The biopsychosocial (BPS) model has been around for a long time and many physical and manual therapists are guided by it in their everyday clinic. Nevertheless, the model itself appears unattainable and abstract to many and a significant amount of clinicians are not yet familiar with it. There is a need to make it more accessible and understandable, and a need for more clarity on how to find information and how to implement it into everyday clinical practice.
There also appears to be different opinions surrounding what the BPS model should look like in practical reality and the applications may differ significantly between clinicians. Although a variety of interpretations can benefit the development of a treatment model the profession could also benefit from defining what we do, creating common ground and language between therapists.
Also, the prevalence of persistent pain is high and rising, and current knowledge and management within health care is considered to be poor in general. Physical and manual therapists are in a great position to make a positive impact on this problem, but it might require a significant joint effort to make a step towards better care for these patients.
The SERA framework is an effort to help these processes. It combines existing BPS model interpretations created by numerous scientists and clinicians, and the aim is to provide a combined educational framework based on the advantages of these different parts. By having a self-explanatory design and by thoroughly describing its own contents and purposes, the aim is to provide therapists with a suggestive knowledge base and helpful tools to implement BPS thinking into their practice.
SERA is first and foremost an idea or suggestion for education and should not be considered specific treatment advice. This text is meant to be an introduction to the SERA framework and not a comprehensive educational document.
Background
The core of the idea comes from the BPS model and influential therapists who have proposed we should be working as strategists, not mechanics (Sigurd Mikkelsen), as contextual architects (Cory Blickenstaff) (1) or as interactors instead of operators (Jason Silvernail, Diane Jacobs) (2). In essence it means that instead of only being the provider of passive interventions like manual therapy or electrical modalities, or just ushering the patient through predefined repetitions of exercises, we should be looking at the full person in front of us and take into account all the different aspects that are possibly affecting our patient’s health. The SERA framework is partly built on an interpretation of these therapists’ words and may/may not reflect their actual meanings or intentions.
SERA is also influenced by the great work behind Cognitive Functional Therapy (CFT) (3), and work done by pain scientists and clinicians like Luis Gifford, Gregory Lehman, Adriaan Louw, Jo Nijs, Lorimer Moseley and David Butler. It is also a product of social media discussions, ideas and descriptions of clinical decision making processes.
Above all it is the result of invested time and interest in the subject, clinical experience and from working daily with persistent pain patients.
The SERA components
The acronym SERA stands for Screening, Education, Reintegration, Autonomy. It stands open for critique and modulation today, and with emerging evidence. Implementation and application of these contents might vary but the idea of a framework is for the therapist to be guided by, and able to utilize, the knowledge when one sees it fit. At this moment it incorporates the following main elements:
Screening
Ruling out of physical or psychological pathology that would otherwise hinder an active, patient centred recovery.
- Diagnostic triage (yellow/red flags)
- Physical examination
- First visit intake psychosocial and prognostic screening (i.e. Örebro (4), Start back (5), or SERS’s own screening tool
- Further screening if indicated (i.e. for depression, catastrophization, kinesiophobia)
- Recognizing peripheral/central sensitization (6) within the nervous system, letting it guide treatment and rehabilitation choices
Results from the screening process:
– might indicate that the patient is in the wrong place, in need of other types of care
– might be used throughout the treatment process to guide some of, or all subsequent decisions (regarding education, reintegration and/or autonomy).
Education
“De-educate, then re-educate”, meaning that a reconceptualization is often needed, dismantling previously held erroneous or unhelpful beliefs before providing new information, as described by Louw et al (7). The goal is to decrease perceived threat from the painful situation to allow for pain reduction and reintegrating movement. This can be achieved through verbal explanation/discussion, the experience of new movements/behaviour, symptom modification strategies. An important part of the education process is also acknowledging and modifying patient expectations, to affect outcomes.
De-educate: address faulty/unnecessary and threat inducing beliefs surrounding the meaning of
- Imaging findings (X-ray, MRI)
- Body posture
- Structural anomalies like leg length discrepancies
- Movement “flaws” like scapular dyskinesia
- Core strength
- Subluxations and what to expect from manual therapy “adjustments”
- Muscular sore spots or “triggerpoints”
- Other
Re-educate: de-threaten the painful situation through providing
- Pain neuroscience education (8) or explain pain (9) which serves to reconceptualise the painful experience (for example the “pain as an alarm system”-analogy)
- Explanation models/metaphors (for example demonstrating a clenched fist as lower back muscle guarding)
- Experience/exposure-based learning, symptom modification, finding thoughtless and fearless movement
- Hurt/harm reconceptualization (for example focusing blame on tissue irritation due to tolerance/capacity issues, rather than tissue damage)
- Modify expectations for prognosis (for example with the Toblerone graph of recovery, courtesy of Luis Gifford) (10)
Overall the point of education is to reduce the perceived threat surrounding the ongoing or recurring pain through a deeper and more realistic understanding of the physical processes that may contribute to the subjective pain experience. This can remove obstacles and make it easier for:
Reintegration
Reintegration implies “bringing back elements that served the organism/patient well, before the pain occurred”. In some situations the patient might instead need new elements to integrate which will be unfamiliar for that individual.
