There is a global recognition for the need of transition from a biomedical model to Biopsychosocial (BPS) model of clinical practice relevant to pain treatment. Numerous national and international organizations including the IASP, the World Health Organization (WHO), the International Olympic Committee (IOC), and the United States Department of Defense Veterans Affairs have made clear in their mission statements the need for a unified language regarding the basic understanding of pain mechanisms and the integration of biopsychosocial approaches in healthcare treatment of pain. (IASP, 2012, Towards a Common Language for Functioning, Disability and Health – WHO, Comprehensive Policy on Pain Management by the Military Health Care System)

The current biomedical model and the educational frameworks which support all our major professional healthcare education systems have major knowledge deficits in the mechanisms and models of pain treatment, in particular the application of the biopsychosocial model of health to pain. (Thomas, et al. 2018 & Hoeger, et al.)

Despite acknowledging these gaps in knowledge, acceptance and integration of BPS-based models for clinical practice is poor and very rare in both private practice and hospital-based systems. This has been consistent across multiple healthcare disciplines often with concerns of few incentives for adoption of the BPS model with current reimbursement models, the impact of the BPS model on workload, and inadequate resource availability for developing competence in BPS care as significant limiters to adoption.

As there is poor acceptance of these models, healthcare consumers and medical providers have limited options and/or knowledge related to finding providers for adequate care utilizing a biopsychosocial model.

Finally, it is also important to discuss two limitations in early effort to provide biopsychosocially informed care for the treatment of chronic pain. First, to recognize that there have been limitations regarding the implementations and efficacy of stand-alone intensive multidisciplinary biopsychosocial pain programs. (Kamper et at 2015) Many of these stand-alone centers and programs have a number of logistic, financial, and implementation challenges. While there has been some evidence of benefit from multidisciplinary pain programs, current healthcare climate (organizational factors, reimbursement, etc.) the likelihood of scaling centers to meet the needs of this pain epidemic is small. We propose an alternative model to a traditional standalone multidisciplinary approach of implementing the biopsychosocial model to a transdisciplinary training model. (Cartmill et al. 2011).  Utilizing a transdisciplinary perspective allows for individual providers to have cross training with key aspects of pain treatment provided other disciplines. By doing so, this would permit clinics with fewer internal complimentary disciplines to work within their network and community to allow for flexible integration of other disciplines on an as needed basis to meet both the practical clinical and patient needs such as determining the appropriateness of the number of disciplines needed to meet the need of the patient. Second, the main behavior change approach utilized in current efforts for BPS is based on second wave behavior therapies such as cognitive behavioral therapy (CBT). CBT has some measurable improvements but lacked the empirically supported theories of behavior change that make up the third wave behavioral therapies such as contextual functionalism and Relational Frame Theory (RFT). Working therapies within this model include Acceptance and Commitment Therapy which has had a growing body of evidence for improving behavioral outcomes where CBT had previously had failed

There currently is no working curriculum or framework for the use and application of the biopsychosocial model for rehabilitation professionals. This is further compounded by the biopsychosocial implications of COVID19 on society. The difficulty of developing a working framework includes the reality that the biopsychosocial model has had a number of complaints that included philosophical coherence and the confusion of categorization along with biological, psychological, or sociology domains. These complaints highlight the limitations of format, mechanistic, and organicism philosophical viewpoints, as these views are challenged by context and historical reference. Within the viewpoint of contextualism, the biopsychosocial model can be fully appreciated, including the ability to develop contexts and constructs which could be defined for a specific intent to delve into detailed aspects of one domain, such biology, or commonly in physical rehabilitation, neuroscience and biomechanics, but concurrently recognizing the complex overlay of numerous other factors and the context in which these constructs exist. To do so in any of the other lenses could result in unyielding complexity that could not be acted upon. This is discussed in further detail in subsequent sections.

The Human Rehabilitation Framework (HRF) is a biopsychosocial process-based framework for helping clinicians work with individuals struggling with movement and pain problems. It is designed to assist movement and physical rehabilitation professionals to engage in evidence-based psychological informed practice and to fully embrace the biopsychosocial model. It incorporates both identification and engagement of empirically researched processes associated with psychosocial flexibility and a prognostic ladder based on relative psychological flexibility for developing clinical decision-making skills. This prognostic ladder is designed to be expanded to other biopsychosocial flexibility processes with future advances in research on these processes. The HRF has an appreciation for the qualitative representation of motor behavior (with emphasis on movement variability) and load capacity to comprehensively address the needs of movement and pain in physical rehabilitation. The HRF is an ongoing work in progress with the possibility of significant change across the course of its development.

