The Biopsychosocial Model

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

Recent Biopsychosocial Articles

	Chiropractic and Spinal Pain Management A Chiro.Org article collection Explore this collection of articles that discusses the relationship between tissue injury and various pyschosocial factors that may contribute towards developing chronic pain.
	The Trajectories of Low Back Pain A Chiro.Org article collection Researchers have found: “Trajectory clusters differed significantly from each other in terms of disability, psychological status and other symptoms. Most participants remained in a similar trajectory as 7 years previously.”
	A Collection of Biopsychosocial Articles by Craig Liebenson, D.C. A Chiro.Org article collection This collection includes: What to Do about “Yellow Flags” How to Shift LBP Paradigms: The “Hinges” of Practice The Modern Report of Findings: The Role of Reactivation Evidence-Based Care From Guidelines to Practice:   Parts 1–4
	The Association Between Psychological and Social Factors and Spinal Pain in Adolescents European Journal of Ppediatrics 2019 (Mar); 178 (3): 275–286~ FULL TEXT This study indicated that psychological and social factors are associated with SP in adolescents with a higher frequency of these reported factors resulting in higher odds of reporting SP, especially “substantial SP”. Psychological factors appear to be more strongly related to SP than the social variables. Together, this reinforces the importance of understanding psychological and social factors in adolescents reporting SP.
	Measuring Biopsychosocial Risk for Back Pain Disability in Chiropractic Patients Using the STarT Back Screening Tool: A Cross-sectional Survey Chiropractic & Manual Therapies 2019 (Jan 15); 27: 2 ~ FULL TEXT Seventy-nine percent of respondents scored with low risk for developing back pain disability, 21% scored medium-to-high risk for developing back pain disability, and 41% reported at least 1 SBT psychological risk factor. The SBT is a screening tool and cannot be used to diagnose mental health conditions. However, a relatively high prevalence of respondents indicating low mood and anxious thoughts supports the need for future research efforts aimed at quantifying the prevalence of common psychological risk factors and mental health conditions among US patients seeking chiropractic care. Survey results suggest that clinicians at US chiropractic teaching clinics should develop, or continue implementing, management pathways for patients experiencing specific types of psychological distress. Future studies examining how SBT-informed tailored treatment plans influence pain, disability, and quality of life outcomes are also needed.
	A Scoping Review of Biopsychosocial Risk Factors and Co-morbidities for Common Spinal Disorders PLoS One. 2018 (Jun 1); 13 (6): e0197987 ~ FULL TEXT This review presents a compendium of risk and prognostic factors and comorbidities for common spinal disorders. Spinal disorders are co-morbid with several general health conditions. However, no substantial body of literature provides clarity as to which conditions are merely comorbid versus risk factors. Modifiable risk factors may be fertile grounds for initiating research on individual or community-based public health programs that may help prevent or mitigate the effects of common spinal disorders. Summarily, public health and prevention considerations for spinal disorders should be considered in care pathways and models of care, however the model should be flexible to adapt to new research in this emerging field.
	The Biopsychosocial Model and Chiropractic: A Commentary with Recommendations for the Chiropractic Profession Chiropractic & Manual Therapies 2017 (Jun 7); 25: 16 ~ FULL TEXT There is an increasing awareness, interest and acceptance of the biopsychosocial (BPS) model by all health care professionals involved with patient care. The areas of spine care and pain medicine are no exception, and in fact, these areas of health care are a major centerpiece of the movement from the traditional biomedical model to a BPS model of patient assessment and delivery of care. The chiropractic approach to health care has a history that is grounded in key aspects of the BPS model. The profession has inherently implemented certain features of the BPS model throughout its history, perhaps without a full understanding or realization. The purpose of this paper is to present an overview of the BPS model, its relationship with spine care and pain management, and to discuss the BPS model, particularly psychosocial aspects, in the context of its historical relationship with chiropractic. We will also provide recommendations for the chiropractic profession as it relates to successful adoption of a full integration of the BPS model.
