‘Tell me your story’ - How osteopaths apply the BPS model when managing low back pain - A qualitative study

Journal Pre-proof ‘Tell me your story’ - How osteopaths apply the BPS model when managing low back pain - A qualitative study Monica Abrosimoff, Dévan Rajendran PII:

S1746-0689(19)30129-4

DOI:

https://doi.org/10.1016/j.ijosm.2019.11.006

Reference:

IJOSM 527

To appear in:

International Journal of Osteopathic Medicine

Received Date: 8 August 2019 Revised Date:

12 November 2019

Accepted Date: 28 November 2019

Please cite this article as: Abrosimoff M, Rajendran Dé, ‘Tell me your story’ - How osteopaths apply the BPS model when managing low back pain - A qualitative study, International Journal of Osteopathic Medicine (2020), doi: https://doi.org/10.1016/j.ijosm.2019.11.006. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.

Title: ‘Tell Me Your Story’ - How osteopaths apply the BPS model when managing low back pain - a qualitative study

Author details: Monica Abrosimoff - [email protected] Dévan Rajendran - [email protected],b

a

Author Affiliation:

European School of Osteopathy Research Department Boxley House The Street Boxley Kent ME14 3DZ

b

Corresponding author

TITLE

‘Tell Me Your Story’ - How osteopaths apply the BPS model when managing low back pain a qualitative study

ABSTRACT

Background: Low back pain (LBP) is a common reason people seek osteopathic care. The biopsychosocial (BPS) model is a clinical model encompassing complex contextual aspects that contribute to a person’s pain experience. This study aimed to understand osteopaths’ experiences of the practical application of the BPS model to patients with LBP, and to describe any challenges in operationalisation. Methods: We conducted a qualitative study and interviewed purposively- sampled osteopaths who self-identified as applying a BPS approach to managing LBP. A constructivist approach consistent with elements of grounded theory was used to analyse these data. Results: The following themes were constructed to describe participants’ experiences of applying the BPS model; 1) collaboration 2) deriving meaning from narrative 3) coaching 4) empowerment 5) reframing ‘pain’ and 6) desensitizing. Two further themes represent challenges; 7) deficiencies of undergraduate BPS training and clinical integration and 8) osteopathic identity and scope of practice. Two central concepts were established; A) the BPS model is used as an interactive frame; and B) challenges of integration and uncertainty exist and have the potential to lead to unintentional fragmentation of the model. Conclusions:

Participants viewed the BPS model as essential in navigating a

person’s experience of pain; identifying emergent factors contributing to the cause or 1

maintenance of the person’s condition and informing management of these factors. However, the integration of the BPS model into clinical practice remains fraught with obstacles including the dualist nature of beliefs about pain, inadequacies of undergraduate training and uncertainty about remit.

KEYWORDS

Biopsychosocial Model Low Back Pain Osteopathic Medicine Patient-centred Care Uncertainty Manual Therapy

BACKGROUND Low back pain (LBP) is a challenging presentation with a complex etiology. Its global lifetime prevalence is estimated at 60-70% of the population (Duthey, 2013). When LBP becomes persistent, it can have a large impact on physical and emotional quality of life (Maher et al., 2017) and is a substantial burden to society, being identified as a leading cause of disability on a global scale (Vos et al., 2015). Accounting for 90% of all cases of LBP, non-specific low back pain (NSLBP) is multifactorial in nature rather than having a precise nociceptive cause that is readily definable (Maher et al., 2017). The implication of diagnosing a patient with NSLBP is that managing this condition as a simple, patho-anatomical, mechanical problem of the lumbar spine is neither appropriate nor effective (Maher et al., 2017; O’Sullivan and Lin, 2014; Synnott et al., 2015; Waddell, 1987). The traditional tissue-based 2

diagnosis, embedded in the linear, biomedical understanding of pain, has serious limitations in the management of NSLBP and has failed to improve health outcomes and reduce disability (Deyo et al., 2009; Maher et al., 2017). The most widely accepted definition of pain is an “unpleasant sensory or emotional experience associated with actual or potential damage, or described in terms of such damage” (IASP, 1979). Due to the nature of pain, this definition continues to evolve and be debated (Cohen et al., 2018; IASP, 2019; Treede, 2018). Advances in our understanding of pain have highlighted the importance of considering the complex cognitive, psychological and social aspects, and how they interact with physiological factors, in the management of pain (Gatchel et al., 2007; Melzack, 2001; Moseley and Butler, 2015). Psychosocial factors play a key role as predictive and prognostic factors of persistent NSLBP (Grotle et al., 2010; Pincus et al., 2002). When pain persists or recurs for more than three months it is referred to as chronic pain (Nicholas et al., 2019). There are estimates that NSLBP may become a persistent and disabling factor for between 5-10% of cases (O’Sullivan and Lin, 2014; O ’sullivan et al., 2016).These figures may be deceptive as they do not report the recurrence of NSLBP, which is estimated to be between 25-60% (Hestbaek et al., 2003; Stanton et al., 2017). NSLBP has been described as a trajectory of symptoms that fluctuate and reoccur throughout life rather than discreet episodes that are neither acute, subacute or persistent (Ailliet et al., 2018) and these fluctuations are influenced by factors across a wide range of BPS health domains (Kongsted et al., 2016). In contrast chronic pain, including NSLBP, has recently been described as a “health condition in its own right” rather than just a symptom (Nicholas et al., 2019; Treede et al., 2019).

