Biopsychosocial Rehab

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Rehab
The Biopsychosocial Model
Application in Rehabilitation
Rafael E. Salazar II, MHS, OTR/L
Copyright 2019. Rehab U Practice Solutions, SALAZAR ENTERPRISE,
LLC. All rights reserved.

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Rehab
Welcome!
• Graduate of Augusta University
(formerly MCG), Class of 2012
• Select Medical Corporation 2012-
2013
• Charlie Norwood VA Medical
Center 2013-2017
• Community Resource Associates
2017-Present (Contracting
Consultant)
About Me: Rafael E. Salazar II, MHS, OTR/L
• Georgia State Board of
Occupational Therapy 2016-
Present
• Board of Directors, NBCOT 2018-
Present
• AU OT Department (Adjunct
Instructor 2015, 2018)

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Rehab
Why Are We Here?
• Discuss the biopsychosocial model of healthcare
• Explore its application to clinical rehabilitation (OT) practice
• Review relevant literature and research

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Defining the Biopsychosocial Model
• Has been described both as a philosophy of clinical care and a guide
for clinical practice (Borrell-Carrio 2004) [1]
• Takes into account the physical, psychological, and social factors of
the disease or injury and promotes an integrated approach to
treatment (Covic 2003) [2]
• Proposes that suffering, disease, or illness involve a host of factors
from biological (tissues, structures, molecules) to environmental
(social, psychological)

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Basic Principles
1. The relationship between psychological and physical
factors of health can be extremely complex. A patient’s
subjective experience can’t simply be reduced to
physiological factors. (Borrell-Carrio 2004) [1]
2. These factors affect each individual differently (we are
dealing with each individual’s subjective experience).
3. Changes in one of these factors (biological,
psychological, or social/environmental) potentially
create real and notable changes in the other factor(s)
(Moseley 2002) [3] https://www.researchgate.net/

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Example:
https://www.researchgate.net/

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Breaking it Down
1. Physical Factors
2. Psychological Factors
3. Social/Environmental Factors

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Physical Factors
• Stem from biological or physiological roots
• Gets most of the attention from clinicians,
payers, administrators
• ROM measurements, strength assessments,
palpation, soft tissues, postural assessments,
manual therapy techniques, focus on exercises
and stretches, and patient education
• Can affect both physical function and
psychological health
• BMI (physical factor) shown to impact individual’s
social functioning (de Filippis, et al. 2004) [5]

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Physical Factors Cont.
• Important & necessary for effective
clinical evaluation and treatment
• If we only go so far as the tissues, we
potentially miss the other important
aspects that can affect not only our
patients’ experience of pain or
dysfunction, but also their response to
treatment (Moseley 2002)[3] (Moseley & Butler
2015)[4]

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Rehab
Psychological Factors
• Prior to 1970’s, healthcare was based
on the biomedical model of practice
(Engel 1978) [6]
• Main focus was on physical aspects of
disease and health.
• Inclusion of psychological factors
impacts clinical practice
• Ex: Cognitive changes impact physical
abilities (Moseley 2004) [7]

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Psychological Factors Cont.
• Main Takeaway:
• To reduce a patient’s condition, limitation, or dysfunction down to a
“problem” with the tissues or body misses the great impact that the patient’s
psychological state and cognition has on their subjective experience of their
condition.

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Rehab
Psychological Factors: An Example
• Neurophysiology & Neuroscience of Pain
• Combining neuroscience education with traditional physical rehabilitation
treatment can improve outcomes in patients with chronic low back pain
(Moseley 2002) [3]
• Approaching patient education from a purely biomechanical frame of
reference may increase stress, anxiety, and even negatively impact clinical
outcomes (Louw, et al 2011) [8]

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Rehab
Neuroscience Education &
Psychological Factors of Chronic Pain
• ***Pain is always real***
• Pain = Protective mechanism of the
brain
• Clinician’s acknowledgement of
patient’s pain helps build therapeutic
rapport/relationship
http://www.rehabpub.com/2017/11/meet-middle/

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Rehab
Social/Environmental Factors
• Social factors may impact a patient’s
behavioral response to physical
conditions or symptoms (Turk & Gatchel 2018) [9]
• Sociocultural factors can affect patient-
clinician interactions (Turk & Gatchel 2018) [9]
• Social Learning
• Beliefs about illness or treatment
• Social influences
• Cultural norms/ethnic expectations

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Social/Environmental Factors
• Example: Social Learning
• Beginning as children, we learn socially
appropriate (acceptable) ways of reacting
to/dealing with illness or pain.
• How parents respond to children’s minor injuries
may trigger operant learning mechanisms.
• May influence chronic pain conditions (Turk & Gatchel 2018)
[9]

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Clinical Application of the Biopsychosocial
Model in Rehabilitation & OT
• Assessment
• Outcome Measures
• Treatment Approaches
• Levels of Care
• Functional Restoration
• Patient Education & Engagement

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Clinical Application: Assessment
• Biopsychosocial assessment focuses:
• Physical Symptoms/Dysfunctions
• Patient’s experiential Perspective (Gatchel &
Howard n.d.)[10] (Vetter, et al 2013) [11]
• Physical, psychological, behavioral, and
cognitive measures to understand each
patient’s unique pain condition (Gatchel &
Howard n.d.)[10]
• Both physical (objective) measures &
self-reported measures

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Clinical Application: Outcome
Measures
• Goal:
• Complete analysis of the patient’s unique condition &
experience
• Step-by-step approach
• Start with general assessment
• Move deeper to more specific assessment of
physical, psychological, or social factors
• Helps build understanding of patient’s unique
conditions
• Develop a more comprehensive treatment plan
(Gatchel & Howard n.d.)[10]

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Clinical Application: Treatment
Approaches
• Too many factors at play for rigid
treatment protocols or “cookie-cutter”
treatment programs
• Throwing patients into the same exact
treatment program may result in
suboptimal outcomes (Gatchel & Howard n.d.)[10]
• Ex: “a shoulder is a shoulder is a
shoulder.”

