Chronic pain requires a biopsychosocial approach
The main reason people turn to Complementary and Alternative Medicine (CAG) is stress (Nguyen 2016). Stress is a condition and not a disease, but this condition can eventually lead to illness. Osteopaths often incorrectly choose a biomedical approach almost automatically. As osteopaths, what tools do we have from this biopsychosocial model? This newsletter and the upcoming NVO conference focus on a biopsychosocial approach to somato-psychological complaints. You can read more about the biopsychosocial model here. Incidentally, this is, by popular request, the first new-style newsletter, in which the editorial staff sheds more light on four themes and examines what recently published research means for our daily practice as an osteopath.
Table of contents:
In chronic musculoskeletal pain, a patho-anatomic structure is usually indicated as the cause of the patient’s symptoms. But often biopsychosocial factors play an important role in the development and maintenance of the complaints.
A purely biomedical approach to chronic musculoskeletal pain falls short. She mainly ignores important psychological factors such as depression, anxiety, avoidance, social isolation and catastrophe. These factors make an important contribution to the development and maintenance of the pain. Thus, in osteopathic practice, these and other disorders require more attention to biopsychosocial causes. The biopsychosocial model (BPS) is the last of the five explanatory models for complaints (ECOP) that we work with within osteopathy. Romano’s definition is: “The biopsychosocial approach systematically takes into account biological, psychological and social factors and their complex interactions in understanding health, disease and healthcare” (Hruby, 2019). The goals for a biopsychosocial assessment in the osteopathic treatment room, according to Austin (2017), are to identify the biological pain mechanisms, assess the functional status, identify co-morbidity, evaluate psychosocial factors, diagnose pain and develop a multidisciplinary treatment plan. However, it remains unclear how osteopaths apply the BPS framework when examining musculoskeletal pain. Usually a patho-anatomical structure is indicated as the cause of the patient’s symptoms. Unfortunately, this approach turns out to be inadequate. Sampath (2020) researched and carefully showed that an approach in which the BPS factors are taken into account results in a reduction in complaints and is therefore cost-effective.
Kolb (2020) argues for a meaningful, holistic and patient-centered approach, where the patient is not only the recipient but also the experiential expert of his body. Manuel therapies should therefore not be passive and prescriptive, or based on the learning of psychomotor passive skills in isolation, but always in dialogue with and in the context of the patient. Both Kolb and Sampath also use BPS as a model for treatment. This is special because the ECOP model is a-theoretical and purely descriptive. It therefore provides a framework for the diagnostic phase, but no approach during the treatment phase (Calsius 2018). Nevertheless, the results of their studies encourage further study of how we can include biopsychosocial factors in treatment.
Author: Sander Kales
Austin, P. D., & Henderson, S. E. (2011). Biopsychosocial assessment criteria for functional chronic
visceral pain: a pilot review of concept and practice. Pain Medicine, 12(4), 552-564.
Calsius, Cursus Experientieel Lichaamswerk, Panta Rhei, 2018.
William H. Kolb, Amy Wallace McDevitt, Jodi Young & Eric Shamus (2020) The evolution of manual
therapy education: what are we waiting for?, Journal of Manual & Manipulative Therapy, 28:1, 1-3,
Sampath KK, Darlow B, Tumilty S, Shillito W, Hanses M, Devan H, Thomson OP, Barriers and
facilitators experienced by osteopaths in implementing a biopsychosocial (BPS) framework of care
when managing people with musculoskeletal pain – A mixed methods systematic review protocol,
International Journal of Osteopathic Medicine (2020), doi: https://doi.org/10.1016/
Nguyen, J., Liu, M. A., Patel, R. J., Tahara, K., & Nguyen, A. L. (2016). Use and interest in
complementary and alternative medicine among college students seeking healthcare at a university
campus student health center. Complementary therapies in clinical practice, 24, 103-108.
What is asked of us as osteopaths to be able to cooperate with regular health care? Psychiatrist Hoenders gives clear guidelines.
