K. Mescouto1, R. Olson2, P.W. Hodges1, J. Setchell1
1The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia, 2The University of Queensland, School of Social Science, Brisbane, Australia
Background: Low back pain (LBP) is the leading cause of disability worldwide. Clinical guidelines and position statements strongly recommend using the biopsychosocial model (BPS) to inform management of people with LBP by promoting a more humanistic approach. However, there is still no clear consensus regarding the conceptual understanding of this model in physiotherapy and there has been limited critical analysis into how physiotherapy conceptualises and enacts the BPS model.
Purpose: To investigate the concepts and assumptions underpinning the use of the term ‘biopsychosocial’ in physiotherapy literature in LBP care.
Methods: We conducted a critical review and used the qualitative method of discourse analysis to analyse selected articles retrieved from PubMed and Web of Science databases. Our analysis investigated how articles constructed the BPS model in LBP care and how these constructions may inform and shape practices, identities and power relations within the application of the model in physiotherapy. One researcher read through each of the selected articles and, to enhance rigour of the results, two experienced qualitative researchers independently read through the dataset. Discourses were discussed until agreement. Another investigator provided an external perspective and confirmed the final analysis.
Results: Overall, 55 articles were included. Our analysis of these articles discusses four key discourses:
1) BPS as biological (conflation);
2) BPS as (mainly and narrowly) psychological;
3) BPS as (occasionally involving) social; and
4) BPS as other aspects of care.
In most articles, more than one discourse was evident, but the emphasis on certain factors over others was apparent in how the understanding of the BPS model in physiotherapy was constructed. The discourse analysis suggested that although texts acknowledged psychological and social aspects, the focus continued to be on biological aspects. Many texts conflated the BPS with the biomedical model by emphasising the use of treatment approaches that focused on educating patients about pain neurophysiology and reducing the BPS model from its trifecta to the ‘bio’. Texts were also narrowly and mainly focused on some psychological aspects such as cognition and behaviour, and there was little consideration of social aspects. When present, social aspects were largely limited to work and family. Other aspects that may be relevant to a comprehensive approach to LBP management such as culture, patients lived experience, power dynamics, ethics and morality were rarely present or not present at all.
1) BPS as biological (conflation);
2) BPS as (mainly and narrowly) psychological;
3) BPS as (occasionally involving) social; and
4) BPS as other aspects of care.
In most articles, more than one discourse was evident, but the emphasis on certain factors over others was apparent in how the understanding of the BPS model in physiotherapy was constructed. The discourse analysis suggested that although texts acknowledged psychological and social aspects, the focus continued to be on biological aspects. Many texts conflated the BPS with the biomedical model by emphasising the use of treatment approaches that focused on educating patients about pain neurophysiology and reducing the BPS model from its trifecta to the ‘bio’. Texts were also narrowly and mainly focused on some psychological aspects such as cognition and behaviour, and there was little consideration of social aspects. When present, social aspects were largely limited to work and family. Other aspects that may be relevant to a comprehensive approach to LBP management such as culture, patients lived experience, power dynamics, ethics and morality were rarely present or not present at all.
Conclusion(s): Our critical review suggests that a BPS approach in physiotherapy within the selected texts tends to favour the biomedical and psychological and marginalise or subjugate the social aspects of health and other important factors such as interpersonal or institutional power dynamics, cultural considerations and ethical and moral factors of LBP care.
Implications: Some implications of these findings may indicate that the BPS model in physiotherapy is conceptualised and applied fairly narrowly, reinforcing the very thinking the model aims to overcome. Our analysis suggests that the BPS model as the dominant approach to physiotherapy requires reconceptualization, and that broader and new approaches may be warranted.
Funding, acknowledgements: This work was supported by National Health and Medical Research Council of Australia Fellowships [JS: APP1157199 and PH: APP1102905]
Keywords: Biopsychosocial, Low back pain, Qualitative research
Topic: Pain & pain management
Did this work require ethics approval? No
Institution: The University of Queensland
Committee: The University of Queensland Human Ethics Committee A
Reason: This was a systematic search of the literature, therefore no ethics approval was necessary
All authors, affiliations and abstracts have been published as submitted.
