Fragility and back pain revisited
A letter to the editor of Physical Therapy & Rehabilitation
This is a pre-print of a letter to the editors of the American Physical Therapy & Rehabilitation journal that will go into print this week.
Those of you interested in the ongoing discussions around the future of physiotherapy, particularly that section of the profession concerned with treating back pain, may be interested.
Reference: Nicholls, D.A. (2024). Why This, Why Now? Author Response to Stilwell et al and Beneciuk et al. Physical Therapy & Rehabilitation Journal. https://doi.org/10.1093/ptj/pzae174
I am grateful to Stilwell et al1 and Beneciuk et al2 for their generous critical comments on my history essay titled “Fragility and Back Pain.”3 However, I believe their responses highlight some important problems raised by biobehavioral and enactive approaches to physical therapy.
I should make clear that I have no clinical skin in this game: I have no modality to promote or approach to defend. I am not a pain specialist, so I am happy to leave the efficacy of psychologically informed practice (PIP) and enactivism to others. Rather, my interest is in what these new emerging approaches can tell us about physical therapy’s professional evolution. The question that interests me is “why this, why now?”
To begin with, it seems unclear to me whether PIP and enactivism actually offer anything new to practice. Stilwell et al and Beneciuk et al also seem unclear on this point. On the one hand, both letters call back to the past suggesting that both enactivism and PIP retain strong biological roots and solid clinical foundations. The body has not been left behind, they say, and there is no need to “throw the baby out with the bathwater”²: “Physical therapy for back pain has always been both physical and psychological”¹ and “[P]atient behaviors have long been recognized as pertinent in the management of low back pain.”² But they also criticize those pathoanatomically-focused manual therapies that have traditionally dominated musculoskeletal physical therapy as using “overly simplistic,” “find-and-fix” approaches, ignorant of biobehaviorism. Our view has shifted from the “narrow biomedical or biomechanical model,” say Beneciuk et al.
To my mind, both sets of authors are correct to suggest there is little new in PiP and enactivism. After all, there has been a widespread understanding of patient empowerment and the psychology of pain for decades (see this text from 1976, for example):
‘There are certain aspects of pain control that the patient himself [sic] must implement: We are, in effect, saying to him, “It’s your move!” And, for his sake, we hope he makes it a good one, since his goal of achieving pain relief rests as much on what he does for himself as on what we can do for him. To that end, we ask that he understand some of the psychological impacts of pain and what it has done to his personality (and vice versa); and we ask too that he agree to change his habits, the way he reacts to pain, and the way he has encouraged, even demanded, that others react to him because of his pain. All of this involves coming to terms with his attitudes and emotions’4(p35).
And beyond pain psychology, human pain and suffering have been central to humanist philosophers, existentialists, and phenomenologists since Immanuel Kant published his Critique of Pure Reason in 1781. Writers such as Elaine Scarry, David Morris, and Arthur Frank wrote evocative accounts of the lived experience of chronic pain in the 1980s, and there has been a wealth of interpretive research into the subjective experience of chronic pain since the turn toward qualitative health care research in the 1990s.
So, if enactivism and PIP are not new things in themselves (new only to us), perhaps their rise to prominence can be explained because they “put into focus the whole person”¹ and “reject dualistic (physical vs psychological) sources of pain”?² On the surface this sounds plausible, but I would argue that it obscures more than it reveals. Where, for instance, does pain now reside? Once it was easy for physical therapists to locate pain: it was in the tissues, and all our theories, diagnostic tests, treatment modalities, and approaches to practice were tailored to this belief. We no longer like this kind of biological reductionism and want to look for pain elsewhere. But where? (If pain still resides within the brain and nervous system, as biobehaviorism implies, haven’t we simply replaced one bodily tissue with another?)
Tellingly, no one within the PIP, enactivist, CFT, or biobehavioural communities has yet been prepared to openly reject the biological basis of pain. And there have been no calls for physical therapists to truly embrace phenomenological and existential explanations. Neither have there been any calls for physical therapists to view pain as a function of social determinants such as gender, race, social class, access, stigma, and prejudice.
I suspect this is because Stilwell, Beneciuk, and colleagues cannot afford to reject the biological outright (as phenomenology and social constructivism would certainly do), because physical therapy is still too reliant on Western biomedicine for its funding, prestige, and evidential legitimacy. Enactivism and PIP are compromise positions at best, then, and so it is overgeneralizing to suggest—as Stilwell et al do—that they are now “filling the gaps” in the biopsychosocial model.
Contrary to the arguments put forward by Stilwell, Beneciuk, and colleagues, my sense is that enactivism and biobehaviorism have come to prominence in part because they speak to a culture of self-care, personal resilience, and well-being in the West that flourishes at a time when public health care and our sense of community and collective co-dependence has suffered sustained attacks.5 And for this reason alone, they are worthy of our interest.
Stilwell P, Harman K, Coninx S, On VD. Fragility and back pain: lessons from the Frontiers of biopsychosocial practiceNicholls DA. Phys Ther. 2023;103:pzad040. Https://doi.Org/10.1093/ptj/pzad040. Phys Ther. 2024;104(3):pzad170. https://doi.org/10.1 093/ptj/pzad170.
Beneciuk JM, George SZ, Simon CB, et al. On fragility and back pain: lessons from the Frontiers of biopsychosocial practiceNicholls DA. Phys Ther. 2023;103:pzad040. Https://doi.Org/10.1093/ptj/pzad040. Phys Ther. 2024;1(3):pzae002. https://doi.org/10.109 3/ptj/pzae002.
Nicholls DA. Fragility and back pain: lessons from the frontiers of biopsychosocial practice. Phys Ther. 2023;103(6):pzad040. https://doi.org/10.1093/ptj/pzad040.
Sealy NC. The Pain Game. Millbrae, California: Celestial Arts; 1976.
Nicholls DA. Physiotherapy Otherwise. Tuwhera Open Access Books; 2022. https://doi.org/10.24135/TOAB.8