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physioscience 2010; 6(3): 112-120
DOI: 10.1055/s-0029-1245646
Originalarbeit

© Georg Thieme Verlag KG Stuttgart · New York

Das biopsychosoziale Modell als Leitfaden für die Behandlung von muskuloskelettalen Schmerzen und Behinderungen durch bewegungsbasierte Therapie

The Biopsychosocial Model as Guide to the Management of Musculoskeletal Pain and Disability with Movement-Based TherapyM. Zusman1
  • 1School of Physiotherapy, Curtin University of Technology, AUS-Perth
Further Information

Publication History

eingereicht: 7.4.2010

angenommen: 20.5.2010

Publication Date:
14 September 2010 (online)

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Zusammenfassung

Hintergrund: Ob Schmerzpatienten aus physiotherapeutischer Sicht geeignete Kandidaten für die Rehabilitation in Form einer bewegungsbasierten Therapie sind, hängt vor allem von der zugrunde liegenden Pathologie ab.

Ziel/Methode/Ergebnisse: Sowohl für geeignete als auch ungeeignete Pathologien werden Beispiele angeführt. Selbst bei fehlender Kontraindikation sind die Erfolgschancen klinischer Entscheidungen, die auf dem mittlerweile als überholt geltenden „biomedizinischen” (strukturbasierten) Modell basieren, als recht gering einzuschätzen.

Die Evidenz der „Best Practice” zeigt, dass sich bessere klinische Ergebnisse und eine bessere Wahrnehmung der Selbstwirksamkeit durch die Therapeuten am wahrscheinlichsten durch Strategien erreichen lassen, die auch die psychologischen „Triebfedern” der muskuloskelettalen Schmerzen berücksichtigen. Anhand von Beispielen und Evidenz wird dargelegt, dass sich gut ausgebildete Physiotherapeuten in einer idealen Position befinden, um auf den Prinzipien und der Praxis der kognitiven Verhaltenstherapie basierende Strategien anzuwenden.

Schlussfolgerung:Die kognitive Verhaltenstherapie ist ein Produkt des heutzutage bevorzugten biopsychosozialen Modells von Schmerzen und schmerzbedingter Behinderung.

Abstract

Background: Whether or not pain patients presenting to physiotherapists are suited for rehabilitation using movement-based treatments depends critically on the nature of the underlying pathology.

Objective/Method/Results: Examples are given of suitable and unsuitable pathologies. However, even when not contraindicated, where clinical decisions are based on the outmoded ”biomedical” (structure-based) model, which often seems to be the case, the chances of success are seriously limited.

”Best practice” evidence indicates that better clinical outcomes, along with therapists’ improved perceptions of self efficacy, are likely to be achieved by strategies that also address psychological drivers of musculoskeletal pain. On the basis of examples and evidence it is argued, that well-trained physiotherapists are ideally positioned to utilise appropriate strategies based on the principles and practice of cognitive behavioural therapy.

Conclusion:Cognitive behavioural therapy is a product of the now preferred biopsychosocial model of pain and pain-related disability.

Schlüsselwörter

Schmerzen - Rehabilitation - Physiotherapie - biopsychosoziales Modell - kognitive Verhaltenstherapie

Key words

pain - rehabilitation - physical therapy - biopsychosocial model - cognitive behavioural therapy