The views of proponents and opponents of complementary and alternative medicine (CAM) appear to be based on a number of common prejudices. Still, about half of the Dutch population uses CAM. Meanwhile, it remains unclear for patients and practitioners what works and is safe and what is not (Hoenders et al. 2006). Integrative medicine (IM) is a worldwide development in mainstream health care that combines CAM and mainstream care, among other things. The principles of IM are: (a) reassessing and optimizing the therapeutic relationship; (b) an open and critical attitude towards all therapeutic disciplines and systems based on the principles of evidence-based medicine (EBM); (c) focus on promoting health and well-being; (d) treatment takes place in a healing environment from a holistic view. A CAM protocol has been drawn up that describes the conditions under which cooperation between regular health care, complementary and alternative medicine is established. This protocol is based on existing laws and regulations in the Netherlands (the Medical Treatment Contracts Act and the Individual Health Care Professions Act), the KNMG’s rules of conduct (2008), the multidisciplinary guidelines in mental health care, the rules of conduct for medical professionals (Crul; Legemaate 2006) and scientific evidence. It had to meet the needs of patients, do justice to their freedom of choice and provide regular, complementary and alternative treatment options that have proven to be safe and effective.
The CAM protocol distinguishes between complementary and alternative medicine. The first are non-regular treatments that do have good scientific substantiation (evidence) with positive results in (reviews of) several well-conducted studies, but are not (yet) integrated in the regular treatment offer for practical, ideological or social reasons. This includes osteopathy. Then there are alternative remedies such as homeopathy for which there is (too) little scientific support. The CAM protocol states that a treatment with a complementary alternative medicine may only start when it has been carefully tested whether regular treatments have been applied according to multidisciplinary guidelines. If it is decided to treat with CAM, then in the case of a regular medical diagnosis, the treatment must be applied on the basis of the definition of EBM. One can therefore opt for an intervention with a lower form of evidence, if the patient explicitly asks for it and there are no reasons for refusing from the professional expertise. Treatment with CAM can only start when it has been carefully tested whether regular treatments have been applied in accordance with multidisciplinary guidelines. If a decision is made to treat, then with a regular medical diagnosis, the treatment must be applied on the basis of the definition of EBM. One can therefore opt for an intervention with a lower form of evidence if the patient explicitly asks for it and there are no reasons from the professional expertise to refuse.
Treatment with CAM can only start when it has been carefully tested whether regular treatments have been applied in accordance with multidisciplinary guidelines. If a decision is made to treat, then with a regular medical diagnosis, the treatment must be applied on the basis of the definition of EBM. One can therefore opt for an intervention with a lower form of evidence if the patient explicitly asks for it and there are no reasons from the professional expertise to refuse. For alternative treatments, for which there is little or no evidence, a referral will be made to an external network when the patient explicitly requests this. The alternative treatment does not replace regular treatment, but is applied at the same time as regular or proven complementary treatments. With such an external referral and cooperation, extensive conditions apply regarding the professional practice, practice and practice of the doctor / therapist and regarding his professional association, consultation with the regular practitioner and cooperation in evaluation. For us osteopaths it is therefore important that we work evidence-based and ensure that more good research is done into osteopathic interventions.
Author: Joppe ten Brink
Titel: Protocol for complementary and alternative medicine within the Dutch mental health services
Publicatie: Tijdschrift voor psychiatrie, januari 2010.
Auteur: Hoenders, R.H.J.
The treatment of the osteopath also always has unintended side-effects on the pain and complaint experience.
Most people are familiar with the placebo effect, which refers to the power of positive expectations for improvement in symptoms. The placebo effect has been well studied. Many studies show that the placebo effect is an important indicator of the response of the treatment and its contribution to the effectiveness of a treatment in reducing pain (Hashmi, 2018; Kong et al, 2014). Less known is its counterpart, the nocebo effect. Where the placebo provides a positive improvement, the nocebo has a negative effect. When patients are told that the treatment can lead to abdominal pain, headaches or other side effects, nocebo research shows that these symptoms are more likely to be experienced (Napadow et al, 2015). The role of the nocebo effect is increasingly being investigated. The question now is whether osteopaths should also take into account a nocebo effect when they tell patients that they can expect an aftereffect from the treatment just given. How does this affect recovery and the pain perception? And may patients recover more quickly by turning negative thoughts into positive ones?