- Recreate tissue tolerance and capacity through everyday physical activity and/or exercise, calming things down before building them up again (paraphrasing Gregory Lehman) (11)
- Reintegrating pain and fear free movement and behaviour, through exploration and symptom modification
- Recreate belief in functional capacity
- Recreate or build patient self-efficacy and resilience, creating treatment independency
- Return to social activities
- Improve psychological health (tackling depression, anxiety, if needed with help from psychologists)
- Improving sleep and stress management, daily planning
- Other
Autonomy
Overall the point of creating autonomy is to create a permanent solution if possible, to make the patient independent of the therapist and to strengthen patient self-efficacy. The goal should be to guide the patient to become the master of their situation.
- Long term functional health behaviours, for example through regular exercise, individualizing physical activities so it creates realistic, achievable movement habits
- Pain and fear free movement and behaviour, creating more permanent changes through integration into daily routines
- Long term functional psychosocial behaviour, through for example self-help relaxation, relationships
- Functional sleeping patterns or diurnal rhythms that are realistic long term
Suggestions for treatment and rehabilitation
- Exercise, building tolerance and capacity where needed. Cognition targeted exercise therapy, especially for persistent pain, as described by Nijs et al (12), or Booth et al (13). Time-contingent exercise as opposed to pain-contingent, to de-threaten the pain experience with movement
- Graded exposure to movement (10), “poking the bear” (11). Utilize the reintegrated belief in functional capacity to gradually get the patient moving again.
- The SERA framework can be used with or without manual therapy. The goal for manual therapists should be to utilize the positive effects of manual interventions, and minimize the risks of iatrogenic consequences through proper patient communication. Manual therapy should always be a part of a bigger picture, and basically never a standalone treatment
- Individualization of interventions to patient expectations and preferences. Patient preferences and expectations play a significant role for treatment results (14,15). Also, according to research it is doubtful that therapists can accurately identify (16,17,18) or correct most “dysfunctions” in the human body, and whether they are even relevant to the problem (19). In addition, the existence of non-specific treatment effects that are common between different treatments (20,21), combined with the knowledge that most manual therapy interventions have similar low to moderate effect sizes regardless of hugely different underlying explanations and/or proposed mechanisms (22), frees the therapist from many shackles of specificity and makes individualization of the intervention to the patient easier. This indicates a clear step-away from pure mechanistic reasoning and streamlined solutions
Who is SERA applicable to?
Providers: of musculoskeletal care (Physiotherapists, Osteopaths, Chiropractors, Naprapaths and similar) who are familiar with diagnostic triage, physical assessment and treatment.
Patients: The BPS model in general, and also the SERA framework, is meant for patients with any musculoskeletal pain, in any part of the time-spectrum, from the most acute to persistent conditions.
It is hard to see any type of musculoskeletal pain complaint that could not benefit, or could not fit, within this framework (except specific physical or psychological conditions which should be ruled out through the screening process). That does not mean that it is needed with every patient or complaint, but a framework is just that: something you utilize when you see it fit.
It could be argued that the necessity for such an approach becomes greater with patients with persistent pain as psychosocial factors dominate the picture to a larger extent, and many of the SERA elements comes from science on persistent pain, as well as the clinical experience that is behind the creation of it.
On the other hand, the broad lens utilized with the SERA framework should also be important with recurring pain/flare ups, or pain on a time-depended trajectory, as education and autonomy can be an important part of understanding and coping in these situations. Even acute or sub-acute conditions could benefit from de-threatening information, symptom modification or other parts of the SERA framework.
Also, considering the growing evidence surrounding iatrogenic consequences this framework should also inspire caregivers to create less treatment dependency or spread less unhelpful or outdated information.
Suggested knowledge base
- Pain neuroscience education, for example PNE or Explain Pain (8,9)
- Motivational Interviewing (MI), through books or online courses (23)
- The Graded Exposure concept, for example through Luis Giffords books “Aches and Pains” (10)
- Familiarity with exercise strategies for persistent pain patients, like cognition targeted exercise therapy, as described by Nijs (12), Booth (13).
- Familiarity of clinical biopsychosocial physical therapy assessment (24)
- Familiarity with using and interpreting screening forms like Örebro (4), Start Back (5)
- Updated knowledge related to unnecessary, threat inducing beliefs about the human body, and the power our words have on a patients’ beliefs and behaviours (scattered information)
- Knowledge about non-specific treatment effects and what to realistically expect from treatment techniques and modalities (scattered information)
- Cognitive Functional Therapy (3), a treatment framework with limited but growing and promising evidence when applied to low back pain. Today, CFT seems to be growing into a more encompassing treatment philosophy and has inspired, and share many elements with, the SERA framework
- A background in for example Cognitive Behavioural Therapy (CBT) or Acceptance and Commitment Therapy (ACT) is not necessary, although it should provide many tools for behaviour change which many patients could benefit from
Limitations
One important limitation to consider regarding this framework is: where does my responsibility/competence as a physical/manual therapist start, and where does it end? There is a good reason we have different professional specialities for different health problems, and the point is not to make physical therapists into psychologists. Nevertheless, education regarding pain mechanisms and fear-reducing strategies do show promising scientific results on reducing pain and increasing function, which I guess is the epitome of what is trying to be achieved in this profession. If some additional help can be given regarding sleep habits, encouraging social activities or promoting relaxation or stress management, I think musculoskeletal therapists might fill an important role without inappropriately trespassing the land of psychology. You might even call it “seeing and helping a PERSON”, not just a patient.
