Pain might be powered by a rich and funky stew of social and psychological factors as well as biological ones, like injury and pathology. Treatment strategies inspired by the biopsychosocial (BPS) model of healthcare — a humanistic, holistic vision of care that tries to integrate all that stuff (see Engel) — have become quite fashionable in the last twenty years. So it’s worth testing them. Is BPS-ified pain treatment effective? Or is it just another faddish strike out?
I think it’s fair to say we just don’t know yet. And you should not hold your breath until we do. But we do have some data.
Understanding the “whole person” might be an important part of pain treatment. But it is not easy to understand whole people! Or cheap. And we don’t actually know how much it even matters.
A meta-analysis of pooled data from two dozen trials showed almost no differences between the results of BPS-inspired therapy and traditional “just physical” therapy: it’s all equally underwhelming. Specifically, “behavioral/psychologically informed interventions,” with or without physical ones added into the mix, performed just as poorly as physical treatments alone.
The meta-analysis is flawed (as most of them are), and it was harshly criticized in a letter to the editor. However, that complaint might be mostly a case of sour grapes, because the letter’s authors “know” that BPS-inspired treatments are effective (oh, if only). While those turf-defending motives are depressingly clear, everyone is probably right in some important way: nothing about the BPS model of pain, even if completely valid, suggests it’s going to be easy to treat it “biopsychosocially.” On the contrary, the model suggests it will be a beast to apply! But that doesn’t mean that it makes no sense and we shouldn’t be trying and checking.
Dr. Lorimer Mosely wrote of this kerfuffle: “The biopsychosociality of pain might not necessarily mean biopsychosocial treatments work.” And we should expect BPS-inspired treatment to be hard to standardize and test — because it’s messy by nature! Hell, that’s part of the point of the BPS model. And so the poor performance of “psychologically informed” treatments in the scientific literature so far is hardly any kind of a surprise, and BPS-inspired treatment could still have has unconfirmed virtues, could still be one of the least bad options we have for pain.
But it’s certainly not evidence-based so far, and it might never be.
Note that although this paper is from 2016, there has been nothing like it since. The penultimate big one was in 2014 (Kamper et al., focusing on back pain), and it concluded that “multidisciplinary biopsychosocial rehabilitation” was modestly effective — a bit less pain, a smidgen less disability — but also required a lot of time and resources, and was not clearly an overall win compared to more accessible treatments. So not really very effective.
This is a new entry in a series of posts about the biopsychosocial theory of healthcare, and a by-product of my ongoing effort to level up PainSci’s coverage of the topic. These BPS posts are probably not all going to harmonize with each other! They are all just pieces in one of the most complicated puzzles I can imagine.