Understanding the process of care for musculoskeletal conditions—why a biomedical approach is inadequate

N. E. Foster, T. Pincus1, M. R. Underwood2, S. Vogel3, A. Breen4 and G. Harding2

Department of Physiotherapy Studies and Primary Care Sciences Research Centre, Keele University, Keele, Staffordshire,
1 Department of Psychology, Royal Holloway, University of London, Egham, Surrey,
2 Department of General Practice and Primary Care, St Barts and the London, Queen Mary's School of Medicine and Dentistry, Mile End, London,
3 Research Centre, The British School of Osteopathy, London and
4 Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, Dorset, UK

Chronic musculoskeletal pain is a major health problem affecting a quarter of the population [1], accounting for around a quarter of GP consultations [2]. It has large direct and indirect health care costs, with most available financial data focusing on back pain. In 1998 physical treatments for back pain cost the UK almost £500 million [physiotherapy £251 million (£151 million NHS), osteopathy £173 million and chiropractic £69 million] [3].

A range of practitioners, often conceptualized as offering only single therapeutic approaches in either NHS or private primary care, manage the majority of those seeking care for musculoskeletal problems. These include drug therapists (general practitioners and community pharmacists), physical therapists (chiropractors, osteopaths and physiotherapists), behavioural therapists (counsellors, psychologists and psychotherapists) and complementary medicine practitioners (for example, acupuncturists and aromatherapists). Few, if any, of these treatments have robust evidence of lasting efficacy or effectiveness. For most interventions the most we are offering is some alleviation of symptoms, rather than resolution. As there is no evidence to suggest that the problem of chronic musculoskeletal pain is reducing, then current, mainly biomedical approaches are clearly inadequate.

Recognizing the complexity of the way musculoskeletal symptoms present, and the settings in which these problems are mainly treated, the Primary Care Topic group in the 1999 NHS research and development review highlighted ‘the ill-defined symptom complex' around chronic musculoskeletal pain as a research priority [4]. In addition, an increased recognition of the burden posed by musculoskeletal conditions is one of the aims of the WHO Bone and Joint decade [5]. Consequent upon this is a need for appropriately configured health care services and delivering these requires an understanding not only of likely need but also how the process of care impacts upon outcomes.

It is well documented that the management of chronic musculoskeletal pain of uncertain origin presents a particular problem for both clinicians and patients alike [69]. Where there is no clear pathophysiological explanation for the pain, and few guidelines relevant to individual practitioner's needs, treatment regimens for musculoskeletal pain may reflect the personal foibles and beliefs of clinicians. For example, there is some evidence to show that physiotherapist's treatment choices are informed more by their original trainer's beliefs than critically appraising available evidence [10]. Without any clear pathophysiological explanation to direct practitioners in treating these patients, attention is increasingly being paid to other than just biomedical models of persistent back pain. In an effort to manage these patients better, the biopsychosocial model has gained increasing support. This combined approach, integrating the biological with the psychological and social forces, presents a potentially powerful aid to understanding persistent back pain. Although important progress has been made in discovering the personal factors, which predict the onset and persistence of pain, we know very little about the influence of treatment or of the health care system [11]. Thus paying attention not just to the pathology but the context in which the symptoms are reported, the complex doctor/patients' social and psychological circumstances surrounding the consultation, a deeper understanding and more effective management regimen should be possible. Such a broader approach is not only desirable, but also necessary given the failure of the traditional biomedical approach for most people with chronic musculoskeletal pain.

Such a composite approach is timely, since integrated solutions with multiple perspectives to problems that were intractable to unidisciplinary approaches have become increasingly popular [12]. This has been notable within primary care in recent years, with the burden of care for a range of hitherto medical treatments and procedures being shared among other health care professionals such as nurses and pharmacists [13]. Extending the treatment paradigm for musculoskeletal pain treatment and management to embrace the broader biopsychosocial model should be based on sound research evidence of its efficacy. However, evidence for efficacy remains thin on the ground. Although there have now been hundreds of randomized controlled trials testing dozens of candidate back pain treatments, there are only some data to show any approach used in primary care will have a sustained impact on patient-centred outcomes.

The current interpretation of the biopsychosocial model often comprises a rag bag of piecemeal information whereby the psychological effects of persistent pain such as:

  1. awareness of pain;
  2. expectations regarding pain;
  3. ability to cope with pain;
  4. perceptions and beliefs about ongoing life events;
  5. decision-making processes; and
  6. attitudes toward yourself and others
are combined with a recognition of social factors such as the patient's level of social support from their spouse and/or care givers, their socio-economic background plus societal factors around provision of benefit payments and provision of health care services to produce a detailed patient profile. Such an approach may miss opportunities to consider, in depth, the complex interaction between somatic dysfunction, its expression within a psychosocial context and societal (including health care) perspectives on pain and disability. There are parallels to this approach with the burgeoning interest in the application of qualitative research methods applied to health care issues [14]. The opportunity available to us is to learn from some of the limitations of current interventions and randomized trial evidence in trying to integrate these issues better and investigate them through perhaps more complex, but sound research approaches.