	The Impact of Pain-related Fear on Neural Pathways of Pain Modulation in Chronic Low Back Pain Pain Rep. 2017 (Apr 11); 2 (3): e601 ~ FULL TEXT Our results might indicate a maladaptive psychobiological interaction in chronic LBP characterized by an attenuation of amygdala-PAG-FC that is modulated by the degree of pain-related fear. Besides the established role of the PAG in the modulation of nociceptive inputs, our results add further evidence to the involvement of the PAG in negative emotional processing not directly related to nociception. [9, 28] Furthermore, while we have previously shown that pain-related fear is positively correlated with amygdala activity in chronic LBP, [16] enhanced pain-related fear seems to simultaneously dampen the neural cross-talk between the amygdala and the PAG. This decreased informaion exchange between 2 key pain modulatory structures might ultimately tip the balance of PAG function to facilitation, ie, increased pronociception. [11] Thus, the decreased cross-talk between the amygdala and the PAG, in conjunction with increased amygdala activity, might be the neurobiological basis of how pain-related fear contributes to pain and its chronification.
	Multivariable Modeling of Factors Associated with Spinal Pain in Young Adolescence European Spine Journal 2016 (Sep); 25 (9): 2809–2821 ~ FULL TEXT Psychosomatic symptoms and pain comorbidities had the strongest association with 1-month period prevalence of spinal pain in young adolescents, followed by factors from the physical and psychosocial domains. The role that "physical factors" play in non-adult spinal pain may have been underestimated by previous studies.
	Factors Affecting Return To Work After Injury Or Illness: Best Evidence Synthesis of Systematic Reviews Chiropractic & Manual Therapies 2016 (Sep 8); 24 (1): 32 ~ FULL TEXT Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.
	Work Related Psychosocial and Organizational Factors for Neck Pain in Workers in the United States Am J Ind Med. 2016 (Jul); 59(7): 549–560 ~ FULL TEXT This study suggests several new psychosocial and work organization risk factors that may be associated with neck pain in the US working population. Interventions for reducing these risk factors could be developed to assist workers in reducing irregular work arrangements and long hours of work, dealing with job insecurity and effectively managing work-life imbalances. Consultation and educational programs could also be developed to address workplace bullying and hostile work environments. Much of the prior research and policy recommendations have focused on the occupational hazards of verbal coercion and physical assaults for healthcare workers. Some of the policy goals for promoting and protecting healthcare workers should be applicable for workers in a wide range of occupations. The two relevant policy goals could include: first, recognizing exposure to a hostile work environment as a pressing and preventable occupation hazard and, second, earmarking research funding and promoting workplace intervention programs for factors related to hostile work environments. A growing body of research has suggested the detrimental effect of work-family imbalance on workers’ mental health, wellbeing and physical health outcomes and it could be considered as an important area for health promotion strategies.
	Neural Correlates of Fear of Movement in Patients with Chronic Low Back Pain vs. Pain-Free Individuals Front Hum Neurosci. 2016 (Jul 26); 10: 386 ~ FULL TEXT In the current fMRI study, we applied a novel approach encompassing: (1) video clips of potentially harmful activities for the back as fear of movement (FOM) inducing stimuli; and (2) the assessment of FOM in both, chronic low back pain (cLBP) patients (N = 20) and age- and gender-matched pain-free subjects (N = 20). Derived from the fear avoidance (FA) model, we hypothesized that FOM differentially affects brain regions involved in fear processing in patients with cLBP compared to pain-free individuals due to the recurrent pain and subsequent avoidance behavior.
	Importance of Psychological Factors for the Recovery From a First Episode of Acute Non-specific Neck Pain - A Longitudinal Observational Study Chiropractic & Manual Therapies 2016 (Mar 16); 24: 9 ~ FULL TEXT Previous bio-psycho-social studies have posited that anxiety, depression and catastrophizing are associated with chronicity. However, whether they are merely “associated with” versus “contribute towards” is really still up in the air (JMHO).   To test whether these emotional elements are a natural side-effect of chronic pain as opposed to being causal, these researchers worked with 850 patients with acute non-specific neck pain with no history of previous neck or arm pain.
	Psychological and Behavioral Differences Between Low Back Pain Populations: A Comparative Analysis of Chiropractic, Primary and Secondary Care Patients   NCT01539863 BMC Musculoskelet Disord. 2015 (Oct 19); 16: 306 FONT COLOR="#8B0000">~ FULL TEXT This study has described patients seeking chiropractic primary care for LBP with regards to psychological and behavioral characteristics and compared them to the characteristics of patients from a sample at high risk of developing chronic disabling NP and/or LBP and long term sick leave in primary care, and two secondary care samples with chronic LBP. Contrary to the hypothesis the chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on these findings the 4 samples may be considered statistically and clinically different.
	Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care Front Med (Lausanne). 2015 (Oct 8); 2: 73 ~ FULL TEXT Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care.
	Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4 ~ FULL TEXT Pain and depression often co-exist [1–3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6]. Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].
	Rethinking the Fear Avoidance Model: Toward a Multidimensional Framework of Pain-related Disability Pain. 2013 (Nov); 154 (11): 2262–2265 ~ FULL TEXT Nearly 20 years ago the Fear Avoidance Model (FAM) was advanced to explain the development and persistence of disabling low back pain. The model has since inspired productive research and has become the leading paradigm for understanding disability associated with musculoskeletal pain conditions. The model has also undergone recent expansion by addressing learning, motivation and self-regulation theory [10, 34].
	Results of an International Survey of Practice Patterns for Establishing Prognosis in Neck Pain: The ICON Project Open Orthop J. 2013 (Sep 20); 7: 387–395 ~ FULL TEXT Results of an international survey of health care providers for neck pain are reported. The survey specifically collected self-reported practice patterns for establishing a prognosis in neck pain. Over 440 responses from 27 countries were collected. Descriptive results indicate that respondents assigned large prognostic impact to factors including mechanism of injury and psychological or behavioral constructs. Range of motion, age and sex were routinely collected despite relatively moderate impact on prognosis. A comparison between chiropractic and manual/physical therapy groups showed differences in practice patterns that were unlikely to affect prognostic accuracy.
	The Rationale for Primary Spine Care Employing Biopsychosocial, Stratified and Diagnosis-based Care-pathways at a Chiropractic College Public Clinic: A Literature Review Chiropractic & Manual Therapies 2013 (Jun 9); 21 (1): 19 ~ FULL TEXT Current management practices for low back pain have led to rising costs without evidence of improvement in the quality of care. Low back pain remains a diagnostic and management challenge for practitioners of many types and is now thought to be a leading global cause of disability. Beyond many published clinical practice guidelines, there are emerging, evidence-based care-pathways including stratification according to the patient's prognosis, classification-based management, diagnosis-based clinical decision guides and biopsychosocial models of care. A proposed solution for successfully addressing low back pain is to train residents at a chiropractic college public clinic to function as primary spine care practitioners, employing evidence-based care-pathways.
	What Happened To The ‘Bio’ In the Bio-psycho-social Model of Low Back Pain? European Spine Journal 2011 (Dec); 20 (12): 2105–2110 ~ FULL TEXT This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain. Six potential misunderstandings are discussed. Until diagnosis is shown to improve outcomes it is not worth investigating; without a gold standard it is not possible to investigate diagnosis of low back pain; the presence of pathology in some people without low back pain means it is not important; dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; we seem to have forgotten the ‘bio’ in biopsychosocial low back pain.
	Psychosocial Risk Factors For Chronic Low Back Pain in Primary Care — A Systematic Review Fam Pract. 2011 (Feb); 28 (1): 12–21 ~ FULL TEXT Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.
	Preliminary Study Into The Components Of The Fear-Avoidance Model Of LBP: Change After An Initial Chiropractic Visit And Influence On Outcome Chiropractic & Osteopathy 2010 (Jul 30); 18: 21 ~ FULL TEXT The results presented suggest that catastrophisation, fear-avoidance belief (FAB) and low self-efficacy could be potential barriers to early improvement during chiropractic care. In most patients presenting with higher psychological scores these were reduced within a few days of an initial chiropractic visit. Those patients who exhibited higher adverse psychology post-initial visit appear to have an increased risk of poor outcome at 1 month.
	The Nordic Subpopulation Research Program: Prediction of Treatment Outcome in Patients With Low Back Pain Treated By Chiropractors -- Does the Psychological Profile Matter? Chiropractic & Osteopathy 2009 (Dec 30); 17: 14 ~ FULL TEXT Psychological factors were not found to be relevant in the prediction of treatment outcome in Swedish chiropractic patients with LBP.
	Nature Versus Nurture Segues to Choice Versus Circumstance in the New Millennium: One Consideration for an Integrative Biopsychosocial Philosophy, Art, and Science of Chiropractic J Chiropractic Humanities 2009 (Dec); 16 (1): 26–31 ~ FULL TEXT Recovery from persistent low back pain is determined not solely by clinical factors but also by the individual's psychological state [1]. Such psychological and social factors have come to be considered important in general practice and occupational back pain populations [2]. However, chiropractic investigators have given these less attention. This is not to suggest that chiropractors themselves regard these issues as unimportant. In a recent survey of 1,045 chiropractors [3], 80–90% reported their belief that emotional factors influence pain syndromes. However, less than half said they were able to evaluate these factors while just one-third felt able to treat them.