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Since the mid-seventies, there has been a shift towards a multidimensional approach to health through the introduction of the biopsychosocial (BPS) model, in which Engel criticised the reductionism of the biomedical model and called for the inclusion of ‘social, psychological and behavioural dimensions of illness’ alongside the pathophysiological variables in healthcare (Engel, 1977). The BPS model acknowledges that pain is a dynamic, evolving and unique phenomenon that results from interweaving one’s biology, emotions, society, culture, environment, past experience as well as beliefs, attitudes, and expectations (Gatchel et al., 2007; Turk and Okifuji, 2002). The latest UK guidelines on NSLBP (NG59) acknowledge the complexity of BPS factors, recommending that manual therapy is incorporated as part of a multi-modal approach in combination with exercise and cognitive or psychological interventions, rather than a stand-alone therapy (NICE, 2016). Although research has shown the importance of identifying BPS factors as prognostic indicators (Draper-Rodi et al., 2018; van Tulder et al., 2006), clinicians lack confidence on how to manage these factors, which may act as obstacles to recovery (Zangoni and Thomson, 2017). Furthermore, communication is often problematic between the clinician attempting to explain the BPS nature of pain and the patient trying to understand their experience (Stilwell and Harman, 2019). The complexity of the BPS factors are conceptually challenging for clinicians and there is evidence that they are often fragmented into either ‘bio’ or ‘psychosocial’ or conceptualised as linear rather than emergent contributors to NSLBP (Arnaudo, 2017; Hancock et al., 2011; Jull, 2017; Stilwell and Harman, 2019). Whilst recent systematic reviews have provided insights into how physiotherapists use elements of the BPS model (Lakke and Meerman, 2016; Synnott et al., 2016), and qualitative studies have described osteopaths’ beliefs and attitudes regarding 4

BPS factors associated with chronic pain (Delion and Draper-Rodi, 2018; Formica et al., 2017) there remains limited qualitative research that explores and describes the process of the operationalising the BPS model within osteopaths’ practice. Often having more time to spend with patients, osteopaths are well placed in health care to address psychosocial aspects of NSLBP. Several qualitative studies, however, have shown that the multifaceted BPS approach is often difficult to implement and clinicians may be conflicted when broadening a traditional approach that is firmly seated in the biomechanical paradigm (Gardner et al., 2017; Sanders et al., 2013). Practitioners also face difficulties in addressing the social implications of a pain condition (Harding et al., 2010) and in the BPS integration within wider manual therapy environments (Foster and Delitto, 2011). Within the osteopathic profession there is evidence that osteopaths remain paternalistic and biomedical in their approaches (Formica et al., 2017; Thomson et al., 2014a; Van Wilgen et al., 2014). Over the last 20 years osteopaths profess to have adopted the BPS model (Chila, 2011; Hruby et al., 2017; Penney, 2010) however, there is limited research data that elucidates the process of how qualified osteopaths practically apply it within an clinical setting, or what challenges they face. The aims of this study were to explore the experiences and challenges of osteopaths who employ the BPS model, and to describe how the BPS model is being practically applied in their clinical practice with people with NSLBP.

METHODOLOGY Study Design Our study used an exploratory qualitative design with elements of constructivist grounded theory (Charmaz, 2006) to capture individual perspectives of applying the 5

BPS model

(Table 1). Semi-structured interviews provided descriptions of how

operationalisation of the BPS model occurs in clinical practice through socially constructed discussions of patient- practitioner relationships. [TABLE 1 - Elements - about here: (Charmaz, 2006; Glaser and Strauss, 1967; Glaser, 1978; Strauss, 1987)] Interviews were conducted by MA, a female, final year Masters of Osteopathy student at an Osteopathic Educational Institution (OEI) in the UK. A topic guide (Table 2) with a broad set of open questions was derived by the researcher and after a pilot interview was conducted, revisions were made. All interviews were audiorecorded via QuickTime ® Version 10.4 (894.12), transcribed verbatim and anonymised by MA. Participants were offered a number of interview modes that included flexibility of interview location or the use of remote interviewing technologies (e.g. Skype ™

(Version 7.58 (501) or FaceTime ® (Version 3.0)). An independent researcher checked transcription quality by comparing random samples of audio-recorded data from each interview to the corresponding transcript: no inaccuracies were found. No repeat interviews were conducted. Data from the pilot interview were incorporated into the analysis. [TABLE 2 - Topic guide: insert around here]

Participants and Recruitment An email was sent to 2,444 osteopaths registered with the General Osteopathic Council, inviting participation to those who professed to use a BPS model to manage people with NSLBP to participate. Through this purposive sampling method, we received 34 responses from interested participants and 17 consented to take part in 6

this study. Inclusion criteria were osteopaths who treated NSLBP and who selfidentified as using a BPS approach. We excluded osteopaths who were not familiar with or did not use the BPS model. Participants were selected to be interviewed in order to ensure a range of gender, age and clinical experience that allowed us to explore a wide range of information-rich perspectives (Palinkas et al., 2015). No participants dropped out during the study. Data were collected until theoretical saturation occurred after the analysis of 8 interviews, meaning that the gathering of new data no longer identified any unique insights into the established themes (Charmaz, 2006). Ethics approval for this study was obtained from the Research Ethics Committee of the OEI. Data Analysis A constructivist approach (Charmaz, 2006), which assumes the researcher is part of the creation of data and analysis through the shared experiences and relationships with participants, underpins this research (See Table 3). [Table 3: Summary of Constructivist Assumptions: insert around here] (Blaikie, 2007; Thomson et al., 2014b) Line by line coding was followed by conflation of coding that led to a series of focused codes, which helped to find repeated patterns and determine significance to the research question. All coding was done by MA and an example of this process can be found at Table 4. To ensure rich data and analysis, ongoing collaborative and personal reflection took place during the interview, coding and modelling phases (MA and DR). Diagramming was used as a visual tool to connect themes and identify meaningful relationships (Holloway and Wheeler, 2010). [Table 4: Examples of Coding: insert around here] 7

