The value of the biopsychosocial model in clinical physiotherapy

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Biopsychosocial model was formulated by an American Psychiatrist, George Engel in the year 1977.The biopsychosocial model is a general model accounted for biological, psychological, and sociological factors which are interconnected spectrums in an individual's body system. (Lakhan, 2006) According to Reynolds (2005, p.29), the biopsychosocial model acknowledges not only biological aspect, but also the psychological and social factors when diagnosing and treating a patient clinically. This model was introduced for the medical professionals to be more holistic understanding of patient's complex experiences of health and illness.

Application of the biopsychosocial model in reality was witnessed during the clinical placement. Mr. Y, a 56 year old man who was accompanied by his wife walked into the physiotherapy department with abnormal gait. The physiotherapist politely introduced herself and greeted Mr. Y and her wife. Based on the physician's report, Mr. Y had been diagnosed a ruptured anterior cruciate ligament (ACL) on his right knee. The physiotherapist then began by conducting both the subjective and objective examination. The aim of the subjective examination conducted on patient is to obtain sufficient information regarding the patient's symptoms so as to be able to design an efficient, effective and safe physical examination" (Petty, 2006, p.6).

During the examination, the physiotherapist modestly interviewed Mr. Y about his lifestyle for example working life and social activities. The patient's opinion, experience and expectations also added into consideration before the physiotherapist decide the treatment for the patient. All of this psychosocial factors may indicate either direct or indirect mechanical influences on the knee (Petty, 2006), as knee is more likely to be injured compared to other joint in the human body. All the information obtained from the examination enabled the physiotherapist to paint an accurate picture of the patient's situation, monitor the condition progress and develop a suitable treatment and management plan. (Great Lakes, no date) Evaluation of data from the musculoskeletal examination contributes to establish a diagnosis and prognosis, setting goals and outcomes, and developing and implementing a plan of care (O' Sullivan and Schmitz, 2007, p.159).

The patient interview session was conducted in a quiet room that offers a measure of patient's privacy in order to encourage and initiate the patient to share more about his condition. Mr. Y was asked about his feeling due to the anterior cruciate ligament (ACL) torn incurred by the accident during his football practice. The physiotherapist also enquired his perspectives and expectations on his hobbies in the future. Throughout the interview session, the physiotherapist practiced active listening, maintained adequate eye contact with the patient by facing each other with a comfortable spacing between them. The physiotherapist carefully guided the interview to keep it focus on pertinent information by using conversational language rather than medical terminology so that it matches the cognitive level of the patient and reflects respect for the patient's dignity and unique life circumstances. (O'Sullivan and Schmitz, 2007, p. 56) As Reynolds, F. (2005, p.9) states that medical professionals will be able to obtained accurate information for treatment plan through careful questioning and attentive listening to the patient.

The physiotherapist then explained the knee condition to Mr. Y and his wife. At the same time, the physiotherapist also educated Mr. Y and his wife by sharing adequate knowledge of etiology and precautions about the knee for him to prevent his knee condition to become worst. Before continue with the treatment session, the physiotherapist clearly explained the treatment which is helpful to Mr. Y's knee. The physiotherapist also explained both the benefit and outcome of each choice of the treatment available for Mr. Y. Professionals' role is to outline the expected outcomes of the patient's choice clearly, creatively and precisely as the patient has the autonomous right to accept or reject the care as they have great control over their own lives (O' Sullivan and Schmitz, 2007, p.72). The physiotherapist makes sure Mr. Y has understood the explanation and information given and agreed to receive the treatment before carried out the treatment.

The physiotherapist then positioned Mr. Y in an easeful way which facilitate for treatment process and gave him adequate pillows to his head and knee as physical support. Petty (2004, p.341) states that patient rested and relaxed comfortably during the treatment session is of paramount to gain their confidence in the physiotherapist. Mr. Y's knee and surrounded area was palpated to feel the presence of oedema and the temperature. In order to reduce the swelling and relieve pain, the physiotherapist then applied cold pack on Mr. Y's knee. This is to give an importance to the patient's comfort which is also beneficial in the result of treatment.