Literatur

  • 1 Ali N, Thomson D. A comparison of the knowledge of chronic pain and its management between final year physiotherapy and medical students.  European Journal of Pain. 2009;  13 38-50
    Google Scholar
  • 2 Amir R, Argoff C E, Bennett G et al. The role of sodium channels in chronic inflammatory and neuropathic pain.  The Journal of Pain. 2006;  7 S1-S29
    Google Scholar
  • 3 Apkarian A V, Scholtz J. Shared mechanisms between chronic pain and neurodegenerative disease.  Drug Discovery Today: Disease Mechanisms. 2006;  3 319-326
    Google Scholar
  • 4 Arnetz J, Almin K, Bergström Y et al. Active patient involvement in the establishment of physical therapy goals: effects on treatment outcome and quality of care.  Adv Physiother. 2004;  6 50-69
    Google Scholar
  • 5 Åsenlöf P, Denison E, Lindberg P. Individually tailored treatment targeting activity, motor behavior, and cognition, reduces pain-related disability: a randomised controlled trial in patients with musculoskeletal pain.  The Journal of Pain. 2005;  6 588-603
    Google Scholar
  • 6 Åsenlöf P, Denison E, Lindberg P. Idiographic outcomes analyses of the clinical significance of two interventions for patients with musculoskeletal pain.  Behav Res Ther. 2006;  44 947-965
    Google Scholar
  • 7 Åsenlöf P, Denison E, Lindberg P. Long-term follow-up of tailored behavioural treatment and exercise based physical therapy in persistent musculoskeletal pain: a randomised controlled trial in primary care.  European Journal of Pain. 2009;  13 1080-1088
    Google Scholar
  • 8 Bennett G. Can we distinguish between inflammatory and neuropathic pain?.  Pain Research & Management. 2006;  11 11A-15A
    Google Scholar
  • 9 Bialosky J E, Bishop M D, Price D D et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.  Manual Therapy. 2009;  14 531-538
    Google Scholar
  • 10 Burton A K, Waddell G. Clinical guidelines in the management of low back pain.  Bailliere’s Clinical Rheumatology. 1998;  12 17-35
    Google Scholar
  • 11 Campbell J N, Meyer R A. Mechanisms of neuropathic pain.  Neuron. 2006;  52 77-92
    Google Scholar
  • 12 Campbell W W, Landau M E. Controversial entrapment neuropathies.  Neurosurg Clin N Am. 2008;  19 597-608
    Google Scholar
  • 13 Clauw D J, Crofford L J. Chronic widespread pain and fibromyalgia: what we know, and what we need to know.  Best Practice & Research Clinical Rheumatology. 2003;  17 685-701
    Google Scholar
  • 14 Costigan M, Befort K, Karchewski I et al. Replicate high-density rat genome oligonucleotide microarrays reveal hundreds of regulated genes in the dorsal root ganglion after peripheral nerve injury.  BMC Neurosci. 2002;  3 16-34
    Google Scholar
  • 15 Crombez G, Damme van S, Eccleston C. Hypervigilance to pain: an experimental and clinical analysis.  Pain. 2005;  116 4-7
    Google Scholar
  • 16 Daykin A R, Richardson B. Physiotherapists’ pain beliefs and their influence on the management of patients with chronic low back pain.  Spine. 2004;  29 783-795
    Google Scholar
  • 17 Derbyshire S W, Whalley M G, Stenger V A et al. Cerebral activation during hypnotically induced and imagined pain.  Neuroimage. 2004;  23 392-401
    Google Scholar
  • 18 Devor M. Sodium channels and mechanisms of neuropathic pain.  The Journal of Pain. 2006;  7 S3-S12
    Google Scholar
  • 19 Devor M. Cellular processes associated with ectopia.  European Journal of Pain. 2007;  11 S10
    Google Scholar
  • 20 Djouhri L, Koutsikou S, Lawson S N. Spontaneous pain behaviour is related to spontaneous firing frequency in uninjured nociceptive C-fibre neurons after spinal nerve axotomy.  European Journal of Pain. 2007;  11 S63
    Google Scholar