RESULTS Participant characteristics Demographic details of participants can be found at Table 5. Interviews took place over a four-month period; each lasted between 49 and 75 minutes and altogether totalled 465 minutes (7.75 hours). [Table 5: Participant demographics: insert around here] Themes Data analysis initially identified 13 high level themes and 32 sub-themes and this was refined down to 8 themes that are nested within 2 conceptual summaries (Table 6). The themes are discussed below and supported by illustrative quotes which are given in Table 7. [Table 6: Constructed themes: insert around here] [Table 7: Illustrative Quotes: insert around here] 1. Collaboration We found that participants use the BPS model to recognise that the person’s perspective is paramount (1a). Building a therapeutic alliance through a ‘2-way conversation’ (P4) facilitates a way to delve deeper into their experience from a patient-centred point of view (1b). Participants were self-reflexive, striving towards a values-based approach that monitors practitioner bias and supports the therapeutic partnership (1c). 2. Deriving meaning from narrative

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Participants described the importance of discovering the person’s narrative (2a). Facilitation of patients’ storytelling was essential in the co-construction of meaning within the episode of pain (2b). Participants described the futility of clinical tests and case history taking strategies, which are often used to justify tissue-centric diagnoses devoid of humanistic contributions. They highlighted the value of exploring the story that accompanies these factors (2c). The exchange of stories between practitioner and patient, often employing metaphor, was conceptualized as an essential part for recovery (2d). 3. Coaching We found that the BPS model facilitates participant’s ability to directly address wider aspects of the patient’s life (3a). Using the BPS model allowed participants to expand their management options, thus broadening the traditional scope of osteopathy in NSLBP (3b). Participants perceived opportunities to support the person by providing context for medical scans and language and supporting workrelated problems (3c). At times, participants offered advice and guidance to help patients deal with ‘distress’ and to help suffering (3d). Participants conveyed compassion, the ability to be present, and the value of accentuating the interaction over the intervention (3e). 4. Empowerment Most participants described using the BPS model to promote self-efficacy, offering strategies for self-management and emphasising that the person, rather than practitioner, holds the key to wellness (4a). They enabled the locus of control to be firmly seated with the person (4b). Participants advocated person lead self-regulatory mechanisms (4c). 9

However, there were discordant views, as a paternalistic point of view was sometimes expressed, we found that some participants conceptualise their role as a ‘fixer’ (4d). 5. Reframing ‘Pain’ Participants used educational strategies aimed at helping the patient make connections between the body and the mind to de-threaten as a practical application of the BPS model to attenuate the experience of NSLBP (5a). Most participants expressed the importance of reinforcing learning with messages like ‘hurt doesn’t mean harm’ (P6) therefore helping the patient to understand the multiple factors of their pain (5b). Participants sometimes prioritised helping the patient make sense of pain over offering manual therapy (5c). 6. Desensitising Participants described discordant views of balancing the use of hands-on interventions with interactive strategies. Some participants viewed hands-on as a way to interact with descending pain mechanisms (6a).

Other participants

expressed targeting desensitisation through ‘reassurance and education’, rather than hands-on intervention (6b). These participants addressed maladaptive beliefs with a duty of candour, acknowledging the psychosocial elements of NSLBP (6c). Participants generally tried to offer some contextual information to broaden and explain the focus of the manual therapy. Their clinical reasoning often led them to offer manual therapy within a multidimensional package of care (6d, 6e).

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Meanwhile, other participants were more dualist, describing that the 1tissues can be dealt with’ (P4) using manual therapy ‘regardless’ of the patient’s psychosocial belief systems. Supplementary Themes: Challenges Two supplementary themes were constructed from these data, which represent challenges in the clinical application of the BPS frame. 7. Deficiencies of undergraduate BPS training and clinical integration Participants communicated challenges of clinically integrating the BPS model at an undergraduate level (7a). There was a consistent thread in these data that undergraduate training was focused on practical elements with a priority upon technically focused skills rather than integrated BPS expertise (7b). This was evident through divergent views describing the patient made up of parts, rather than an integrated whole (7c). Some participants’ views oscillated from a tissue-centric approach to a mind-centric approach (7d). Most participants identified their undergraduate BPS training as inadequate and sought post graduate education to support their clinical integration of the BPS (7e). 8. Osteopathic identity and scope of practice

Participants expressed discordant views about osteopathic principles in relation to the application of the BPS model, describing them as ‘dualist’ (8a). Dissonance was expressed in the practitioner-centred perspective of traditional osteopathic principles and approaches (8b). Acknowledging the scope of osteopathic remit came up in all interviews. Participants did not identify as counsellors and each practitioner had an

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individual understanding of when to refer depending on training and intuition with the focus on factors around the pain (8c). Development of a conceptual summary Two central concepts were constructed to demonstrate how the BPS framework is operationalised and what challenges are involved (see Table 8) [Insert Table 8: conceptual summary - around here]

We modelled the concept A and used circular arrows to denote the multidirectional nature of the interacting elements of the BPS frame (Figure 1). [Figure 1: Conceptual Summary: insert about here]

DISCUSSION As far as we know this is the first qualitative study to describe the conceptualisation of a BPS framework into clinical practice within a UK osteopathic setting. Using the BPS model as an interactive frame Our participants used additional ‘therapeutic tools’, such as reassurance and education, as previously suggested as a part of the clinical application of the BPS model (Penney, 2010). Our findings link to research which describes the value of collaborating in a therapeutic alliance in the osteopathic encounter to bring hope and reassurance to patients (Orrock, 2016). These tools were used to forge and maintain a therapeutic alliance, which may be associated with enhancing positive outcomes in NSLBP (Ferreira et al., 2013; Hall et al., 2010; O’Keeffe et al., 2016).

