To approach with an approach or to approach our approach? Tackling the biopsychosocial presentation

So I recognise I have diverged somewhat from what I originally set out to explore. Initially, I set out to determine whether or not I managed patients who presented with biopsychosocial factors ‘correctly’. I wanted to explore what treatment approaches were most effective based on the current evidence.
After my most recent blog I begun to change my way of thinking. I thought it is all being well exploring what the most appropriate treatment approach is but if our views tend to be more biomedical orientated and as clinicians we do not recognise biopyschosocial factors well nor discuss and approach these factors with our patients then surely attempting to utilise a particular treatment approach may have little effect.
I then considered whether the beliefs and attitudes we take towards the biopyschosocial presentation of pain could have a detrimental effect on our patients, their clinical experience and consequently overall outcome.

A systematic review by Darlow et al (2012) set out to explore the association between healthcare professionals attitudes and beliefs and patient related factors in patients with low back pain. They hypothesised there would be an association between health care professionals attitudes and beliefs and patient attitudes and beliefs, patient clinical management and patient outcome.
The results showed a strong relationship between the attitudes and beliefs of patients with low back pain and the attitudes and beliefs of the health care professional that they were consulted by.
The review found the greater the perceived pathology and biomedical focus the more likely the recommendation not to work. This was found mostly among physiotherapists and general practitioners. Also, the higher the fear avoidance beliefs the more sick leave prescription and onward referral to specialist care there was.
Among general practitioners the higher the fear avoidance beliefs the less likely guidelines to physical and occupational therapy were followed.
Physiotherapists that held views that were more biomedically focused viewed activities as more harmful and advised patients to limit their activity. There was also an association between the education that was given to patients. Those with higher biomedical beliefs than those with a more biopsychosocial view gave less instruction and advice to patients. Sample sizes for these studies among practicing therapists in the musculoskeletal outpatient setting were small though.
Rheumatologists that tended to have high fear avoidance belief scores significantly increased the risk of patients also having a high score. Restrictive work and activity recommendations were also made more so by rheumatologists that held higher fear avoidance beliefs.

The study included studies of both qualitative and quantitive data. An extensive literature search was conducted of controlled trials. Studies were scrutinised, if deemed low quality based on if they fulfilled less than 50% of the criteria they were disregarded. The majority of the studies were cross sectional designs, two that were mostly relevant to physiotherapy were both semi structured interviews although the sample size and methodology was good the flexibility of the interview could flaw the results. The authors did consider the rigour of the studies that they identified, this increasing the reviews reliability. The authors used two reliable forms of assessing the strength of the evidence, the AHCPR and the GRADE rating. Attempts to reduce the sources of bias was made; a hypothesises was set from the start, two reviewers independently completed each stage of the review process and a range of reviewers collaborated from a number of institutions, countries, and backgrounds with different research interests and experience. The results of each of the studies were clearly displayed among the type of assessment methods. Assessment methods were in keeping with previous studies such as the Pain, Attitudes and Beliefs Scale (PABS).

The review highlights the negative effect that biomedical beliefs and attitudes that clinicians hold have on patient care. However, physiotherapists often recommend activity and exercise often justified by using a tissue based biomedical explanation. It appears the two schemas are still often seen as as being separate from each other. General Practitioners recognise the importance of psychological factors but seem to lack the time and training to incorporate it into practice. Thinking back to my second post where I looked at how the interpretation of pain can be shaped by a whole host of factors I touched on what influence the beliefs and attitudes that we have towards pain can have on the development of chronicity and disability and what effect how well our expectations of pain are managed can have on clinical outcome. As discussed in that post the literature suggests the better our expectations are managed the higher the likelihood of a better clinical outcome. Therefore it is not surprising that if expectations are poorly managed this can lead to pain catastrophising leading to poorer recovery and worse clinical outcome.

Looking at all of these points in this post, would it be fair to say that there is a likelihood of practitioners adding to the chronicity of pain in patients presenting with biopyschosocial factors.


Darlow B, Fullen B, Dean S, Hurley D, Baxter G, Dowell A. (2011) The Assosciton between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review. European Journal of Pain. 16 (2012) 3-17