Application in Rehabilitation · URehab References Cont. •[7]Moseley, G. (2004). Evidence for a direct relationship between cognitive and physical change during an education intervention

URehabThe Biopsychosocial Model

Application in Rehabilitation

Rafael E. Salazar II, MHS, OTR/L

Copyright 2019. Rehab U Practice Solutions, SALAZAR ENTERPRISE, LLC. All rights reserved.

URehabWelcome!

• Graduate of Augusta University (formerly MCG), Class of 2012

• Select Medical Corporation 2012-2013

• Charlie Norwood VA Medical Center 2013-2017

• Community Resource Associates 2017-Present (Contracting Consultant)

About Me: Rafael E. Salazar II, MHS, OTR/L

• Georgia State Board of Occupational Therapy 2016-Present

• Board of Directors, NBCOT 2018-Present

• AU OT Department (Adjunct Instructor 2015, 2018)


URehabWhy Are We Here?

• Discuss the biopsychosocial model of healthcare

• Explore its application to clinical rehabilitation (OT) practice

• Review relevant literature and research


URehabDefining the Biopsychosocial Model

• Has been described both as a philosophy of clinical care and a guide for clinical practice (Borrell-Carrio 2004) [1]

• Takes into account the physical, psychological, and social factors of the disease or injury and promotes an integrated approach to treatment (Covic 2003) [2]

• Proposes that suffering, disease, or illness involve a host of factors from biological (tissues, structures, molecules) to environmental (social, psychological)


URehabBasic Principles

1. The relationship between psychological and physical factors of health can be extremely complex. A patient’s subjective experience can’t simply be reduced to physiological factors. (Borrell-Carrio 2004) [1]

2. These factors affect each individual differently (we are dealing with each individual’s subjective experience).

3. Changes in one of these factors (biological, psychological, or social/environmental) potentially create real and notable changes in the other factor(s) (Moseley 2002) [3] https://www.researchgate.net/


https://www.researchgate.net/

URehabExample:




URehabBreaking it Down

1. Physical Factors

2. Psychological Factors

3. Social/Environmental Factors


URehabPhysical Factors

• Stem from biological or physiological roots

• Gets most of the attention from clinicians, payers, administrators• ROM measurements, strength assessments,

palpation, soft tissues, postural assessments, manual therapy techniques, focus on exercises and stretches, and patient education

• Can affect both physical function and psychological health • BMI (physical factor) shown to impact individual’s

social functioning (de Filippis, et al. 2004) [5]


URehabPhysical Factors Cont.

• Important & necessary for effective clinical evaluation and treatment

• If we only go so far as the tissues, we potentially miss the other important aspects that can affect not only our patients’ experience of pain or dysfunction, but also their response to treatment (Moseley 2002)[3] (Moseley & Butler 2015)[4]


URehabPsychological Factors

• Prior to 1970’s, healthcare was based on the biomedical model of practice (Engel 1978) [6]

• Main focus was on physical aspects of disease and health.

• Inclusion of psychological factors impacts clinical practice • Ex: Cognitive changes impact physical

abilities (Moseley 2004) [7]


URehabPsychological Factors Cont.

• Main Takeaway:• To reduce a patient’s condition, limitation, or dysfunction down to a

“problem” with the tissues or body misses the great impact that the patient’s psychological state and cognition has on their subjective experience of their condition.


URehabPsychological Factors: An Example

• Neurophysiology & Neuroscience of Pain

• Combining neuroscience education with traditional physical rehabilitation treatment can improve outcomes in patients with chronic low back pain (Moseley 2002) [3]

• Approaching patient education from a purely biomechanical frame of reference may increase stress, anxiety, and even negatively impact clinical outcomes (Louw, et al 2011) [8]


URehabNeuroscience Education & Psychological Factors of Chronic Pain

• ***Pain is always real***

• Pain = Protective mechanism of the brain

• Clinician’s acknowledgement of patient’s pain helps build therapeutic rapport/relationship

http://www.rehabpub.com/2017/11/meet-middle/


http://www.rehabpub.com/2017/11/meet-middle/

URehabSocial/Environmental Factors

• Social factors may impact a patient’s

behavioral response to physical

conditions or symptoms (Turk & Gatchel 2018) [9]

• Sociocultural factors can affect patient-

clinician interactions (Turk & Gatchel 2018) [9]

• Social Learning

• Beliefs about illness or treatment

• Social influences

• Cultural norms/ethnic expectations


URehabSocial/Environmental Factors

• Example: Social Learning

• Beginning as children, we learn socially appropriate (acceptable) ways of reacting to/dealing with illness or pain.