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Our participants appeared to cultivate skills akin to Values-Based Practice (Woodbridge and Fulford, 2004), which bolsters collaboration and cultivates compassionate detachment. Values-Based Practice examines complex and possibly conflicting values in clinical practice and tailors patient-centred clinical decisionmaking (Fulford, 2008). Metacognitive skills like self-awareness and critical reflection, were described by participants as part of the application of the BPS model (Borrell-Carrió et al., 2004; Freudenreich et al., 2010; Jones, 1995). Delving deeper to elicit a new story of wellbeing, our participants used Socratic questioning skills and curiosity to draw out storytelling, then reframe the story (Greenhalgh and Hurwitz, 1999; Launer, 2002). The BPS model was employed to go beyond the physical elements, where people are not so different and onto the historical, where in the narrative of each patient is unique (Sacks, 1985).

Our

participants valued patient narrative as a deeper, more abstract way of comprehending subtleties and complex interactions which give to stories of illness (Charon, 2008). This was exemplified in participants’ descriptions of drawing out the deeper aspects of the patient’s story in the interview and links to recently described interactive behavioural approaches (O’Sullivan et al., 2018). The coaching aspect of BPS application has been described by others (Wijma et al., 2016) and has highlighted a need to understand the process of behavioural change. Participants described using coaching as a tool to interact with top down factors offering patient-centred strategies for shifting perception to influence the generation of ‘safe neurotags’, a theoretical pattern of activity in the nervous system that is interprets sensory input as non-threatening and therefore does not require any protective responses (Moseley and Butler, 2017). Opportunities within the clinical encounter were actively sought out to help address wider BPS factors of pain and 13

function to modulate distress and lived experience of NSLBP (Foster et al., 2010; Melchert, 2011). Approaches such as mindfulness, acceptance-commitment therapy and educational interventions, which all show promise in positive outcomes for NSLBP, were utilised by our participants (Gatchel et al., 2007; Mars and Abbey, 2010; Morley et al., 1999; Synnott et al., 2016; Williams et al., 2007). These approaches have been found to positively influence patient cognitions, decrease fear and reduce pain (Louw et al., 2016). There is evidence to suggest approaches targeting patient behaviour alongside manual therapy (O’Sullivan et al., 2018; Vibe Fersum et al., 2013) and psychological interventions delivered by non-psychologists (Bostick, 2017) benefit people with chronic NSLBP. Our participants used strategies to help the person reframe their pain in the context of the emergent BPS factors of NSLBP, specifically beyond what’s happening in the tissues. Our participants strived to re-able and bolster agency (Gatchel et al., 2007; Tyreman, 2015) to increase confidence and stimulate health by promoting behavioural change. Promoting greater self-efficacy in people with NSLBP has been associated with improved prognosis and long-term health outcomes (Costal et al., 2011; MartinezCalderon et al., 2017; Reid et al., 2003). Although persistent pain is complex, being influenced by many variables including catastrophisation and fear, addressing selfefficacy may contribute to preventing the transition from acute to persistent pain (Marcuzzi et al., 2018). Understanding pain helps patients make sense of it and pain science education (Moseley and Butler, 2015) was used as a tool by our participants, to modulate the patient’s ability to cope with pain and help patients understand the bidirectional nature of the connections. These techniques were used to de-threaten and contextualise the patient's pain with the goal of understanding the sophisticated 14

complexity of the nervous system and therefore changing the perceived threat (Gifford, 1998; Melzack, 2001; Moseley and Butler, 2017). A systematic review of pain science education interventions has been found them to be effective in the treatment of chronic LBP (Louw et al., 2016), with improvements in outcomes such as return to work, physical performance and disability (Louw et al., 2011) and catastrophisation and kinesiophobia (Watson et al., 2019). However, recent findings (Traeger et al., 2018), demonstrate that offering intensive pain science education to acute LBP patients did not improve pain outcomes and although there is some improvement in the pain and disability in the short term for chronic LBP, this is not sustained in the long term (Wood and Hendrick, 2019). Further research is needed to discover if conceptual change strategies couched within a comprehensively integrated BPS approach, have the potential to improve functional long term outcomes. Challenges of integration and uncertainty in application Studies have identified challenges involved in the full integration of a BPS framework in other health care settings (Cowell et al., 2018; Foster et al., 2010). Even when doctors and physiotherapists are psychosocially aware, they are either uncertain and/or sceptical about how to practically apply these concepts (Astin et al., n.d.; Nijs et al., 2013; Sanders et al., 2013; Singla et al., 2015). This often results in the persistence of a biomechanically focused assessment and treatment (Synnott et al., 2015; Valjakka et al., 2013), which was evident in some participants’ comments. Beliefs drive clinical behaviour and both implicit and explicit beliefs of clinicians who treat people with NSLBP have the potential to influence clinical decision making and integration of models of care (Gardner et al., 2017; Jeffrey and Foster, 2012) Partial discordance was observed in participants’ affinity to paternalism, which has deep 15

