowledge on the understanding and integration of the biopyschosocial pain presentation compared to those who are more experienced and knowledgable. Jensen et al (2000) and Edwards et al (2004) also support better psychosocial orientated reasoning among experienced physiotherapists in their studies that evaluated the clinical reasoning process of experienced clinicians.

With the understanding that there seems to a gap in the knowledge of the biopsychosocial understanding of pain and it’s incorporation into the clinical reasoning process particularly among less experienced clinicians. In the next post I hope to look at how this influences our practice does it affect clinical outcome?


Daly L, Bourke G Interpretation and uses of medical statistics. Oxford: Blackwell Science 2000

Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM (2004) Clinical reasoning strategies in physical therapy. Physical Therapy. 84 312-335

Jensen G, Gwyer G, Shephard K, Hack L, (2000) Expert practice in physical therapy. Physical Therapy. 80 28-52

Latimer J, Maher C, Refshauge K (2004) The Attitudes and Beliefs of Physiotherapy Students to Chronic Back Pain. Clinical Journal of Pain. 20 (1) 45-50

Overmeer, T, Boersma K, Main C, Linton S (2009) Do Physical Therapists change their beliefs, attitudes, knowledge,mskills and behaviour after a biopsychosocially orientated university course? Journal of Evaluation in Clinical Practice. 15 724-732

Parsons S, Harding g, Breen A, Foster N, Pincus T, Vogel S, Underwood M (2007) The influence of Patients’ and Primary Care Practitioners’ Beliefs and Expectations About Chronic Musculoskeletal Pain on the Process of Care. Clinical Journal of Pain. 23 91-98

Rainville J, Bagnall D, Phalen L. (1995) Health care providers’ attitudes and beliefs about functional impairments and chronic back pain. Clinical Journal of Pain. 11 287–295.

Smart K, Doody C (2006) The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Manual Therapy. 12 40-49


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