Vögtle (2019) states that if someone is diagnosed with a medical condition and then reads about another person’s experience with the same condition on a social media blog or feed, it is likely to affect that person’s symptoms. And so the same nocebo and placebo effects apply to therapists, health supplements, exercise routines, and just about anything that supposedly hurts or heals. “How many people are really intolerant to gluten or lactose, and how much of that has nocebo effect?” Asks Vögtle. Expectation creates not only psychosocial but also neurobiological events that determine how a person feels. Knowing this, the nocebo effect may have a greater influence on the patient’s recovery than previously thought (Kong et al, 2014). Further research should reveal whether this is the case. What can be concluded is that it is important for a practitioner to take into account the nocebo effect where possible.
Author: Nadi Blokhuis
Hashmi J.A. 2018. Placebo Effect: Theory, Mechanisms and Teleological Roots. Department of
Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Nova Scotia Health
Authority, Halifax, NS, Canada. Chapter ten, pages 234-248.
Kong, J., & Benedetti, F. 2014. Placebo and nocebo effects: An introduction to psychological and
biological mechanisms. Handbook of Experimental Pharmacology, 225, 3–15.
Napadow V., Li A., Loggia M.L., Kim J., Mawla I., Desbordes G., Schalok P.C., Lerner E.A. 2015. The
imagined itch: brain circuitry supporting nocebo‐induced itch in atopic dermatitis patients. EAACI,
Volume70, Issue11, November 2015, Pages 1485-149.
Vögtle E., Kröner-Herwig, B., Barke N. 2019. Nocebo Hyperalgesia can be Induced by the Observation
of a Model Showing Natural Pain Expressions. The Clinical Journal of Pain, Volume 35, Number 9,
September 2019, pp. 737-743(7).
Whoever works with patients has to deal with transference and countertransference: the projection of thoughts and feelings on the other. Yet this phenomenon is hardly discussed in osteopathy.
It is increasingly recognized that the effectiveness of health care treatments depends at least as much on “generally effective factors” (such as the quality of the therapeutic relationship) as on specific treatment techniques (Hafkenscheid). These “common factors” also include the practitioner’s willingness, skill, and ability to recognize and handle his own countertransference. The therapist’s countertransference feelings can be a powerful tool in the treatment – if the therapist is able to make the countertransference conscious – but a serious obstacle, if the countertransference remains violent, but largely unconscious “. The therapist who, of course, at appropriate times and in a respectful manner, dares to take open and honest responsibility for his or her countertransference reactions is the best possible example for his or her patients, says Hafkenscheid (2015).
However, “Countertransference” is far from a straightforward concept. In traditional psychoanalysis, countertransference is understood as the therapist’s response to the patient’s transference. Countertransference is seen less and less as purely therapist-bound, but also (and especially) as patient-bound. That is, different therapists with different backgrounds and personality development may experience the same or similar countertransference reactions in the same patient. Projective identification and countertransference are always and simultaneously created by both the patient and the therapist. Although osteopathy is not psychoanalysis, and the elaboration of countertransference in the treatment relationship goes too far, it is necessary to recognize countertransference, for example in a man-woman treatment relationship. During osteopathy treatment there is an active “giver”, namely the osteopath, and a passive “receiver”, the patient. This setting has the danger that a hierarchy of powers and regression can arise. It is therefore important that an osteopath can verbally express such feelings. Furthermore, it is necessary to learn to experience boundaries and to be trained in them, so that you learn to perceive transfer and countertransference (Zellner). Those who want to see firsthand how transfer and counter-transfer work in the treatment room, come to the NVO annual conference. There Eva Banninger, professor of clinical psychology, will visualize both phenomena in a video contribution (see recent NVO newsletter).
Author: Sander Kales
Hafkenscheid, A. (2015). Tegenoverdracht: van een psychoanalytisch naar een trans theoretisch
concept. Tijdschrift voor Psychiatrie, 57(3), 202-209.
Zellner, K. (2014) Übertragung und Gegenübertragung – Phänomene einer gegenseitigen
therapeutischen Beziehung! Eine Hinführung auf das Thema Patienten-Therapeuten-Beziehung mit
Bezug zur Osteopathie, Thesis Osteopathie Schule Deutschland, Berlin.