roots in the biomedical paradigm; a finding described in other studies (Gardner et al., 2017). Similarly, Macdonald et al. reported that although osteopaths are able to acknowledge psychosocial factors, they remain strongly biomedical in their approach (Macdonald et al., 2018). The problematic integration may relate to the proposed inadequacy of the BPS model itself (Cabaniss et al., 2015; Stilwell and Harman, 2019). It has been suggested that its fragmented application often results in dualistic and reductionist beliefs (Stilwell and Harman, 2019) which is evident in some of our participants’ descriptions. Incomplete integration of the BPS model may be associated with how the BPS model is taught in OEIs. A recent study of osteopathy students identified that the lack of specific training regarding psychosocial factors is one of the main barriers to managing them in a clinical environment and called for psychosocial factors to be better integrated into osteopathic education (Delion and Draper-Rodi, 2018). Biomedical views persist in OEIs and clinical practice, perpetuating the idea that pain originates in the tissues and osteopathic treatment can be applied to ‘fix’ restrictions to improve symptoms (Fryer, 2017, 2016). A lack of engagement with postgraduate education is associated with technical rationality, characterised by non-critical, positivist, paternalistic and biomedical views to person-centred care (Thomson et al., 2013). This may be explained by the overemphasis on biomechanics and technical skills coupled with the absence of BPS clinical integration at undergraduate level, as described by some of our participants. In our study we observed fragmentation of the BPS approach as some participants attributed more or less weight to one sphere of the BPS Venn diagram or disregarded another part altogether. One example was self-identification as a ‘structural osteopath’ (P8). Osteopathic principles shape professional identity and 16

have been criticised for ambiguity (Tyreman, 2013), to which our participants expressed discord. Most osteopaths identify with the diagnosis of ‘somatic dysfunction’ as a central concept for the theory and the practice of osteopathy (Fryer, 2016). However, as a clinical diagnosis it is deeply reliant on the osteopath discovering structural and mechanical restrictions (Chila, 2011; Licciardone and Kearns, 2012). The term does not incorporate any psychosocial dimensions to pain (Moran, 2016) and has been criticised as anachronistic and obsolete, reinforcing beliefs in an esoteric structural cause of pain (Fryer, 2016). The biomechanicalpathological and paternalistic approach is reported in other manual therapy settings, in which the clinician is ‘fixing’ rather than facilitating change (Lluch Girbés et al., 2015) and this was also seen in some of our participants descriptions. There is evidence that practitioner beliefs in the primacy of osteopathic philosophy drives rejection of evidence informed guidelines for managing LBP (Figg-Latham and Rajendran, 2017; Inman and Thomson, 2019). However, as the discussion around ‘real’ versus ‘rubbish’ evidence-based medicine mounts (Greenhalgh et al., 2014), the osteopathic profession has an opportunity to be leaders in applying a biopsychosocially-oriented, person-centred, and evidence-informed model of health care. In other manual therapy settings, integration of a multimodal BPS approach is being advocated by the use of ‘soft skills’ and

other integrated behavioural

approaches to directly address beliefs and behaviours associated with pain (Fitzgerald et al., 2018; O’Sullivan et al., 2018; Pelletier et al., 2017). As dualistic societal beliefs about pain drive behaviour, perhaps osteopaths, as Allied Health Professionals (NHS England, 2017) have a new role to play as leaders influencing wider public health initiatives (Foster et al., 2018). The results of this study provide some guidance on pragmatic ways of clinically applying the BPS model to patient 17

care and expands the traditional biomechanical focus of osteopathic remit. These themes could help clinicians embrace clinical uncertainty with tangible strategies to infuse clinical practice with a flexible person-centred approach, turning the BPS model into the air that we breathe, rather than the thing that we do to patients in clinical practice (Hilton, 2017). Limitations and strengths of our study We did not gather information on how participant’s conceptualized or defined the BPS model or why other osteopaths did not choose to participate in this study. The analysis was primarily conducted by MA who was trained in qualitative methods as part of an undergraduate course. Although member checking was carried out on the transcripts to establish accuracy, we did not involve participants in interpretative, descriptive, theoretical or evaluative validity processes. Strengths from our study include rich data from a diverse set of participants. Methodological strengths can be judged against four components of trustworthiness described by Lincoln and Guba (Lincoln and Guba, 1985): credibility; transferability; dependability and confirmability. In our study, credibility was enhanced by member checking. All participants were offered a copy of the transcript to check for accuracy. MA was immersed in these data, allowing for prolonged observation and reflexion (Charmaz, 2006). The findings can be used as a guide for clinicians to operationalise the BPS model, using the descriptions offered as templates to integrate a BPS framework. To bolster dependability, a memo-writing process was adopted to declare and minimise bias. Regular reflexive discussions were scheduled with DR to draw out and reflect on participant’s views with the aim of boosting the interpretive

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validity, confirmability and dependability of the study results. Finally, this study follows the COREQ standard for reporting in qualitative research (Tong et al., 2007).

Proposals for further study The findings of this study have educational implications for investigation of how the BPS model is integrated in a clinical context. Examination of how BPS knowledge is translated via curricula at a classroom level to the clinical level at OEIs would reveal if implementation strategies are effective. Research is also needed to identify if osteopaths incorporate a competent and critical knowledge of pain neuroscience into the practical application of the BPS model. Identifying attitudes and beliefs of the wider osteopathic practitioners would inform how the profession reconciles the BPS model relating to NSLBP. The BPS model currently applied in quantitative research designs has shown limited success (Bronfort et al., 2010; Kamper et al., 2015). This could be because the ontological depth and breadth of the BPS model may vary for each participant therefore, future research is needed to explore if clinicians adopt a narrowly conceptualised BPS model and what could be done to expand it. Within our study, we noted that some participants’ stated that they understood BPS yet appeared to utilise biomedical pain management strategies and we propose that a combined qualitative/observational study could explore if participants’ beliefs were enacted within their practice. If the emergent dimensions of BPS are poorly integrated in clinical practice, it would be important to study if a narrowness of conception relates to the lack of success in improving outcomes and help to elucidate what possible outcomes a fully integrated, expansive conceptualization of the BPS model could 19

achieve for people with NSLBP (Setchell et al., 2018). This may have implications for CPD or professional standards inclusions.