	Psychosocial Factors And Their Predictive Value In Chiropractic Patients With Low Back Pain: A Prospective Inception Cohort Study Chiropractic & Osteopathy 2007 (Mar 29); 15: 5 ~ FULL TEXT Recovery from persistent low back pain is determined not solely by clinical factors but also by the individual's psychological state [1]. Such psychological and social factors have come to be considered important in general practice and occupational back pain populations [2]. However, chiropractic investigators have given these less attention. This is not to suggest that chiropractors themselves regard these issues as unimportant. In a recent survey of 1,045 chiropractors [3], 80–90% reported their belief that emotional factors influence pain syndromes. However, less than half said they were able to evaluate these factors while just one-third felt able to treat them.
	The Impact of Psychosocial Factors on Neck Pain and Disability Outcomes Among Primary Care Patients: Results from the UCLA Neck Pain Study Disabil Rehabil 2006 (Nov 15); 28 (21): 1319–1329 Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.
	Psychosocial Factors and their Role in Chronic Pain: A Brief Review of Development and Current Status Chiropractic & Osteopathy 2005 (Apr 27); 13 (1): 6 ~ FULL TEXT The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid 20th Century. Several schools of psychological thought proffered linear causal models to explain non-physical pain observations such as phantom limb pain and the effects of placebo interventions. Psychological research has focused on identifying those people with acute pain who are at risk of transitioning into chronic and disabling pain, in the hope of producing better outcomes.

Background Materials    (oldest to newest)

	The Need For A New Medical Model: A Challenge For Biomedicine Science. 1977 (Apr 8); 196 (4286): 129–36 The late George Engel believed that to understand and respond adequately to patients’ suffering — and to give them a sense of being understood — clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century. [1] His new model came to be known as the biopsychosocial model. He formulated his model at a time when science itself was evolving from an exclusively analytic, reductionistic, and specialized endeavor to become more contextual and cross-disciplinary. [2–4] Engel did not deny that the mainstream of biomedical research had fostered important advances in medicine, but he criticized its excessively narrow (biomedical) focus for leading clinicians to regard patients as objects and for ignoring the possibility that the subjective experience of the patient was amenable to scientific study.
	A New Clinical Model For The Treatment Of Low-back Pain Spine (Phila Pa 1976) 1987 (Sep); 12 (7): 632–644 Because there is increasing concern about low-back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low-back disorders.
	How Much Longer Must Medicine's Science Be Bound By A Seventeenth Century World View? Psychother Psychosom. 1992; 57 (1–2): 3–16 The exclusion of nonmaterial human phenomena mandated by medical science's continuing allegiance to a 17th century scientific world view has constituted a major obstacle to medicine's scientific maturation as a human discipline. But 20th century conceptual changes even in physics (not to mention the influence of the theory of evolution) now renders that exclusion untenable and in effect legitimizes efforts to devise scientific means appropriate for the human domain. Practical as well as theoretical issues involved in such an undertaking are discussed within the framework of a 20th century scientific world view as represented by the biopsychosocial model, a counterpart to the traditional biomedical model.
	Behavioral Responses to Examination: A Reappraisal of the Interpretation of "Nonorganic Signs" SPINE (Phila Pa 1976) 1998 (Nov 1): 3 (21); 2367–2371 Waddell et al in 1980 developed a standardized assessment of behavioral responses to examination. The signs were associated with other clinical measures of illness behavior and distress, and are not simply a feature of medicolegal presentations. Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medicolegally. Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding.
	The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry Annals of Family Medicine 2004 (Nov);   2 (6):   576–582 ~ FULL TEXT The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient's subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications.
	Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss New Zealand Guidelines Group ~ FULL TEXT This guide is to be used in conjunction with the New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long-term disability and work loss, and an outline of methods to assess these at risk. Identification should lead to appropriate early management targeted towards the prevention of chronic pain and disability.
	Questionnaire for Assessing Psychosocial Yellow Flags This is the QA designed by Linton & Hallden 1996.

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