Another limitation is knowing where and how to obtain these clinical skills, and getting versed in using them. Many of the SERA elements will probably be available in musculoskeletal therapy educations in the future, and some are today. All of the information is currently available online in science journals and through different courses and books.
There is no current research on the clinical application of the SERA framework. A lot of research exists for several SERA components like PNE or motivational interviewing. There is a promising and growing amount of research for some of the included elements like CFT and cognition targeted exercise therapy.
SERA’s position on the relevance of biomechanics
Considering the current discussions around the relevance of Bio in the BPS model it should be made clear that SERA recognises that biomechanical issues do exist, just like the word “bio” in biopsychosocial suggests. The suggestion is that SERA therapists should seek to find most relevant aspects of the patients’ problems, take into account what is important for the recovery process, de-threaten where possible and normalize the problematic situation. That includes reintegrating biological tissue function, but also biomechanics where evidence (and in some cases clinical experience) supports advice, or an active change/intervention. The prevalence of biomechanical “flaws” in the general population, and the lack of evidence supporting the process of correcting these, should always be taken into consideration when looking at an individual.
In conclusion
In an effort to make the parts of the BPS model attainable and accessible to physical and manual therapists, the SERA seeks to describe and provide an educational framework, a suggestion on how to implement and utilize a modern take on BPS physical therapy treatments. As always, an important job in front of this profession is to work towards what is needed to consistently achieve better results with our patients, especially regarding persistent pain, and how to avoid creating iatrogenic consequences. Hopefully SERA idea can aid in these processes. A more detailed educational framework might follow, provided there is interest and a demand.
Framework created by
Tim Marcus Valentin Hustad, Naprapath and founder of the group “Apply Science – To Physical and Manual Therapy” on Facebook
Peter Viklund, Naprapath, postgraduate
References
1: Blickenstaff C. Therapist as contextual architect. J Man Manip Ther. 2011 Nov; 19(4): 238. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201654/
2: Jacobs D F, Silvernail J. Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. 2011 May; 19(2): 120–121.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172949/
3: Cognitive Functional Therapy publications
http://www.pain-ed.com/healthcare-professionals/cognitive-functional-therapy-publications/
4: Linton SJ, Nicholas M, McDonald S. Development of a short form of the Örebro Musculoskeletal Pain Screening Questionnaire. Spine (Phila Pa 1976). 2011 Oct 15;36(22):1891-5.
https://www.ncbi.nlm.nih.gov/pubmed/21192286
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https://www.ncbi.nlm.nih.gov/pubmed/28257616
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https://www.ncbi.nlm.nih.gov/pubmed/27351541
9: Moseley L, Butler D. Explain Pain Supercharged. Book
http://www.noigroup.com/en/Product/EPSB
10: Gifford L. Aches and Pains, book
https://giffordsachesandpains.com/book-sales/
11: Lehman G. Homepage
http://www.greglehman.ca/
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https://www.ncbi.nlm.nih.gov/pubmed/25090974
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https://www.ncbi.nlm.nih.gov/pubmed/28371175
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https://www.ncbi.nlm.nih.gov/pubmed/26742533
16: Mehta P, et al. Resident Accuracy of Musculoskeletal Palpation With Ultrasound Verification. J Ultrasound Med. 2017.
https://www.ncbi.nlm.nih.gov/m/pubmed/29280168/?i=46&from=musculoskeletal
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https://www.ncbi.nlm.nih.gov/pubmed/28098584
18: Michael Haneline, Robert Cooperstein, Morgan Young, Kristopher Birkeland. An annotated bibliography of spinal motion palpation reliability studies. J Can Chiropr Assoc. 2009 Mar; 53(1): 40–58.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2652630/
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https://www.ncbi.nlm.nih.gov/pubmed/25430861
20: Joel E Bialosky, Mark D Bishop, Steven Z George, Michael E Robinson. Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb; 19(1): 11–19.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172952/
21: Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic ‘common factors’ model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012 Jun;26(2):394-403
https://www.ncbi.nlm.nih.gov/pubmed/21913950
22: Christine Clar, Alexander Tsertsvadze, Rachel Court, Gillian Lewando Hundt, Aileen Clarke and Paul Sutcliffe. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies 2014
https://chiromt.biomedcentral.com/articles/10.1186/2045-709X-22-12
23: Motivational Interviewing learning module, free online
http://learning.bmj.com/learning/module-intro/.html?moduleId=10051582
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https://www.ncbi.nlm.nih.gov/pubmed/27351769