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Rehab
Treatment Approaches: Levels of Care
• Example: Chronic Pain
• Goal of Treatment:
• Increase a patient’s overall functional
capacity
• 3 Levels:
• Primary
• Secondary
• Tertiary (Gatchel & Howard n.d.)[10]

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Rehab
Levels of Care Cont.
• Primary
• Acute symptoms associated with injury or dysfunction
• Focus on movement and function of affected area (Gatchel & Howard n.d.)[10]
• Secondary
• Multifaceted approach
• Neuroscience pain education, graded motor imagery, or cognitive-behavioral treatments
• Goal: Avoid physical deconditioning while reducing any psychological barriers that may
interfere with recovery (Gatchel & Howard n.d.)[10]
• Tertiary
• Functional Restoration

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Levels of Care Cont.
• Tertiary Level: “Functional Restoration”
• Goal: Prevent permanent disability (Gatchel & Howard n.d.)[10]
• Interdisciplinary team develops treatment plan addressing mobility &
function as well as stress management and coping skills (Gatchel & Howard
n.d.)[10]
• Primary Care, Medical Specialties, Physical/Occupational Therapy, and/or
Disability Case Management

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Rehab
Clinical Application: Patient Education
• Goal:
• Tailor clinical education to each individual
patient
• Engage patient throughout the treatment
process
• Open-ended questions & active listening
• Build trust and rapport
• Can improve clinical outcomes; patient
experience, engagement, & retention

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Takeaway
• Physical, psychological, & social/environmental factors affect each
individual patient’s specific diagnosis or dysfunction
• Each factor has been shown to have potential impacts on the others
• Effective rehabilitation assessment and treatment addresses all three
areas
• Rehab clinicians should begin to view each patient as unique, rather
than offering “cookie-cutter”, one-size-fits-all treatment

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Questions? (Contact Info)
• Contact Me:
• Rafael E. Salazar II, MHS, OTR/L
• rafi@rehabupracticesolutions.com
• https://www.linkedin.com/in/rafaelsalazarii
https://rehabupracticesolutions.com/biopsychosocial/

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References
• [1] Borrell-Carrio, F. (2004). The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. The
Annals of Family Medicine, 2(6), 576-582. doi:10.1370/afm.245
• [2] Covic, T. (2003). A biopsychosocial model of pain and depression in rheumatoid arthritis: A 12-month longitudinal
study. Rheumatology, 42(11), 1287-1294. doi:10.1093/rheumatology/keg3
• [3] Moseley, L. (2002). Combined physiotherapy and education is efficacious for chronic low back pain. Australian Journal
of Physiotherapy, 48(4), 297-302. doi:10.1016/s0004-9514(14)60169-0
• [4] Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of
Pain, 16(9), 807-813. doi:10.1016/j.jpain.2015.05.005
• [5] de Filippis LG, Gulli S, Caliri A, D’Avola G, Lo Gullo R, Morgante S. et al. Factors influencing pain, physical function and
social functioning in patients with osteoarthritis in southern Italy. Int J Clin Pharmacol Res. 2004;24(4):103–109. Available
at: https://www.ncbi.nlm.nih.gov/pubmed/15754914
• [6] Engel, G. L. (1978). The Biopsychosocial Model And The Education Of Health Professionals? Annals of the New York
Academy of Sciences, 310(1 Primary Health), 169-181. doi:10.1111/j.1749-6632.1978.tb22070.x Copyright 2019. Rehab U Practice Solutions,
SALAZAR ENTERPRISE, LLC. All rights reserved.

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Rehab
References Cont.
• [7] Moseley, G. (2004). Evidence for a direct relationship between cognitive and physical change during an education
intervention in people with chronic low back pain. European Journal of Pain, 8(1), 39-45. doi:10.1016/s1090-3801(03)00063-6
• [8] Louw A, Diener I, Butler DS, Puentedura EJ. (2011). The effect of neuroscience education on pain, disability, anxiety, and
stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation , Volume 92 , Issue 12 , 2041 –
2056. doi: https://doi.org/10.1016/j.apmr.2011.07.198
• [9] Turk, D. C., & Gatchel, R. J. (2018). Psychological approaches to pain management: A practitioners handbook. New York: The
Guilford Press. Available in part
from: https://books.google.com/books?hl=en&lr=&id=ngBPAgAAQBAJ&oi=fnd&pg=PA3&dq=social+factors+in+the+biopsychoso
cial+model+of+pain&ots=zY1XoWz6h4&sig=iyo8RZ51CH97Zg8-
sHvvQzvH1H0#v=onepage&q=social%20factors%20in%20the%20biopsychosocial%20model%20of%20pain&f=false
• [10] Gatchel, R. J., & Howard, K. J. (n.d.). The Biopsychosocial Approach. Retrieved
from https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach
• [11] Vetter TR, McGwin G, Bridgewater CL, Madan-Swain A, Ascherman LI. Validation and Clinical Application of a
Biopsychosocial Model of Pain Intensity and Functional Disability in Patients with a Pediatric Chronic Pain Condition Referred to a
Subspecialty Clinic. Pain Research and Treatment. 2013;2013:143292. doi:10.1155/2013/143292.
Copyright 2019. Rehab U Practice Solutions,
SALAZAR ENTERPRISE, LLC. All rights reserved.

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