CONCLUSIONS

Participants used the BPS model as an interactive framework to explore connections within the person and with their context in relation to an understanding of modern pain neuroscience and a humanistic understanding of suffering. In our study, we found the BPS model was used as a dynamic process of interaction between practitioner and the person. Participants described the application of the BPS model as a way to modulate pain and suffering by striving, individualistically, beyond the physical factors, to attend to all possible emergent and contextual BPS factors such as behaviours, thoughts and emotions related to their pain. These views broaden the scope of what is traditionally regarded as osteopathic practice and give practical ways of implementing a BPS approach. Since the clinical integration of the BPS model appears fraught with uncertainty and challenges, implementation of the BPS model at a clinical level will not be straightforward. It requires a significant initiative of continuous reflexivity, a competent, critical analysis of BPS contributors to NSLBP and criticality towards osteopathic knowledge and traditions. These data suggest there may be several shortcomings of undergraduate education in the clinical integration of these skills. Integration of the BPS into osteopathic principles has the potential to place osteopathy in a unique role to address NSLBP from a professional artistry, and evidence-based perspective. Within the UK, training in osteopathy appears to remain firmly embedded in the biomedical model with the occasional BPS tinsel apparently sprinkled on as an afterthought. OEIs should embed the BPS frame

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into UK osteopathic curricula and explicitly train graduates in the skills that enable osteopaths to interact within the divergent contextual factors when they ask people to ‘tell me your story’.

LIST OF ABBREVIATIONS: LBP: Low back pain NSLBP: Non-specific low back pain BPS: Biopsychosocial OEI: Osteopathic Educational Institution (UK)

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Table 8 - Conceptual Summary

A. The BPS model is an interactive frame.

Participants’ views demonstrate that: • The BPS model expands osteopathic management to deal directly with the contextual contributors of NSLBP. • The BPS model exists in a dynamic interaction between the person and practitioner as interrelated concepts. The BPS model is used as a multimodal platform to address all aspects of the clinical encounter from assessment to management and attempts to place the patient at the centre of the therapeutic relationship.

B. There are challenges of integration and uncertainty in application

Participants’ views highlight: • The potential for disintegration and unintentional fragmentation of the BPS frame during the practical application • Uncertainty around osteopathic identity, professional boundaries and lack of adequate training

Table 1 - Elements of Grounded Theory utilised in this study

Elements of Grounded Theory: (Glaser and Strauss, 1967; Glaser, 1978; Strauss, 1987; Charmaz, 2006):

1) Data analysis and collection occurred simultaneously 2) Interviews were transcribed verbatim and read and listened to repeatedly throughout the analysis 3) An inductive approach was used to derive the categories (data collection

spotting patterns

construction of concepts). This

was iterative in nature as the data collected was fed back into subsequent interviews and analysis; 4) Memo writing was employed to support the inductive approach 5) Further concepts were then extracted from these themes using diagramming and reflexive discussions 6) Categories and codes were derived from the data through a process of line by line coding which was analytic rather than descriptive. 7) These codes were progressed to focussed coding where relationships were identified in the codes and finally a core category was identified.

Table 2 - Interview Topic Guide One to one interview topics and questions Can you explain your understanding of the ‘biopsychosocial’ model in relation to NSLBP? How do you put the BPS model into action in the osteopathic encounter? How do you feel getting to know the patient more informs your treatment? Once you have identified the PS factors, what do you do with them? Describe a specific patient where you applied the BPS model in practice and what your aim was? What is your understanding of the underlying mechanisms of the osteopathic encounter to modulate a LBP experience? Do you consider there to be BPS mechanisms to osteopathic therapeutic effect? Osteopaths traditionally use manual therapy for LBP. How do you explain this to the patient? Can you elaborate on how your understanding of the pain experience informs your osteopathic management of patients with LBP? How do you integrate the treatment of physical symptoms, amid multiple BPS aspects of a patient’s presentation in a clinical context? How is your osteopathic management informed by the idea that symptoms can be cognitively mediated and can therefore be improved by modifying problematic thinking and inaccurate beliefs? How do you understand the role of osteopathic management to educate the patient in modern pain science? How does getting to know the patient more inform your treatment- what do you do with that information? From an osteopathic perspective how do you manage the complex interactions between environment, behaviours and cognitions? Can you describe how you explain LBP to your patients? How important do you think the language that patient uses in their experience of LBP and how do (do you?) approach incorporating this into an osteopathic management approach? How do you understand your clinical boundaries and the remit of osteopathy in terms of addressing/ engaging with the psychosocial factors of your patient with LBP? Tell me about how your degree in Osteopathy prepared you to address with the BPS and the multifactorial nature of pain and/ or if there were any shortfalls in your learning? What recommendations do you have for osteopathic education, CPD or regulation to support your practice using a BPS mode? Is there something in the conversation that you want to come back to?

Key: NSLBP (non-specific low back pain); BPS (biopsychosocial)’ PS (Psychosocial); CPD (continuing professional development)

Features and assumptions (Blaikie, 2007; Thomson et al., 2014)

Feature

Assumption

Ontology: What is the nature of reality?

