Skills and conundrums in helping people with pain

Using the biopsychosocial understanding for diagnosis and treatment requires an expansion of manual therapy skills. We have already looked in-depth at the explanation of why biomedical reasoning alone is not justified in explaining pain and treatment methods. This post will consider some of the challenges involved in applying biopsychosocial reasoning in clinic.

Osteopathic principles?

The challenges and changes in clinical reasoning from our understanding of pain and the lack of correlation between tissue state and treatment is also a challenge to osteopathic principles. There has already been questions regarding Still’s principles and whether they need reforming in light of current practice and evidence. We can think about this more in next week’s post.

Hands on or hands off?

There’s a lot of controversy within manual therapy about whether practitioners should use hands-on or hands-off treatment. Research evidence demonstrates the importance of improving patient’s self-efficacy and using active treatments. It is widely agreed that using passive treatments alone can lead to patient dependence on treatment and the practitioners which limits their self-efficacy. This has led to some practitioners avoiding hands-on passive treatments altogether and speaking out strongly against those that do use them.  

The power of touc

There is evidence to show that touch is beneficial for its impact on patient’s neurology. Touch is one of the greatest skills that osteopaths have and forms a major part of treatment. In my experience it helps to reduce sensitivity and often opens up opportunities to have conversations that address psychosocial issues. Touching people in pain is a natural instinct. I consider it important to continue to use touch as a therapeutic modality but also to be very conscious to frame the benefits of touch so that patients don’t feel they need to keep coming back so they are realigned or need releasing. They may choose to return for treatment because they enjoy treatment and feel a benefit but not because they need to. Transition to self-efficacy and empowered patients is a key to treatment success especially for long-term conditions. 

Psychosocial skills

Many manual therapists feel concerned about embracing the psychosocial aspect of the biopsychosocial approach because they feel they lack the skills. Addressing psychosocial issues does require additional skills of listening well and being a change instigator. There are many programmes available to help understand psychosocial elements of pain and learn skills from CBT, ACT and/or motivational interviewing for instigating and supporting lifestyle change. 

Outcome monitoring

Several of the new proposed models suggest the use of questionnaires. Monitoring outcomes is not widely used in osteopathy. The PROMs tool developed NCOR is one way of monitoring outcomes. The STARTback questionnaire developed at Keele university is widely recommended as a means of identifying patients at risk of chronicity and tailoring treatment appropriately. 

Treatment focus

Another challenge with regard to approaches to treating chronic pain is that the focus changes from aiming for pain resolution to attaining goals and increasing self-efficacy. For many people with persistent pain they won’t be able to resolve their pain problem but treatment aims to enable them to live a life where they feel in control of their pain problem rather than being controlled by the pain. 

Patient beliefs

Changing patient beliefs is difficult. Costa et al (2019) showed that nearly 85% of patients identify biomedical triggers for low back pain. These include active movements, static postures, overdoing a task, biomechanical dysfunction, comorbidities, lack of exercise and medications. Non-biomedical triggers reported by 15% included psychological state, weather, sleep, diet and fatigue. Patients generally identify biomedical factors to be the main triggers of low back pain but some acknowledge nonbiomedical triggers.

I have outlined several of the challenges but there will be more that you are aware of. This is generally the nature of healthcare and clinical reasoning. Answers are often not straight forward. There needs to be a balance of applying evidence and clinical expertise to justify diagnostic reasoning and treatment planning. Framing this in the context of osteopathy will be the subject of the next blog. 


A definition of flare in low back pain (LBP): A multiphase process involving perspectives of individuals with LBP and expert consensus.

Costa N, Ferreira ML, Setchell J, Makovey J, Dekroo T, Downie A, Diwan A, Koes B, Natvig B, Vicenzino B, Hunter D, Roseen E, Rasmussen-Barr E, Guillemin F, Hartvigsen J, Bennell K, Costa L, Macedo L, Pinheiro M, Underwood M, Van Tulder M, Johansson M, Enthoven P, Kent P, O’Sullivan P, Suri P, Genevay S, Hodges PW.

J Pain. 2019 Mar 20. pii: S1526-5900(18)30522-4. doi: 10.1016/j.jpain.2019.03.009

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