Petty (2006, p.345) also states that, the option and priority of the physical testing procedures are depend on the severity, irritability and the original condition of the complained area. To confirm the ligament insufficiency and damaged, the physiotherapist then performed the anterior drawer's test on Mr. Y's knee. The special test results give an idea to the physiotherapist on the stage of damaged on the anterior cruciate ligament (ACL) in certain extent. (Skill Builders, 2009)

The patient was afraid to move his right lower limb especially when he was asked to move his leg as required for the physiotherapist to measure the range of motion (ROM) during the physical examination session. At the same time, the physiotherapist also observed the quality of movement at the knee joint and also his facial expression. The physiotherapist then questioned his fear and found that he was anxious that his movement might be aggravates pain in the knee. The physiotherapist then taught Mr. Y some exercises to get rid of pain. Exercises are also useful to improve the range of motion and resume an almost normal knee joint function (Skill Builders, 2009). These exercises include both the equipment in the rehabilitation centre and home exercises. The physiotherapist taught and showed Mr. Y the correct way to use the stationary bike. Not only that, the physiotherapist also explained the effect and how effective the exercises help in his anterior cruciate ligament (ACL). This helps Mr. Y to empower himself and by doing the exercises, Mr. Y potentially facilitate his self efficacy and gain control over his own medical condition (Petty, 2004).

The physiotherapist always talked to Mr. Y and provided him some encouragement and support during his treatment session so that he will felt that the time passed easily. The physiotherapist motivated Mr. Y upon his success in strengthening his quadriceps muscles by praised and gave him positive feedback for instance, "Very good", "You can do it", "Try your best" to gain his confidence. Offering positive feedback can facilitate motivation which empowers the patient thus decrease the depression and initiate self control (O'Sullivan and Schmitz, 2007, p. 46).

Through the conversation between the physiotherapist and Mr. Y, the physiotherapist found that Mr. Y stays in the first floor of a double storey house and he usually need to climb up the staircase to rest in his master room. The physiotherapist then suggests few alternatives to Mr. Y and his wife as the therapist was worried that it might aggravate his recovering condition. The suggestion was also given to allow Mr. Y's to move easily and for convenience purpose. Health care professionals must perform in the manner of beneficience as soon as they are alert the patient is in a jeopardy of harm or loss and the main aim is to prevent patient from harm and loss (O' Sullivan and Schmitz, 2007, p.68).

Mr. Y was encouraged by the physiotherapist by involving his wife throughout the physiotherapy session. His wife has strong influence him by sent him to the rehabilitation thrice a week and provided him assistance to transfer him from the car to the wheel chair. Not only that, his wife sat beside him and waited him to finish his treatment each and every time. Mr. Y's wife also gave him moral support especially when he was impatient and felt annoyed to perform the exercises that will aggravate pain. Social support is classified as the availability of an individual in the surroundings who can provide support, encouragement, financial help and emotional support (O' Sullivan and Schmitz, 2007, p.52). Increased level of social support may promote healthy behaviours, for example, compliance to treatment and more adaptive coping method ( Widerstorm-Noga, Finnerup, Siddal, 2009, p.7 ).

According to World Health Organization (WHO, 2003), Health is defined as a state of absolute physical, mental and social well-being and not merely the absence of disease or illness. Therefore, the biopsychosocial model which focuses on biological, psychological and sociological aspects play a very important role in clinical practice. It is also relevant to fulfill the definition of health by WHO. The biopsychosocial model takes consideration of the empowerment of patient, thus create a good quality of life and strong relationship between the patient and the physiotherapist (Lakhan,2006). As a conclusion, the outcome of the biopsychosocial model is good and there are effective to improve the patient's health condition in clinical practice.