There are multiple perspectives which are socially constructed

Epistemology: What kinds of knowledge are possible?

There are no absolute truths

Knowledge

Knowledge is not discovered but constructed through past and present experiences as well as perspectives

Researcher & participants

The researcher’s observations along with the participants are involved in the construction of knowledge

Purpose of Research

The purpose of the study is to examine specific perspectives and experiences. The result is an understanding but not the only understanding.

Research question & hypothesis

Broad question which is refined during data analysis

Table 3 - Constructivist Assumptions

Table 4 – Examples of Coding

Quote P2: Our job is to understand their reality, the patient reality, and find out how they come to that point where they come in and have told you this, this and this. Why do they say that? Why do they say it like that?

Example of line by line coding

Example of focussed code

Understanding our patient’s reality Understanding the patient’s perspective

Collaborating Exploring options

P1: So I’ve had conversations like that with patients, really sowing seeds as to whether they are ready to explore or want to explore , if it’s appropriate to explore some other psychological support if it’s appropriate for them

Holding space for the patient to understand their context Laying foundations. Walking with the patient

Cultivating a relationship

Table 5 - Participant demographics

Participant number

Age (years)

Gender

Years in Practice

Other degree or qualification

P1

62

F

5

Y

P2

36

M

3

N

P3

57

M

14

Y

P4

51

F

25

Y

P5

35

M

10

Y

P6

51

F

25

N

P7

41

M

19

Y

P8

43

F

2

N

Table 6 - Themes constructed from the data - how participants clinically apply the BPS model in practise

THEME

DESCRIPTION

1. COLLABORATION

Emphasizing the person’s perspective

2. DERIVING MEANING FROM NARRATIVE

Finding value in the person’s story

3. COACHING

Directly addressing the emergent contributors to the pain experience

4. EMPOWERMENT

By shifting the locus of control and building self -efficacy

5. REFRAMING ‘PAIN’

Facilitating learning (pain science education) to reassure and de-threaten

6. DESENSITISING

Balancing interaction and hands-on techniques consistent with a BPS model

SUPPLEMENTARY THEMES: CHALLENGES

7. DEFICIENCIES OF UNDERGRADUATE BPS TRAINING AND CLINICAL INTEGRATION

8. OSTEOPATHIC IDENTITY AND SCOPE OF PRACTICE

Table 7 Themes with illustrative quotes from participants (see Table 5 for participant identity number linked to demographic data)

MAIN THEMES - Participant Identity number (Px) Theme 1: Collaboration 1a: “Our job is to understand their reality, the patient reality, and find out how they come to that point” (P2)

1b: “You have to talk to the people, you have to discover things about how they live, you have to discover their belief systems about life in general, pain, you know, their cat, their aunt, whatever it might be. So it’s about learning about people’s lives and hopefully trying to find a way in…” (P6)

1c: “… it’s really becoming aware of your own values and acknowledging that your values are different from someone else’s values and we are conscious on some of our values and others are less conscious so we might not be able to phrase them but they are still part of us, and by being aware of these, it is much easier to tune in the patient’s values and try to fit with theirs rather than yours because your values are not that interesting (laughing) towards the patient’s recovery.” (P5) Theme 2: Deriving meaning from narrative 2a: “…[on my desk] ‘I’ve got a note which says, ‘tell me your story’” (P3)

2b: “I think the use of words has a resonance and a wavelength, if you like, where if you hit the right one, which actually resonates, that that person is actually thinking or feeling, that recognition or acknowledgement is a powerful tool” (P4)

2c: “if you have all the tests in the world, all the data, all the imaging, but the best way to get to know a patient is to talk to them ... you know just

sit and listen” (P2)

2d: [Talking to the patient]...’But you for example, your mother in law is particularly ill, or is poorly and you are having to drive back and forwards, your wife’s all stressed, you’re worried about your wife. That has just turned it from being like an acoustic guitar, into somebody playing an electric guitar. So, it’s all increased in volume and size.’ (P3)

Theme 3: Coaching 3a: “… in essence, what we do as osteopaths is that we facilitate beneficial change” (P1)

3b: “I think where the Biopsychosocial model has brought much more to what we are doing is in the, sort of, management options. My view is that before that, it was really hands on and that we were ‘correcting’ or ‘fixing’ the body. And by mobilising, improving the movement, then we would help to decrease the symptoms. What the Biopsychosocial model,… brought was exploring lots of different aspects in someone’s life that could, you know, have an impact on their symptoms and their perception of symptoms and also keys on how we could maybe help the patient, on these different fields which could be, you know, lifestyle changes or advice and CBT or motivational interviewing, whichever ways you want to approach that but, really looking at more than just the body but looking at the person and their beliefs and their context and how we could help with these.” (P5)

3c: “…but I facilitated a change … it’s just like having a discussion with a friend, really. You know, a guided discussion, about, you know, have you thought about this? And that helps the anxiety, depression side, how they could, you know, make a change, that will, you know, impact, not just their back pain” (P6)

3d: “, I think that distress.... is either the biggest factor related to their behaviour and their outcome”. (P7)

3e: “And I think that so much of what I do is talking patients better... and being involved in their lives… than what I do with my hands. Oh, I’m sure that I’m good, I’m a good manipulator and all the rest of it, you know osteopathy is fab and all the rest of it. But I actually think that the majority of the place that we have an effect is being with the people” (P6)

Theme 4: Empowerment

4a: “‘I can wiggle your spine around for 20 minutes now but then we’ll see you, if you can afford it, twice a week, until you are feeling better, or you can do this twice a day for free’” (P2)

4b: “ …so with the journey of gaining health … it is to empower people so that they can take charge and control of their bodies and their health and their life” (P4).