****Human Rehabilitation Framework (HRF) was previously known as the Movement with Pain Framework (MWPF)

More specifically, the HRF integrates the psychological flexibility processes developed for ACT built on the RFT with 3 additional biopsychosocial processes to develop functional analysis, skill education and development, and prognostic ladder for advancing clinical practice.

• There are 6 categories of biopsychosocial processes which make up the HRF
  • Attentional Processes
  • Cognitive/Emotional Processes
  • Social Processes
  • Sensorimotor Processes
  • Loading Capacity Processes
  • Behavioral Processes
• Under these are 9 specific process based skills used for clinical interventions and delivered in support of a prognostic ladder

The HRF was an attempt to address the gap in the working framework for training rehabilitation professionals to engage in the biopsychosocial model. In an attempt to minimize the redevelopment of research that is readily available, significant effort was to draw on available models, theories, and processes to build the MWPF. The vast research work is done relative to pain science, motor behavior, and tissue capacity, RFT, Acceptance and Commitment Therapy (ACT), psychological flexibility, cognitive network psychology, and process-based therapy have been instrumental to the development of the HRF. The six core psychological flexibility processes of ACT, and the inflexibility processes they target, have been extensively studied in empirical research. The evidence for ACT in comparison to Cognitive Behavioral Therapy (CBT) for chronic pain is equivalent, but the transdiagnostic benefit, such as concurrent improvement in depression and anxiety, is greater in ACT (see here). Psychological flexibility changes account for the majority of improvements in patient functioning with ACT interventions (see here). Initial efforts to integrate physical therapy with ACT (PACT) demonstrated feasibility for physical therapists to implement ACT into practice. PACT when compared to usual physical therapy care showed short term superiority but not long term superiority (see here). We hypothesize that some of the limitations of the PACT approach for long term effectiveness may in part be associated with coherence difficulties between standard physical therapy and ACT. As previously described here, inconsistencies of the worldviews in which an intervention was developed may present with problems of coherence for both the client and the clinician. We propose that a comprehensive re-evaluation of the movement strategies in combination with psychosocial strategies may result in more sustainable benefits and enhance transdiagnostic benefits for improving quality of life. The Human Rehabilitation Framework (HRF) is built on a philosophic worldview of contextualism with the pragmatic scientific philosophy of functional contextualism. It is transdisciplinary and rooted in the biopsychosocial model for health. Relational Frame Theory both in the context of language and cognition and as unofficially proposed representation of motor behavior relationships relative to sensory, cognitive, and emotional stimuli. Its interventional approach is process-based and it draws upon the psychological flexibility and inflexibility processes developed for Acceptance and Commitment Therapy (ACT). Finally, efforts to ease the difficulty merging mechanistic views of traditional physical rehabilitation into the contextual aspects of pain and movement, the MWPF was designed to provide a prognostic ladder as a technology to assist with clinical decision-making pathways to help guide treatment planning.

• The biopsychosocial model has had a number of complaints that included philosophical coherence and the confusion of categorization along with biological, psychological, or sociology domains. These complaints highlight the limitations of format, mechanistic, and organicism philosophical viewpoints, as these views are challenged by context and historical reference. Within the viewpoint of contextualism, the biopsychosocial model can be fully appreciated, including the ability to develop contexts and constructs which could be defined for a specific intent to delve into detailed aspects of one domain, such biology, or commonly in physical rehabilitation, neuroscience and biomechanics, but concurrently recognizing the complex overlay of numerous other factors and the context in which these constructs exist. To do so in any of the other lenses could result in unyielding complexity that could not be acted upon.