  • 21 Dyson M. Inflammation, wounds and wound healing. In: Shamley D, (ed) Pathophysiology: An Essential Text for the Allied Health Professions.. Edinburgh: Elsevier; 2005
    Google Scholar
  • 22 Edwards R R, Bingham C O, Bathon J et al. Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases.  Arthritis & Rheumatism. 2006;  55 325-332
    Google Scholar
  • 23 Eisenberger N I, Lieberman M D, Williams K D. Does rejection hurt? An FMRI study of social exclusion.  Science. 2003;  302 290-292
    Google Scholar
  • 24 Evers A, Kraaimaat F, Riel van P et al. Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial.  Pain. 2002;  100 141-153
    Google Scholar
  • 25 George S, Fritz J, Bialosky J E et al. The effect of fear-avoidance-based physical therapy intervention for acute low back pain: results of a randomized controlled trial.  Spine. 2003;  28 2551-2560
    Google Scholar
  • 26 Gracely R H, Geisser M E, Giesecke T et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia.  Brain. 2004;  127 835-843
    Google Scholar
  • 27 Hahn C, Schwartz M A. Mechanotransduction in vascular physiology and atherogenesis.  Nature Reviews Molecular Cell Biology. 2009;  10 53-62
    Google Scholar
  • 28 Harding V, Williams A C. Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain.  Physiotherapy. 1995;  81 681-688
    Google Scholar
  • 29 Haythornthwaite de J, Benrud-Larson L. Psychological aspects of neuropathic pain.  The Clinical Journal of Pain. 2000;  16 S101-S105
    Google Scholar
  • 30 Hinz B. Formation and function of the myofibroblast during tissue repair.  Journal of Investigative Dermatology. 2007;  127 526-537
    Google Scholar
  • 31 Hinz B, Phan S H, Thannickal V J et al. The myofibroblast: one function, multiple origins.  The American Journal of Pathology. 2007;  170 1807-1816
    Google Scholar
  • 32 Jensen T, Madsen C S, Finnerup N B. Pharmacology and treatment of neuropthic pains.  Current Opinion in Neurology. 2009;  22 467-474
    Google Scholar
  • 33 Keefe F J, Dunsmore J, Burnett R. Behavioral and cognitive-behavioral approaches to chronic pain: recent advances and future directions.  J Consult Clin Psychol. 1992;  60 528-536
    Google Scholar
  • 34 Keefe F J, Dixon K E, Pryor R W. Psychological contributions to the understanding and treatment of pain. In: Merskey H, Loeser J D, Dubner R, (eds) The Paths of Pain 1975 – 2005.. Seattle: IASP; 2005
    Google Scholar
  • 35 Koes B, Tulder van M, Ostelo R et al. Clinical guidelines for the management of low back pain in primary care.  Spine. 2001;  26 2504-2514
    Google Scholar
  • 36 Legrain V, Guérit J M, Bruyer R et al. Attentional modulation of the nociceptive processing into the human brain: selective spatial attention, probability of stimulus occurrence, and target detection effects on laser evoked potentials.  Pain. 2002;  99 21-39
    Google Scholar
  • 37 MacDonald M R. Catastrophizing, coping and validation for chronic pain: a comment on Boothby et al (2004).  Pain. 2004;  112 221
    Google Scholar
  • 38 Mackinnon S E. Pathophysiology of nerve compression.  Hand Clinics. 2002;  18 231-241
    Google Scholar
  • 39 Main C J, Watson P J. Psychological aspects of pain.  Manual Therapy. 1999;  4 203-215
    Google Scholar
  • 40 Maitland G D, Banks K, English K et al. Maitland’s vertebral manipulation. Butterworth-Heinemann. Oxford; 2005 7th ed
    Google Scholar
  • 41 Mayer E A, Bushnell M C. Functional pain syndromes: presentation and pathophysiology. IASP. Seattle; 2009
    Google Scholar
  • 42 Méchaly I, Bourane S, Piquemal D et al. Gene profiling during development and after a peripheral nerve traumatism reveals genes specifically induced by injury in dorsal root ganglia.  Mol Cell Neurosci. 2006;  32 217-229