Complementing a biomedical research agenda with psychological, sociological and societal approaches to understanding the enigma of persistent musculoskeletal pain holds the promise of illuminating the long neglected patient's perception of their problem and its management, and the dynamic interaction between the condition, the patient's perception and the practitioners' influence.

Understanding the myriad factors that drive the complex patterns of care for those with chronic non-specific musculoskeletal pain is probably as important as the development of an understanding of basic immunology is to the understanding and management of inflammatory arthropathies. With these ideas in mind, we welcome the call from the Arthritis Research Campaign's 2001 research strategy document ‘Research into Practice’ for more patient- rather than laboratory-centred research [15].

This research agenda should be driven by the questions that we need to answer, rather than framing the questions to suit the research methods we are familiar with. This does not mean we should reject the quantitative health services research methods such as randomized controlled trials, but that we should add to these drawing on other disciplines such as sociology, anthropology, psychology, education and health policy analysis. This should put us in a better position to set the needs of our patients in their appropriate context. By doing this we can start to understand why patients and practitioners do what they do and how we might influence these processes to improve clinical outcomes. Such an odyssey will be fraught with challenges, we may on occasion feel that we are between Scylla and Charybdis unable to see our way forward. What we do know, however, is that this path is as yet rather less charte and, therefore, more challenging. Possible areas for study include the following.

  1. Systematically reviewing qualitative data on the practitioner–patient interaction. This will require developing new methodology to assess the quality of such studies and combine their information with more accepted quantitative approaches such as systematic reviews.
  2. Exploring what influences practitioners' decisions to integrate new evidence or guidelines into practice.
  3. Understanding the phenomena of consumerization of health care.
  4. Developing and testing improved models of health care delivery which try to integrate the biomedical approach better with psychological and sociological perspectives.
  5. Exploring clinicians' and patients' cognitions about the consultation.
  6. Determining to what extent addressing musculoskeletal problems will have an overall societal benefit.
  7. Exploring patients' pain histories to help identify those people whose chronic disability can be averted, and the reasons why some people recover whilst others do not.

As a group we are starting to explore some of these issues. We hope that others will also see this as a productive research area with the prospect that different types of evidence can be produced to allow us to improve how care is delivered to those with chronic musculoskeletal pain.

Notes

Correspondence to: N. E. Foster, Department of Physiotherapy Studies and Primary Care Sciences Research Centre, Faculty of Health, Keele University, Keele, Staffordshire ST5 5BG, UK. E-mail: n.foster{at}keele.ac.uk Back

References

  1. White KP, Harth M. The occurrence and impact of generalised pain. Baillieres Clin Rheumatol 1999;13:379–89.
  2. McCormack A, Fleming D, Charlton J. Morbidity statistics from general practice. Fourth national study 1991–1992 Series MB5 no. 3. London: HMSO, 1995.
  3. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95–103.[CrossRef][ISI][Medline]
  4. NHS R&D. Available from: http://www.doh.gov.uk/research/documents/rd3/primary_care_final_report.pdf [Accessed 01/05/02].
  5. Woolf AD, Akesson K. Understanding the burden of musculoskeletal conditions. Br Med J 2001;322:1079–80.[Free Full Text]
  6. Najman JM, Klein D, Munro C. Patient characteristics negatively stereotyped by doctors. Soc Sci Med 1982;16:1781–9.[CrossRef][ISI][Medline]
  7. Klein D, Najman J, Kohrman AF, Munro C. Patient characteristics that elicit negative responses from family physicians. J Fam Pract 1982;14:881–8.[ISI][Medline]
  8. Album D. The prestige of diseases and medical specialties (1991) cited in Steen E, Haugli L. Generalised chronic musculoskeletal pain as a rational reaction to a life situation? Theor Med 2000;21:581–9.[ISI]
  9. Gamsa A. The role of psychological factors in chronic pain. II. A critical appraisal. Pain 1994;57:17–29.[CrossRef][ISI][Medline]
  10. Turner PA, Whitfield TWA. Physiotherapists' reasons for selection of treatment techniques: a cross-national survey. Physiother Theory Pract 1999;15:235–46.[CrossRef]
  11. Kendall NA. Psychosocial approaches to the prevention of chronic pain: the low back paradigm. Baillieres Best Pract Res Clin Rheumatol 1999;13:545–54.[CrossRef][ISI][Medline]
  12. Baldwin DC, Baldwin MA. Education for teamwork in primary health care. In: Knopke HJ, Diekelmann NL, eds. Approaches to teaching primary health care. St. Louis: Mosby, 1981:176–95.
  13. Harding G, Taylor KMG. Responding to change: the case of community pharmacy. Sociol Health Illn 1997;19:521–34.[CrossRef][ISI]
  14. Gantley M, Harding G. Social science research and researchers in primary care. In: Carter Y, Thomas K, eds. Opportunities in primary care research. Oxford: Radcliffe Medical Press, 1999:227–37.
  15. Arthritis Research Campaign 2001 Research Strategy Document. Available from: http://www.arc.org.uk/about_us/ResPracPrecis.pdf [Accessed 23/9/02].