• Emphasis on movement vs. exercise prescription
  • Our emphasis on improving functional understanding, awareness, and meaningful action during movements and positions such as sitting, standing, walking, lifting, pushing, pulling are that these are movement behaviors present in most ADL. We know clients/patients have very low adherence to HEP after discharge, let alone during the POC itself. Most of the benefits of clinical treatment are occurring along with broad biopsychosocial processes that are more important than strength and flexibility, despite so many clinicians emphasizing these elements exclusively. Most successful outcomes can be predicted by early increases in psychological flexibility, such as what may be noted after expectation violation. We are double-dipping into researched processes for movement as well as psychosocial processes emphasized formally in ACT work. With this process-based approach we are working on weaving skill developments into ADL for a long term sustainable improvement. The behavioral skills we are attempting to emphasize are often self-reinforcing. “If I am present and pay attention, I make better decisions and often I feel better” “When I forget or am distracted, I start to have problems”, this also overlaps with the literature on work injury, distraction and moving awkwardly are the primary biomechanical mechanisms driving injury secondary to work satisfaction and depression. No exercise prescription will accomplish improvement in attentional ability, only practicing attention will do so. Our working hypothesis is that diverse biopsychosocial attentional efforts combined with developing of skills to promote true ownership for the setting the stage for building further biopsychosocial capacity and ultimately thriving in these practices will maximize the opportunity of a lifetime of improvement beyond the clinical space and redirect trajectories of disability and
• “You can skip steps, function on one step, fall down the steps, and then climb back up”
  • The HRF is NOT intended to serve as a mechanistic linear progression
  • The psychological flexibility processes of ACT as described in the hexaflex are designed for constant pivoting in which the clinician first is flexible to determine where change is possible for a client. While the prognostic ladder we propose contains key biopsychosocial processes it is expected that that engagement in processes outside of the “step” on the HRF will and should be engaged to meet the needs of the client in front of you.
• Self as defined by RFT
  • In RFT, the experience of self is divided into an umbrella of two parts,self-as-perspective (observing mind, transcendent mind, among many other names) and “content of self”. The content of self is further divided into self-as-process and self-as-story. Self-as-process is the “ongoing, observable process of ourselves”, such as memories, emotions, bodily sensations, and thoughts. It only exists here and now and as a result, is open for change. This dynamic nature of self-as-process is important because this means memories are not always thought of or remembered in the same way, nor does sensation always feel the same, and our emotional state and how we interpret emotions is also variable. Self-as-story is the “who I am”, identity part built on our history, and it is important that this story is coherent and a connected whole. The self-as-perspective, or observing self, is difficult to describe. As Hayes describes it, “it’s borders are fuzzy”, we cannot observe it and it is devoid of content, it is the lens through which we look that is not influenced by what it sees. The observing self is also a powerful process to engage in from a therapeutic perspective, classically emphasized in mindfulness strategies but explicitly engaged with Acceptance and Commitment Therapy. While there are numerous directions (in particular “I/you”, “here/there”, “now/then” relationships!) for which I could take this and future posts, I will for now leave these for specific courses on these approaches and end on the note that the experience of self, as defined by RFT, provides a clinical framework for understanding the difficulty of addressing beliefs, memories, relationships with emotions and sensations, and sustainable behavior change.

Psychological flexibility influence of the prognostic ladder function

• • We recognize the fragmented nature of research on psychological flexibility, for the purpose of creating a construct for which the HRF could operate with, we utilize the definition recommended by Kashdan:
    • “Psychological flexibility actually refers to a number of dynamic processes that unfold over time. This could be reflected by how a person:
      1. adapts to fluctuating situational demands
      2. reconfigures mental resources
      3. shifts perspective
      4. balances competing for desires, needs, and life domains Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility have to incorporate repeated transactions between people and their environmental contexts.” – Kashdan, 2010
    • A metaphor that may be helpful for clinical purposes is to look at psychological flexibility as the availability of space in a defined area of land for tending vegetation, with vegetation representing relational frames and networks. Larger amounts of land yield greater space for opportunities to change arrangements of vegetation growth. Conversely, less availability of space limits options and opportunities for variability and change.
    • The role of psychosocial processes in chronic pain has been well established. While some evidence for the prognostic representation of psychological flexibility in physical rehabilitation exists (here), the principal limitation of the MWPF is the lack of research related to the prognostic ability of psychological flexibility in physical rehabilitation for pain. We have drawn extensively the prognostic ability of psychological flexibility in multiple aspects of human health (here, here, here) and some research on psychological flexibility prediction and mediation role in chronic pain (here, here, here). Our hope is the open-source nature of MWPF will draw on the community of researchers who resonate with the proposed framework.

