Where Does The Social Fit In Biopsychosocial?

 

BIAS ALERT: I LOVE the biopsychosocial model.

I must tell you my bachelor’s degree is in psychology.  When I started my master’s in physical therapy and we focused on biomedicine, I constantly was screaming “but what about the rest of the patient?!?”

I had been exposed to enough injury through my athletic training degree and personally with my father’s chronic disease to know it wasn’t just about a biologic derangement.  Pain, recovery,  and function are much more complicated than that.

The reality is, this model has been around since 1977 when Dr George Engel published his paper critiquing biomedicine.  The paper considered the patient-clinician relationship, the patient’s perspective of the symptoms, the fact that pain can exist without a biological derangement and how patients are profoundly influenced by the way they are studied.

The last couple decade’s technology has allowed neuroscience to study the brain and give us a new understanding why.  Luckily people treating pain got involved and clinically applied the neuroscience to patient care.  I was thrilled when Adrian Louw, Lorimer Moseley and David Butler started a big push in the physical therapy world to incorporate pain science (therapeutic neuroscience education) to our regular PT interventions.

Traditionally our coursework focus on the bio portion of this model: What tissue issue does the patient have?  More recently many published articles focus on the psychological portion of the model.  How do the patient belief systems, stresses, mental health, and expectations affect their pain?

The focus has not been on the social piece of the model.  Arguably the social piece impacts the psychological.  Patient’s interpersonal relationships can be stressors or helpers in their pain story.  The cultural norms can also affect the patient’s mental health.

Should we use the social part of this model to tap into strengths and facilitate our patient’s recovery?  Is there research behind this? 

Prescribing The Social

I started reflecting on these questions recently.

I currently treat a patient referred for chronic pelvic pain and urgency/frequency with urination.  She is an insulin dependent diabetic, has RA and has had multiple pelvic and abdominal surgeries.  She is married to a professional who travels a lot for work. Travelling with her partner used to be an option, however, with a recent trip coming, was very upset she couldn’t go.

Although there has been an improvement with treatment, and I felt like she could travel with a few modifications for her pelvic/coccyx pain.  After a long discussion I essentially “assigned” her to go on the trip. 

We discussed all sorts of strategies to manage her pain, her urgency, and allow her to enjoy her trip.  She came back a completely different person.  What also amazes me is the exceptional progress she’s made in the last 3 weeks and has even gone on another trip.

This made me think about another patient I had last year.

Their history is way too long but the short version: hysterectomy that led to pelvic pain that led to the doctor telling her “don’t do it if it hurts” which led to self-imposed bed rest for an entire year.  She was so deconditioned by the time I saw her she was wheelchair and housebound.  About 6 months into her treatment, I gave her the HEP (home exercise program)  to have lunch with her friends.  This was an activity she had done at least once a week prior to her surgery 2 years earlier.  Since the surgery, she hadn’t even allowed people to visit her in her home.  We discussed the importance of seeing her friends and how much they cared for her.  It started with her friends bringing her lunch.  Within 2 weeks she was going out to a close restaurant for lunch.

Again, this seemed to be a catalyst for recovery.

So, What Does The Research Say?

First,  the research suggests chronic pain in adults and adolescents negatively affects social relationships.

People with persistent pain have fewer friends, worse peer relationships, hindered ability to take part in social activities and tend to withdraw from social peers.  Adolescents in pain are perceived by their peers to be less likeable and less fun to spend time with.

But does increasing social interaction decrease pain?

Studies suggest that dynamic interaction and social interaction and empathy of others may reduce pain and have a positive effect on coping.  One study published in February 2018 looked at physical social interaction and pain.  Two people held hands while one was administered a painful stimulus.  Both subjects were connected to EMG.  When the two subjects were holding hands, the pain subject reported less pain and their EMG was less active in the correlative centres.

The control was the administration of the stimulus while they were not touching.  This suggests that physical touch and social interaction may change a patient’s pain experience.  It’s important to note, the subject not receiving the pain stimulus had an INCREASE of brain EMG activity and reported empathy for the pain subject.

So what does this mean?

Because the social piece closely ties with the psychological piece, we should look for opportunities to utilize this as a patient strength to facilitate recovery.  However, not all social interactions are good interactions.  We must find out what matters to the patient.  Who do they want to see? What outings matter the most to them? 

Dosing social interactions may be very similar to dosing exercise.

My patient wasn’t ready to ride in a car and go out to a restaurant after almost 2 years of being housebound.  The first graded exposure involved people coming to her and sitting a shorter time.  After that, she was ready to leave the house.

However, some people may need to repeat something like this several times before venturing out of the house.  We may need to brainstorm scenarios and coping strategies to set our patients up for success.  You can’t do this without pain education.  The patient needs to understand soreness doesn’t equal damage.  And just like exercise, we need to follow-up with them to assess tolerance and give them advancement to their program.

Next time you have a patient whose pain is causing isolation, I challenge you to look for opportunities to make social activity part of their home program.  Getting our patients to return to supportive social environments could be an important part of their care.

 

References:

Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136

Engel G. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544

Borrell-Carrio F et al.  The Biopsychosocial Model 25 Years Later: Principles, Practice and Scientific Inquiry. An Fam Med. 2004: December 576-582.

Markris U et al. Physical, Emotional and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study. Pain Medicine. 2017; 18:1225-1235.

Block P et al. Social Interaction and Pain. Social Science and Medicine. Jan 2018: (196) 47-55

Goldstein P et al. Brain-to-Brain Coupling during Handholding is Associated with Pain Reduction. PNAS March 13, 2018. 115 (11) E2528-E2537

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