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Biopsychosocial approach to tendinopathy

Edgar, N., Clifford, C., O'Neill, S., Pedret, C., Kirwan, P. and Millar, N.L., 2022. Biopsychosocial approach to tendinopathy. BMJ Open Sport & Exercise Medicine, 8(3), p.e001326.

In today’s letter

• Overview of the psychological impact on patients with tendinopathies

• Rapid Results = It’s important to explain to patients that pain should not be feared and that physical exercise will help them improve, enhancing their self-efficacy and adherence to the treatment plan

• 3 Reads to check out to further you knowledge about pain

• Meme of the week: Did I hear you say canceled? 🥳

Aim of the study

This review discusses current psychological and social factors in musculoskeletal medicine and how to address them when treating tendinopathies

Did you know?

• Tendinopathy, often disabling, painful, and persistent, is characterised by activity-related pain and loss of function due to excessive loading.

• Science have made promising advances in understanding the mechanisms of the injury, however, theres still a gap in clinical practice when treating patients with tendinopathies

• Persistent tendon pain can negatively impact a persons psychology, leading to poor outcomes and the development of long lasting discomfort (chronicity)

• There is growing awareness of the role that psychosocial and psychological factors play in either facilitating or hindering rehabilitation outcomes

Biopsychosocial factors in chronic MSK conditions

What does bio-psycho-social mean?

It refers to an approach that considers human biology, psychology, and social factors in understanding and treating health

Biological factors:

• Genetics

• Physical health

• Physiological processes

Psychological factors:

• Mental health

• Emotions

• Cognitive processes

Social factors:

• Relationships

• Cultural influences

• Socioeconomic status.

• In chronic musculoskeletal (MSK) conditions, psychosocial factors such as fear, anxiety, and depression have been shown to affect pain and disability levels, negatively affecting rehabilitation.

• Adverse psychosocial exposure, leading to depression, stress, or a sense of hopelessness, can increase chronic discomfort

• In these chronic conditions, a persons perception of their ability to succeed in specific situations influences the relationship between pain and disability.

• This perception is described as self-efficacy; high self-efficacy is associated with lower levels of pain and disability and overall better physical functioning.

• Negative perceptions of pain can lead to a catastrophising

• The resulting hyper vigilance and disuse can develop into fear of movement, starting a harmful cycle of long lasting discomfort

• Additionally, hyper vigilance and avoidance of physical activity can cause deconditioning, which increases the persons risk to further injury.

Psychosocial factors in Tendinopathy

• The structural changes seen on imaging of tendinopathic tendons often do not explain the response to exercise, suggesting that physical factors are not the only influential component of rehabilitation.

• Psychological factors may have a greater influence on clinical outcomes than visible structural damage.

• Psychological fears, patient rating of pain, and tendinopathy’s impact on quality of life were recently identified as core health aspects in tendinopathy

• For clinicians, understanding how psychological factors can affect tendinopathy and patients' lives is essential to effectively communicate the potential impact of these factors on their pain

• Dunn et al found a modest association between physiological issues and clinical outcomes in tendinopathy, but acknowledged the need for more longitudinal studies to investigate the impact of psychosocial issues on clinical outcomes.

• Despite the widespread acceptance of psychosocial factors in tendinopathy, there is currently a distinct lack of trials measuring how these factors affect patient outcomes

Patient Education in tendinopathy

• Patient education aims to provide a deeper understanding of a persons condition.

• Recently, patient education has evolved to enable patients to make informed choices about treatment and management.

  This knowledge acquisition is referred to as health literacy, defined as the ability to seek, understand, and act on health-related information.

• The goal of successful patient education is patient empowerment, allowing patients to largely self-manage their condition.

• Clinicians are responsible for developing patients’ health literacy and understanding psychosocial factors

• A successful interaction between health professionals and patients, where the patient is involved in the consultation process and receives emotional support, is known as a working alliance.

• Aim to establish a working alliance. This is when you and the patient have a good interaction, allowing them to get involved in the discussion and receives emotional support.

What should a biopsychosocial approach involve?

• In MSK settings, especially tendinopathy, using a biopsychosocial model in patient education could enhance management and recovery

• The varied clinical presentation, high recurrence rates, and persistent functional impairments in tendinopathy indicate that factors beyond physiology are involved.

• While the biomedical model of patient education focuses on pain mechanisms and treatment options, the biopsychosocial model includes psychological and psychosocial factors. Such as barriers to exercise and mental health

Pain education

• Reframing patient beliefs about pain, treatment, and prognosis may reduce the impact of psychological and psychosocial factors on rehabilitation

• In chronic pain conditions, there is often a disconnect between clinical presentation and pathology observed on imaging; this is also seen in tendinopathy.

• The lack of clear functional pathways to explain tendinopathy mirrors the disconnect found in other chronic pain conditions.

• Chronic pathological pain in tendinopathy is associated with functional changes that increase sensitisation within the central nervous system, potentially explaining resistance to tissue-based treatment

  Central sensitisation refers to the increased responsiveness of the central nervous system, which includes altered sensory processing in the brain, disrupted descending pathways, and increased activity of pain facilitatory pathways.

• Central sensitisation is common in various chronic MSK pain disorders and involves psychosocial elements

• Pain in tendinopathy can vary depending on the affected area.

• It is important to inform patients that not all pain is harmful and that experiencing pain during rehabilitation is acceptable.

• Self-efficacy may improve if patients understand that their pain is unlikely to cause further tendon degeneration or lead to rupture.

• Reproducing pain through loading and resistance programs, while educating patients that the pain is not harmful, may help address fear-avoidance and catastrophising beliefs

Treatment education

• Despite a large amount of studies supporting loading programs, patient perception of these programs is generally poor.

• Simply prescribing exercise programs and emphasising adherence is not sufficient to increase self-efficacy and optimise outcomes.

• A significant issue with loading programs for tendinopathy is that over 50% of patients abandon them

• Patients need to understand how the program will benefit them, and barriers to adherence must be addressed.

• Patients should be informed that, despite tendinopathy often being referred to as an "overuse injury," self-prescribing rest will not lead to optimal outcomes.

Addressing misconceptions

• The Common-Sense Model of Self-Regulation is a theoretical framework that explains how patients respond to and manage health “threats”.

• When a “threat” is perceived, people develop emotional and cognitive responses that guide their actions.

• Clinicians can improve patient outcomes by educating and raising awareness of biopsychosocial factors, thereby shaping the patient’s perception of their condition.

• Addressing misconceptions is crucial in conditions where the patient's perception and self-efficacy often have a greater impact on clinical outcomes than structural damage

Top 3 resources to check out

And learn about pain

1. Helpful resource to send to patients - LINK

2. The Bio-psycho-social model explained - LINK

3. Chronic pain & sensitisiation (VIDEO) - LINK

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