4c: “It’s very much about trying not to create dependency it’s helping them understand what capacity the body actually does have and that optimising that is as much what we talk about them doing in between as much as what they come into treatment scenario for” (P1)

4d: “..so basically in the understanding that you [the practitioner] take blocks away to allow harmony to dwell in the tissue, so you get good function, good blood flow and from that you would obviously had good nerve flow and the physiology and the homeostatic mechanism can balance.” (P4)

Theme 5: Reframing Pain

5a: “I had a look at him and, you know, I said, “look, there’s really nothing wrong with you. I think what’s happened is..”. You know I showed him a

picture…, I showed him where the facets were, I explained that, you know, they are very pain sensitive and the brain is very protective, and I said, what’s happened is that your brain thinks that you were hurt. In fact, you weren’t! Um... um, but it thinks you were and it’s protected you with a massive amount of spasm. And I said, you know, an element of that is that you are quite stressed in your work…. and you know, it was about saying to him, “You’re going to be fine!” um.. and, and taking that fear away” (P6)

5b: “…helping people understand those connections. I think often it’s a huge relief to patients to grasp the fact that the body will go into a response to pain that be ameliorated by how we think about it.” (P1)

5c: “.. because I’m probably becoming more and more convinced that that’s a better way to start then by rubbing a muscle or wiggling a joint.” (P2) Theme 6: Desensitising

6a: “… hands-on has a role where people are struggling to self-manage and I think they get to a point where they’re in this vicious cycle where they made…they don’t want to go to the gym anymore, they don’t go running anymore, because it hurts and I think that’s where hands on treatment can help because it makes it hurt a bit less and then they can start the process,....” (P7)

6b: “You know, I think more this way, you haven’t even touched them you’ve not really put hands on but you could have done an awful lot of reassurance and education” (P2)

6c: “I will do hands on work, … I’ll still try to do the education, because often when those people come in, they come in saying, you know my back is out of alignment, my disc has slipped out again, can you pop it back in for me? So that’s definitely my cue to educate.” (P2)

6d: “And also trying to move away from, you know, ‘Once your right SIJ is going to move well, you are going to feel much better’, sort of thing,

having a, sort of, more context, more talk around their context, rather than just their body’” (P5)

6e: “So, for that patient, strongly nociceptive patient, I would probably offer hands-on because there might be some sort of nociceptive input from somewhere, but I would also provide some form of, CBT or motivational interviewing or something for these psychosocial factors to try to decrease the risk of developing chronic pain for that patient” (P5)

SUPPLEMENTARY THEMES: CHALLENGES Theme 7: Reflections on training and integration

7a: “And I felt my training was very much like that [mechanically focused]. ...I can’t say we weren’t taught these things [BPS model]. We were exposed to them but I think almost too early in the course. So by the time you come to third/ fourth year in clinic [exams], it’s all in the background, it’s all gone.” (P2)

7b: “I remember in my third year being reprimanded in clinic (laughing) because I felt that a patient who had just witnessed her son have a cardiac arrest at the finish line of a marathon the previous day to treatment was extremely traumatised by this experience and needed some space to talk... to be told by a tutor that I was being too empathetic ...that that wasn’t really what we are here for” (P1)

7c: “….. I have 4 boxes which I tick one or more of these [pain mechanisms], of which I think is going on with that patient, and by this time I am past the psychosocial, I’m on to bio now…” (P7)

7d: “I mean, I suppose I’m a bit of a structural osteopath in that I will always look for, I hate to say it, the ‘tissue-causing symptoms’” (P8)

7e: “…I really saw how unfit for practice my understanding of pain was. It was very simplistic, as I said, you know, based on this, sort of, teaching which was simple biomechanical stuff and nothing about neurosciences and pain mechanisms and, you know, the Biopsychosocial model. ….So, that’s how I started my journey and doing my PhD on the Biopsychosocial model and trying to understand a bit better, you know, patients experience and what symptoms means for someone and that context(. Um.. so in the last 6 years my way of practicing has completely changed, you know, related to this..” (P5)

Theme 8: Osteopathic identity and scope of practice

8a: “… the whole structure governs function thing, …, unfortunately that seems to be the one mantra that everyone knows and it’s probably the worst because it’s, it sets everything up to become dualist so that, you know, there’s no room for psychosocial stuff … but actually the structure versus function thing is a , is just in the way of everything sensible.” (P7)

8b: “so I think it’s more about not creating a dependency on needing to be ‘fixed’ which is a phrase in osteopathy that i really don’t like ‘ Find it, fix it, leave it alone’, does not resonate with me particularly.” (P1)

8c: “Where do we stop? How much can we tap into someone’s life? They came for their pain and we start talking about stuff, you know. And I think that’s very important to think about this. In my point of view, I think all the, sort of, psychosocial support or management I do is all pain related.” (P5)

Figure 1 - Model of Concept A - Using BPS as an interactive frame.

Highlights (between 3 and 5- 85 characters per point) • • • • •

Participants provide pragmatic strategies to operationalise the biopsychosocial model Operationalisation requires critical knowledge of the emergent nature of pain Challenges and uncertainty lead to unintentional fragmentation of the model Application of the biopsychosocial model expands traditional osteopathic practice Undergraduate training, to clinically integrate the biopsychosocial, must improve

1) Conflict of interests DR is a salaried employee of the OEI and MA graduated from the OEI 2 Funding Sources The OEI funded this study 3) Ethics approval and consent to participate Approval for this study was obtained from the OEI Research Ethics Committee. All participants provided informed consent prior to participating in this study.