Why do we look at medical imaging to determine the cause of someone’s pain, even though research has proven that there’s no correlation between the two? Why do most clinicians still recommend opioids and injections before trying a few simple breathing exercises? These are the kinds of questions Dr. Tim Flynn has thought about for years, and the kind of practices he’s trying to change. Join us as Dr. Flynn, a widely-published physical therapist and host of the podcast “Pain Reframed,” shares the secret to his practices's success: believing in your patients.
What is the biopsychosocial model of pain?
The biopsychosocial model is a relatively recent development. For most of the 20th century, medicine was mostly based on a Descartes model, which is a very linear approach to disease. In other words, we image things, and we expect that if we see something amiss there, we cut it out/ burn it out/ inject it. That’s a very old model of looking at pain, but that's the model of pain that many physicians carry to this day, especially when we look at musculoskeletal pain.
A biopsychosocial model incorporates the “bio” - biology - of the human, the psychology, and the social framework in which that individual lives. We can have nearly the same biology and suffer a similar injury, but depending on our psychological and social frameworks at the time, the outcome can be different. For instance, what is our capacity to resist that trauma? If we’re just getting by day-to-day and one more event tips the scales for what our body and mind are capable of, then we may go on to develop a persistent condition.
So the biopsychosocial model really encompasses what it means to be human. When we have some complaint, like an ache or a pain, we really need to take all of those factors into consideration, not just the biology at that moment in time.
What role do more cognitive approaches, like therapeutic neuroscience education, play in your practice right now?
I would say that is 100% of my practice. A comment I make frequently is “never underestimate the power of the medical system to make you worse.” When it comes to pain conditions, we’re too aggressive. We need to first understand why someone hurts. Whether they sprain their ankle or have a chronic neck pain, it’s the same neurology.
Everyone I see gets a basic level of pain education, because the current understanding of pain in our society is really distorted. It goes back hundreds of years to a model that’s no longer valid, but is still being taught in a lot of medical schools.
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What do you say to patients when you talk to them about this?
First, I try to do motivational interview. What is the patient after? What will make their life better? Then, I ask “what do you think is wrong?” It’s always amazing what you’ll get when you ask an open-ended question like that.
If they respond with pathology terms and a recitation of what the MRI shows, I say “okay, this is the belief system of the patient. They put a lot of stake into what that imaging shows.” That will lead me to explain that most people have changes in the musculoskeletal system that show up on imaging, especially as we age. We get wrinkles on the inside… these are normal, age-related changes, but we often give them nasty words like “degeneration” and “torn” and “herniated.”
A lot of it is just trying to get folks to put less stake in the imaging. They should use it for what it’s designed to do: rule out serious pathology like cancer that may be life-threatening in nature. The imaging is really good at that. It’s not good at determining treatment decisions for the vast majority of musculoskeletal conditions.
I ask folks “are you pleased with where you’re at to date?” And inevitably, people are not. That gives you a window to say, “well let’s try something different - a bigger, more holistic approach.”
[This was an excerpt. Listen to the full podcast above]