• How parents respond to children’s minor injuries may trigger operant learning mechanisms. • May influence chronic pain conditions (Turk & Gatchel 2018)

[9]


URehabClinical Application of the Biopsychosocial Model in Rehabilitation & OT• Assessment

• Outcome Measures

• Treatment Approaches

• Levels of Care

• Functional Restoration

• Patient Education & Engagement


URehabClinical Application: Assessment • Biopsychosocial assessment focuses:

• Physical Symptoms/Dysfunctions

• Patient’s experiential Perspective (Gatchel &

Howard n.d.)[10] (Vetter, et al 2013) [11]

• Physical, psychological, behavioral, and

cognitive measures to understand each

patient’s unique pain condition (Gatchel &

Howard n.d.)[10]

• Both physical (objective) measures &

self-reported measures


URehabClinical Application: Outcome Measures

• Goal:• Complete analysis of the patient’s unique condition &

experience

• Step-by-step approach• Start with general assessment • Move deeper to more specific assessment of

physical, psychological, or social factors

• Helps build understanding of patient’s unique conditions• Develop a more comprehensive treatment plan

(Gatchel & Howard n.d.)[10] Copyright 2019. Rehab U Practice Solutions, SALAZAR ENTERPRISE, LLC. All rights reserved.

URehabClinical Application: Treatment Approaches • Too many factors at play for rigid

treatment protocols or “cookie-cutter”

treatment programs

• Throwing patients into the same exact

treatment program may result in

suboptimal outcomes (Gatchel & Howard n.d.)[10]

• Ex: “a shoulder is a shoulder is a

shoulder.”


URehabTreatment Approaches: Levels of Care

• Example: Chronic Pain

• Goal of Treatment: • Increase a patient’s overall functional

capacity

• 3 Levels: • Primary• Secondary• Tertiary (Gatchel & Howard n.d.)[10]


URehabLevels of Care Cont.

• Primary• Acute symptoms associated with injury or dysfunction

• Focus on movement and function of affected area (Gatchel & Howard n.d.)[10]

• Secondary• Multifaceted approach

• Neuroscience pain education, graded motor imagery, or cognitive-behavioral treatments

• Goal: Avoid physical deconditioning while reducing any psychological barriers that may interfere with recovery (Gatchel & Howard n.d.)[10]

• Tertiary• Functional Restoration


URehabLevels of Care Cont.

• Tertiary Level: “Functional Restoration”

• Goal: Prevent permanent disability (Gatchel & Howard n.d.)[10]

• Interdisciplinary team develops treatment plan addressing mobility & function as well as stress management and coping skills (Gatchel & Howard

n.d.)[10]• Primary Care, Medical Specialties, Physical/Occupational Therapy, and/or

Disability Case Management


URehabClinical Application: Patient Education• Goal:• Tailor clinical education to each individual

patient

• Engage patient throughout the treatment process• Open-ended questions & active listening • Build trust and rapport

• Can improve clinical outcomes; patient experience, engagement, & retention


URehabTakeaway

• Physical, psychological, & social/environmental factors affect each individual patient’s specific diagnosis or dysfunction• Each factor has been shown to have potential impacts on the others

• Effective rehabilitation assessment and treatment addresses all three areas

• Rehab clinicians should begin to view each patient as unique, rather than offering “cookie-cutter”, one-size-fits-all treatment


URehabQuestions? (Contact Info)

• Contact Me:• Rafael E. Salazar II, MHS, OTR/L • [email protected]• https://www.linkedin.com/in/rafaelsalazarii


https://rehabupracticesolutions.com/biopsychosocial/

mailto:[email protected]

https://www.linkedin.com/in/rafaelsalazarii

https://rehabupracticesolutions.com/biopsychosocial/

URehabReferences• [1] Borrell-Carrio, F. (2004). The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. The

