Getting the mix right for bio-psycho-social interventions

Easy as baking a cake?

Have you ever baked a cake and it hasn’t risen despite having added all the ingredients? Maybe you didn’t separate the eggs? Maybe it was the oven?

As a new graduate working a rehab setting many years ago, I sometimes felt – despite best intentions – that implementing bio-psycho-social approach was like baking a very specific cake, without the recipe, using a wood stove, blindfolded.

For over 20 years we’ve been told to treat patients within a bio-psycho-social model. We’ve told GPs to provide reassurance and refer early. We’ve told rehab practitioners to consider the psychological factors when treating musculoskeletal conditions. So have outcomes improved during this time, or does the metaphorical recipe need a revamp?

A group of persistent Australian researchers have focused their attention on systematically addressing this issue – specifically for Whiplash Associated Disorders. The findings of this research are now being implemented by the physiotherapists and psychologists at Axis, and this is the subject of Nick Kendrick’s presentation for the 2022 ARPA National Conference, “Is there a vaccination for whiplash? Stress Inoculation Training for improving outcomes.”

Whiplash – factors predicting the development of long term pain

Not everyone who experiences a whiplash injury will go on to have long term problems, but for those who do there’s hope for improved outcomes being treated with ‘stress inoculation’ training with their physiotherapy. The original research, by Dr Michelle Sterling and colleagues at the RECOVER Injury Research Centre, UQ, identified that people were more likely to have poor outcomes had specific features including:

• post-traumatic stress, anxiety / fear of movement
• high neck related physical impairments and
• were of older age.

The secret recipe?

Given the growing body of evidence supporting the impact of psychological factors, the focus for treatments shifted away from single interventions – such as standalone exercise therapy – to multimodal treatments.

The idea of offering holistic, bio-psycho-social treatment for people with pain is not new, but what is impressive about this program is the critical research which has informed its development.

The program goes beyond saying simply – ‘get some physio and see a psychologist’. The Stress Inoculation program identifies those people most at risk of developing long term symptoms and provides a course of treatment, delivered by specifically trained physiotherapists.

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What is Stress Inoculation Training?

A bit like the Colonel’s 11 Secret Herbs and Spices, we’ll leave it to Nick to share the Stress Inoculation Training (SIT) modules in detail in his presentation. Suffice to say the SIT involves psychologically informed practice, empowering people to self-manage their condition along the way. Physiotherapists participating in the Axis program, underwent specific training to effectively incorporate these modules into their treatment sessions.

Nick commented, ‘At uni we were all trained in a biopsychosocial approach but once you’re in clinics/hospitals it is still a very bio-medical model. A real benefit from the SIT program is it trains physios to integrate psychology into practice.’

The SIT features:

• Abdominal breathing and body scan-style meditation to increase awareness of tension and pain
• Engaging the person to problem solve barriers to recovery
• Use of positive re-framing of emotive pain language
• Integration of stress management techniques into daily life
• Coping skills maintenance and planning for relapses

The SIT is incorporated into musculoskeletal physiotherapy treatment and is based on a significant body of research which has refined key elements to specifically support and empower the at-risk group.

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What are the outcomes?

The original StressModex trial (published in 2019), concluded,

‘The combined stress inoculation training and exercise intervention was more effective than exercise alone for the primary outcome of pain-related disability at all follow-up points.’(1)

The outcome measures used at Axis are broader than those in the original study and include:

• Return to Work
• Neck Disability Index
• Quality Of Life measures
• An individual’s goals.

‘It’s still surprising how effective it is!’

Despite having worked within a psychologically informed practice at Axis for over ten years, Nick acknowledged the SIT is ‘still surprising how effective it is!’

'As a physio, I just want to get my hands in and work on people’s tense muscles. But it’s eye-opening how well people respond to even the initial breathing and rate of breath modules in reducing their pain and tension.’

Nick explained, ‘You see someone’s self-rated pain improve and I can say, “I didn’t have to touch you – you did that yourself”.’

What should we tell employers?

While the SIT was developed for people who have had a motor vehicle accident (think CTP and WorkCover Queensland journey claims), there is potential for the approach to be used with those who have low back pain or neck pain. Nick emphasised, ‘Whilst it is unlikely that the impact of stress alone was the primary cause of the pain in an injured worker, the SIT is a useful way of getting back to the workforce. For this group of people, they need more than advice to “just stay active” to effectively get them back to function.’

Key take-aways?

1. Identify and refer early (telemedicine is an effective means of early identification)

2. Demand evidence-based treatment programs.

We look forward to Nick’s presentation on 20 July 2022. Registrations are still available via https://www.arpa.org.au/events/category/2022-arpa-national-virtual-conference .

References 1. https://bjsm.bmj.com/content/53/19/1240