Psychological flexibility as a process in a Biopsychosocial Process-Based Framework

• • The Human Rehabilitation Framework integrates the psychological flexibility processes developed for ACT built on the RFT with 3 additional biopsychosocial processes with a target of improving biopsychosocial process workability.
  • There are 6 categories of biopsychosocial processes which make up the HRF
    • Attentional Processes
    • Cognitive/Emotional Processes
    • Social Processes
    • Sensorimotor Processes
    • Loading Capacity Processes
    • Behavioral Processes

Presence Skill Processes

ACT promotes ongoing non-judgmental contact with psychological and environmental events as they occur. The goal is to have clients experience the world more directly so that their behavior is more flexible and thus their actions more consistent with the values that they hold. This is accomplished by allowing workability to exert more control over behavior; and by using language more as a tool to note and describe events, not simply to predict and judge them. A sense of self called “self as process” is actively encouraged: the defused, non-judgmental ongoing description of thoughts, feelings, and other private events. – Via https://contextualscience.org/the_six_core_processes_of_act

Observing Self Skill Processes

As a result of relational frames such as I versus You, Now versus Then, and Here versus There, human language leads to a sense of self as a locus or perspective, and provides a transcendent, spiritual side to normal verbal humans. This idea was one of the seeds from which both ACT and RFT grew and there is now growing evidence of its importance to language functions such as empathy, theory of mind, sense of self, and the like. In brief the idea is that “I” emerges over large sets of exemplars of perspective-taking relations (what are termed in RFT “deictic relations”), but since this sense of self is a context for verbal knowing, not the content of that knowing, it’s limits cannot be consciously known. Self as context is important in part because from this standpoint, one can be aware of one’s own flow of experiences without attachment to them or an investment in which particular experiences occur: thus defusion and acceptance is fostered. Self as context is fostered in ACT by mindfulness exercises, metaphors, and experiential processes.

https://contextualscience.org/the_six_core_processes_of_act

Acceptance Skill Processes

Acceptance is taught as an alternative to experiential avoidance. Acceptance involves the active and aware embrace of those private events occasioned by one’s history without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm. For example, anxiety patients are taught to feel anxiety, as a feeling, fully and without defense; pain patients are given methods that encourage them to let go of a struggle with pain, and so on. Acceptance (and defusion) in ACT is not an end in itself. Rather acceptance is fostered as a method of increasing values-based action.  Via https://contextualscience.org/the_six_core_processes_of_act

Cognitive Defusion Skill Processes

Cognitive defusion techniques attempt to alter the undesirable functions of thoughts and other private events, rather than trying to alter their form, frequency or situational sensitivity. Said another way, ACT attempts to change the way one interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished. There are scores of such techniques that have been developed for a wide variety of clinical presentations. For example, a negative thought could be watched dispassionately, repeated out loud until only its sound remains, or treated as an externally observed event by giving it a shape, size, color, speed, or form. A person could thank their mind for such an interesting thought, label the process of thinking (“I am having the thought that I am no good”), or examine the historical thoughts, feelings, and memories that occur while they experience that thought. Such procedures attempt to reduce the literal quality of the thought, weakening the tendency to treat the thought as what it refers to (“I am no good”) rather than what it is directly experienced to be (e.g., the thought “I am no good”). The result of defusion is usually a decrease in believability of, or attachment to, private events rather than an immediate change in their frequency. https://contextualscience.org/the_six_core_processes_of_act

Social Relational Process Skills

…In process

Sensorimotor Process Skills

Sensorimotor variability processes serve as the most common entry point introducing biopsychosocial workability for the rehabilitation professional. Emphasis of intentional efforts via verbal or touch sensory interactions to promote motor variability in multiple functional contexts are placed here. Flexible cuing and self exploration is encouraged.

Load Capacity Process Skills

Sub-classification of skill emphasis

• Local Tissue
• Kinetic Chain
• Nervous System
• Non-Musculoskeletal
• Psychosocial

Values Process Skills

Values are chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment. ACT uses a variety of exercises to help a client choose life directions in various domains (e.g. family, career, spirituality) while undermining verbal processes that might lead to choices based on avoidance, social compliance, or fusion (e.g. “I should value X” or “A good person would value Y” or “My mother wants me to value Z”). In ACT, acceptance, defusion, being present, and so on are not ends in themselves; rather they clear the path for a more vital, values consistent life. Via https://contextualscience.org/the_six_core_processes_of_act

Committed Action Process Skills

ACT encourages the development of larger and larger patterns of effective action linked to chosen values. In this regard, ACT looks very much like traditional behavior therapy, and almost any behaviorally coherent behavior change method can be fitted into an ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, and the like. Unlike values, which are constantly instantiated but never achieved as an object, concrete goals that are values consistent can be achieved and ACT protocols almost always involve therapy work and homework linked to short, medium, and long-term behavior change goals. Behavior change efforts in turn lead to contact with psychological barriers that are addressed through other ACT processes (acceptance, defusion, and so on). https://contextualscience.org/the_six_core_processes_of_act

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