Annals of Family Medicine, 2(6), 576-582. doi:10.1370/afm.245

• [2] Covic, T. (2003). A biopsychosocial model of pain and depression in rheumatoid arthritis: A 12-month longitudinal study. Rheumatology, 42(11), 1287-1294. doi:10.1093/rheumatology/keg3

• [3] Moseley, L. (2002). Combined physiotherapy and education is efficacious for chronic low back pain. Australian Journal of Physiotherapy, 48(4), 297-302. doi:10.1016/s0004-9514(14)60169-0

• [4] Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain, 16(9), 807-813. doi:10.1016/j.jpain.2015.05.005

• [5] de Filippis LG, Gulli S, Caliri A, D’Avola G, Lo Gullo R, Morgante S. et al. Factors influencing pain, physical function and social functioning in patients with osteoarthritis in southern Italy. Int J Clin Pharmacol Res. 2004;24(4):103–109. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15754914

• [6] Engel, G. L. (1978). The Biopsychosocial Model And The Education Of Health Professionals? Annals of the New York Academy of Sciences, 310(1 Primary Health), 169-181. doi:10.1111/j.1749-6632.1978.tb22070.x

Copyright 2019. Rehab U Practice Solutions,

SALAZAR ENTERPRISE, LLC. All rights reserved.

http://www.annfammed.org/content/2/6/576.full

https://academic.oup.com/rheumatology/article/42/11/1287/1788382

https://www.sciencedirect.com/science/article/pii/S0004951414601690?via%3Dihub

https://www.jpain.org/article/S1526-5900(15)00682-3/fulltext

https://www.ncbi.nlm.nih.gov/pubmed/15754914

https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1749-6632.1978.tb22070.x

URehabReferences Cont. • [7] Moseley, G. (2004). Evidence for a direct relationship between cognitive and physical change during an education

intervention in people with chronic low back pain. European Journal of Pain, 8(1), 39-45. doi:10.1016/s1090-3801(03)00063-6

• [8] Louw A, Diener I, Butler DS, Puentedura EJ. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation , Volume 92 , Issue 12 , 2041 –2056. doi: https://doi.org/10.1016/j.apmr.2011.07.198

• [9] Turk, D. C., & Gatchel, R. J. (2018). Psychological approaches to pain management: A practitioners handbook. New York: The Guilford Press. Available in part from: https://books.google.com/books?hl=en&lr=&id=ngBPAgAAQBAJ&oi=fnd&pg=PA3&dq=social+factors+in+the+biopsychosocial+model+of+pain&ots=zY1XoWz6h4&sig=iyo8RZ51CH97Zg8-sHvvQzvH1H0#v=onepage&q=social%20factors%20in%20the%20biopsychosocial%20model%20of%20pain&f=false

• [10] Gatchel, R. J., & Howard, K. J. (n.d.). The Biopsychosocial Approach. Retrieved from https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach

• [11] Vetter TR, McGwin G, Bridgewater CL, Madan-Swain A, Ascherman LI. Validation and Clinical Application of a Biopsychosocial Model of Pain Intensity and Functional Disability in Patients with a Pediatric Chronic Pain Condition Referred to a Subspecialty Clinic. Pain Research and Treatment. 2013;2013:143292. doi:10.1155/2013/143292.


https://onlinelibrary.wiley.com/doi/abs/10.1016/S1090-3801(03)00063-6

https://doi.org/10.1016/j.apmr.2011.07.198

https://books.google.com/books?hl=en&lr=&id=ngBPAgAAQBAJ&oi=fnd&pg=PA3&dq=social+factors+in+the+biopsychosocial+model+of+pain&ots=zY1XoWz6h4&sig=iyo8RZ51CH97Zg8-sHvvQzvH1H0

https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819919/

Documents

Application in Rehabilitation · URehab References Cont. •[7]Moseley, G. (2004). Evidence for a direct relationship between cognitive and physical change during an education intervention