    Google Scholar
  • 43 Moalem G, Tracey D J. Immune and inflammatory mechanisms in neuropathic pain.  Brain Research Reviews. 2006;  51 240-264
    Google Scholar
  • 44 Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behavioural therapy for chronic pain in adults, excluding headaches.  Pain. 1999;  80 1-13
    Google Scholar
  • 45 Neugebauer V. Subcortical processing of nociceptive information: basal ganglia and amygdala. In: Cervero F, Jensen T S, (eds) Handbook of Clinical Neurology: Pain. Vol. 81.. Edinburgh: Elsevier; 2006
    Google Scholar
  • 46 Ohara S, Crone N E, Weiss N et al. Attention to painful cutaneous laser stimulus modulates electrocorticographic event-related desynchronization in humans.  Clinical Neurophysiology. 2004;  115 1641-1652
    Google Scholar
  • 47 Ossipov M H, Porreca F. Descending excitatory systems. Handbook of Clinical Neurology: Pain. Vol. 81.. Edinburgh: Elsevier; 2006
    Google Scholar
  • 48 Overmeer T, Linton S J, Boersma K. Do physical therapists recognise established risk factors? Swedish physical therapists’ evaluation in comparison to guidelines.  Physiotherapy. 2004;  90 35-41
    Google Scholar
  • 49 Overmeer T, Boersma K, Linton S J. Psychosocial factors in back pain: a comparison of factors listed by health care providers with the evidence. In: Flor H, Kalso E, Dostrovsky J O, (eds) Proceedings of the 11th World Congress on Pain.. Seattle: Elsevier; 2006
    Google Scholar
  • 50 Pertovaara A, Almeida A. Descending inhibitory systems. In: Cervero F, Jensen T S, (eds) Handbook of Clinical Neurology: Pain. Vol. 81.. Edinburgh: Elsevier; 2006
    Google Scholar
  • 51 Pham K, Gupta R. Understanding the mechanisms of entrapment neuropathies.  Neurosurg Focus. 2009;  26 1-8
    Google Scholar
  • 52 Price D D. Psychological and neural mechanisms of the affective dimension of pain.  Science. 2000;  288 1769-1772
    Google Scholar
  • 53 Robinson D A, Calejesan A A, Wei F et al. Endogenous facilitation: from molecular mechanisms to persistent pain.  Current Neurovascular Research. 2004;  1 11-20
    Google Scholar
  • 54 Rose M, Stanley I, Peters S et al. Wrong problem, wrong treatment.  Physiotherapy. 1999;  85 322-328
    Google Scholar
  • 55 Schofferman J. Restoration of function: the missing link in pain medicine.  Pain Medicine. 2006;  7 S159-S165
    Google Scholar
  • 56 Singer T, Seymour B, O’Doherty J et al. Empathy for pain involves the affective but not sensory components of pain.  Science. 2004;  303 1157-1162
    Google Scholar
  • 57 Söderlund A. Evidence based physiotherapy of chronic pain.  European Journal of Pain. 2009;  13 S3
    Google Scholar
  • 58 Söderlund A, Lindberg P. An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic Whiplash-Associated Disorders, WAD.  Disability and Rehabilitation. 2009;  23 436-447
    Google Scholar
  • 59 Strong J, Unruh A M. Psychologically based pain treatment. In: Strong J, Unruh A M, Wright A, (eds) Pain – A Textbook for Therapists.. Edinburgh: Churchill Livingstone; 2002
    Google Scholar
  • 60 Sullivan M JL, Linton S, Shaw W S. Risk-factor-targeted psychological interventions for pain-related disability. In: Flor H, Kalso E, Dostrovsky J O, (eds) Proceedings of the 11th World Congress on Pain.. Seattle: Elsevier; 2006
    Google Scholar
  • 61 Suzuki R, Rygh L J, Dickenson A H. Bad news from the brain: descending 5-HT pathways that control spinal pain processing.  Trends in Pharmacological Sciences. 2004;  25 613-617
    Google Scholar
  • 62 Tracey I, Mantyh P W. The cerebral signature for pain perception and its modulation.  Neuron. 2007;  55 377-391
    Google Scholar
