An Example of How I Use the Biopsychosocial Model to Explain Pain

Recently I received the following comment on an old blog post of mine:


“I had an injury to my hamstring and sprained my SI ligaments. I had PRP done but over time due to compensation developed a rotated pelvis and a left on right sacral torsion. My L4 facet got stuck in extension for over a year. I left my PT and found a different one that unlocked it in less than a minute. Being stuck like that did serious damage to my body's ability to stay straight. My facet continues to get stuck. I also went to see another specialist and found my tailbone was completely out of place offsetting my center of gravity. I follow the PRI upper body pattern with a tonic right neck from being right handed and sitting at a computer all day, which does contribute to my gait issues however my lower body is somewhat different than the PRI model and my physical therapist tells me the same thing. My right hip is forward compared to when I stand on my left foot most of the time which is opposite the PRI philosophy. I make my back pain worse when I do the PRI exercises for the lower body. My enter body is a mess, twisting all the way up the spine. My L4/L5 is twisted causing issues at T4 and at my neck. Have you found anything to help you fix [a] rotated pelvis?”


I really appreciate it when people take the time to read some of my posts and to also share their personal experiences with pain, which isn’t always an easy thing to do because pain freaking sucks. I always try my best to respond and to answer as many questions as I can to add more of my perspective to the discussion in the hopes that people find it helpful. There were a lot of topics to unpack in what this individual shared, and I actually encounter many patients in my practice who share very similar testimonies and what I believe are erroneous thought processes behind why we experience pain. I wanted to share my response to the above in this blog post in the hopes that it may elucidate more viable mechanisms behind why we experience pain, which will hopefully help more people recover from and manage their chronic pain.


My response:

Thanks for sharing your experience about your pain. I hope you're experiencing improvement or receiving care that is helping with the issues you mentioned so you can go back to doing the things you love with as little pain as possible.

In regards to some of the issues you mentioned, such as the L4 facet being stuck in extension for over a year, your tailbone being out of place and your twisted L4/L5 disc causing thoracic spine and neck pain: These are very hard, "pathoanatomic" explanations for why someone is experiencing pain, and are characteristic of something called the "subluxation model" of pain which is being increasingly challenged as it fails to take into account many other important reasons why someone has pain (with pain neuroscience and psychosocial factors also being large components of someone's pain experience).

To explain in other words, our bodies don't experience pain because they get mechanically "stuck" in certain positions, and when we recover from injuries and pain it's not because those joints or body parts become physically un-stuck or moved back into place. There is very poor reliability when it comes to assessing things like the relative position of a sacrum or ilium (the bones that comprise the sacroiliac joint), and such a weak relationship serves as an insufficient model to explain why someone might be feeling pain there. This concept can be extrapolated to lumbar spine facet joints, tailbone positions and trunk rotation asymmetries. While anatomically, it's possible for there to be small, reduced motion in certain joints in the lumbar spine or surrounding our hips/pelvis, these joint mechanics don't necessarily need to be completely resolved nor restored to symmetry in order for someone to be free from pain.

There is no default, neutral, postural orientation of symmetry that our bodies need to be in in order to feel "normal", and pursuing this as a rehabilitative goal poses the risk of trapping an individual into thought patterns and false pain narratives that may ultimately be irrelevant to one's recovery, or even worse, make the pain increase. A nocebo is when there is a negative health response due to negative expectations or false beliefs about pain. Example: "I'm noticing that my pelvis is tipped forward more on the right than on the left, making this leg 0.75 cm longer than the other, which is jamming my facet joint on the right side which is spreading pain up into my mid-back and neck." This thought pattern in which a small, probably inconsequential biomechanic like a leg length discrepancy triggers a cascade of physical impairments that is unreliable and very poorly related to pain can lead the individual to actually literally feel more pain in all those regions.

There is no default, neutral, postural orientation of symmetry that our bodies need to be in in order to feel “normal”, and pursuing this as a rehabilitative goal poses the risk of trapping an individual into thought patterns and false pain narratives that may ultimately be irrelevant to one’s recovery, or even worse, make the pain increase.

SOME (again some, not all) physical therapists who use a PRI approach utilize this kind of thinking when applying their PRI-approaches and treatments to individuals experiencing chronic pain, and it's that kind of approach that I think requires more scrutiny and critical thinking. In the time that has passed since I wrote this blog post, my criticism has more to do with the explanation/thought-process/narratives that health care professionals employ, and not necessarily against PRI itself. There are individuals out there who use PRI-influenced concepts responsibly, taking into account that there are other biological, neurological and psychosocial mechanisms at play which all influence pain.

Rather than trying to un-twist a vertebral disc back into neutrality, or to get a pelvis on one side to face forward by one or two inches more, an approach that takes factors other than strict biomechanical rules into account (such as pain neuroscience and how the central nervous system processes pain) is to build up your body’s tolerance through load management, strengthening and graded exposure to motions and positions that are currently uncomfortable.

Rather than trying to un-twist a vertebral disc back into neutrality, or to get a pelvis on one side to face forward by one or two inches more, an approach that takes factors other than strict biomechanical rules into account (such as pain neuroscience and how the central nervous system processes pain) is to build up your body's tolerance through load management, strengthening and graded exposure to motions and positions that are currently uncomfortable. This may seem like the same thing but the distinction is very important. Our bodies are resilient and adaptive, and don't need to be in a particular orientation of symmetry to recover from pain. I'd be happy to discuss this more with you if you'd like as this is a lot of information to unpack and I don't want to just be another person who gives you conflicting information from what you've received and just complicates things further. Happy to send you some more information resources as well if you'd like, if so just email me at clintonleept@gmail.com. Thanks again for following this post/comment thread and I wish you the best!