  • 63 Turk D. Biopsychosocial perspective on chronic pain. In: Gatchel R, Turk D, (eds) Psychological Approaches to Pain Management.. New York: Guilford; 1996
    Google Scholar
  • 64 Turk D C. Understanding pain sufferers: the role of cognitive processes.  The Spine Journal. 2004;  4 1-7
    Google Scholar
  • 65 Vicenzino B, Wright A. Physical treatments. In: Strong J, Unruh A M, Wright A, (eds) Pain – A Textbook for Therapists.. Edinburgh: Churchill Livingstone; 2002
    Google Scholar
  • 66 Vlaeyen J WS, Linton S J. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.  Pain. 2000;  85 317-332
    Google Scholar
  • 67 Vlaeyen J WS, Jong de J, Geilen M et al. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence of the effectiveness of exposure in vivo.  The Clinical Journal of Pain. 2002;  18 251-261
    Google Scholar
  • 68 Vlaeyen J WS, Nielson W R, Houdenhove B. Overuse as a risk factor for pain disability: cognitive-behavioral models and interventions. In: Flor H, Kalso E, Dostrovsky J O, (eds) Proceedings of the 11th World Congress on Pain.. Seattle: Elsevier; 2006
    Google Scholar
  • 69 Wang N, Tytell J D, Ingber D E. Mechanotransduction at a distance: mechanically coupling the extracellular matrix with the nucleus.  Nature Reviews Molecular Cell Biology. 2009;  19 75-82
    Google Scholar
  • 70 Wipff P J, Hinz B. Integrins and the activation of latent transforming growth factor &beta1 – an intimate relationship.  European Journal of Cell Biology. 2008;  87 601-615
    Google Scholar
  • 71 Woby S R, Watson P J, Roach N K et al. Are changes in fear-avoidance beliefs, catastrophising, and appraisals of control, predictive of changes in chronic low back pain and disability?.  European Journal of Pain. 2004;  8 201-210
    Google Scholar
  • 72 Woby S R, Roach N K, Urmston M et al. The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy.  European Journal of Pain. 2007;  11 869-877
    Google Scholar
  • 73 Woolf C J. Pain: moving from symptom control toward mechanism-specific pharmacologic management.  Annals of Internal Medicine. 2004;  140 441-451
    Google Scholar
  • 74 Wyke B. Articular neurology – a review.  Physiotherapy. 1972;  58 94-99
    Google Scholar
  • 75 Zhuo M. Cortical excitation and chronic pain.  Trends in Neurosciences. 2008;  31 199-207
    Google Scholar
  • 76 Zubieta J K, Stohler C S. Neurological mechanisms of placebo responses.  Ann N Y Acad Sci. 2009;  1156 198-210
    Google Scholar
  • 77 Zusman M. The meaning of mechanically produced responses.  The Australian Journal of Physiotherapy. 1994;  40 35-39
    Google Scholar
  • 78 Zusman M. Mechanisms of musculoskeletal physiotherapy.  Physical Therapy Reviews. 2004;  9 39-49
    Google Scholar
  • 79 Zusman M. Associative memory for movement-evoked chronic back pain and its extinction with musculoskeletal physiotherapy.  Physical Therapy Reviews. 2008;  13 57-68
    Google Scholar
  • 80 Zusman M. Mechanisms of peripheral neuropathic pain: implications for musculoskeletal physiotherapy.  Physical Therapy Reviews. 2008;  13 313-323
    Google Scholar
  • 81 Zusman M. Pain science and mobilisation of painful compressive neuropathies.  Physical Therapy Reviews. 2009;  14 285-289
    Google Scholar
  • 82 Zusman M. Übersicht über Schmerzmechanismen: Implikationen fur Diagnose und physiotherapeutische Behandlung „problematischer” Schmerzpatienten.  manuelle Therapie. 2009;  13 167-172
    Google Scholar
  • 83 Zusman M. There’s something about passive movement.  Medical Hypotheses. 2010;  (in press)
    Google Scholar

Max Zusman

Adjunct Associate Professor, Curtin University of Technology

Perth, WA 6845

Australia

Email: M.Zusman@curtin.edu.au

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