Tiger’s Sacrum: A reflection on my experiences of applying a bio-psycho-social approach to typical clinical practice setting

Aidan Tighe is a physiotherapist working in a Primary Care setting in Ballina, Co. Mayo on the west coast of Ireland. He graduated from University College Dublin with a B.Sc. in Physiotherapy in 2000, and completed a M.Sc. in Sports Medicine in Trinity College Dublin in 2001. He has a particular clinical interest in dealing with chronic persistent pain, and is equally passionate about sports medicine and all things sports-related. Aidan is currently involved as a treating clinician in a randomised controlled trial with the Pain-Ed team.

The sports medicine story of the last month or so had to have been the controversy generated around Tiger Woods’ sacrum. While the mainstream media ran some pretty shocking reports it was great to see that the myth-busters (e.g. here and here) among healthcare professionals were out in force online. It’s brilliant that healthcare professionals are no longer letting these type of comments slide by unchecked – instead they are been exposed as myths using solid science. What I found very interesting about the whole affair were Tigers’ own words in that he in no way portrayed a man in fear of his body.  “My sacrum went out, it pinched the nerves and hence the spasms. Once the bone was put back in it was all good. The spasms went away and I started to get some range of movement. I’m not in any pain that is the good part.”  Certainly the comment “it was all good” shows the resolve of an incredible athlete. So while twitter reacted brilliantly to educate and dispel fears in the general public regarding popped sacrum’s, the man at the centre of it all didn’t appear fearful at all.  This lack of fear in the face of pain, this warrior type mindset made me reflect on all those athletes and weekend warriors I’ve treated over the years with a similar attitude and confidence in their body and how I’ve treated them.

I’m a musculoskeletal physiotherapist who likes to try following the evidence trail laid down by the researchers.  Over the past few years, as a result of attending numerous brilliant workshops with the Pain-Ed team, I’ve been trying to adopt a much more bio-psycho-social approach to my work.  Initially I was very unsure and really questioned the concept – I guess I’m a bit of a doubting Thomas, a bit cynical – either way the proof of any pudding is in the eating and the results brought about by changing my approach were very rewarding both for my clients and myself.

Initially I found the concept of the bio-psycho-social model fitting in well with the classic chronic pain patient who had been to numerous medical professionals, had multiple diagnoses and very negative back beliefs.  A patient group who had completely lost confidence in their bodies, who were worn out and fed up (sounds familiar I’m sure).  I found if you listened to their story and worked through their pain story within a bio-psycho-social framework you could really help them to flourish.

But what of the super confident, dare I say it “Tigeresque” clients, who have no obvious fear of their back, and are less severely disabled? The athletes who just wants to “get it sorted” or “pop it in and off we go”?  Too often I went with them. While of course I would try and explain that there was no such thing as a popped sacrum, I didn’t really challenge their thought process much.  Who knows what their take home message was but in hindsight I feel I probably did them a disservice.  I failed to really hear their story or to get to the root of their problem, partly because they displayed no obvious psychological vulnerability. I found it too easy to ignore the lifestyle and psycho-social aspects and fall back into the old biomedical model.  Perhaps on some level at this stage I was only paying lip service to the term bio-psycho-social and was failing to really get it. Perhaps I was talking the talk but not walking the walk. While I have a long way to go on the road to understanding the entity that is pain, I at least know now, that ALL pain is influenced by a range of bio-psycho-social factors. It’s not just a label for the highly anxious, fearful or depressed – it is a factual statement of how ALL human beings experience pain, including the seemingly super-confident sports population.

The reasons that the biomedical model may be slower to die out in the sports world are multiple but I believe include;

  1. Validation: The biomedical model gives immediate validation as to why an athlete can’t complete an event – pain due to tissue X being injured. Sometimes athletes wear injuries as a badge of honour and this fits well with their gladiatorial instincts.
  2. The lure of the quick fix: If the problem is simple, then it follows that the solution is too (e.g. sacrum popped out, therefore pop it back in). There is a huge placebo effect to many treatments, but especially ones which have an air of mystique to them. This allows many people with good confidence in their body to go a long way even if they have some tissue “damage”.
  3. Money: High-end sport is awash with money and technology. More scans and more investigations inevitably lead to more “issues in the tissues” being discovered. Whether any of this “pathology” is relevant or not is a whole other question, but the concept of pathology or tissue damage fits well with the biomedical model

Of course whatever the elite do, others mere mortals want to copy.  Therefore regular sports people, manual workers and weekend warriors will want the same scans and treatments that they see the elite getting. This reinforces the biomedical model as it cascades down the sporting ladder from elite sports to everyday life.

I believe by rolling with this simplistic model we are doing our sports clientele a disservice. In fact, the athlete can often be so used to their body responding in a positive way to exercise that they automatically, and might I add quite logically, assume that the answer will lie in working harder, training harder – “pushing the envelope” as they say. However, in doing so they can often compound the problem, and end up in an awful cycle of injury recurrence.

I have seen many sports people blow up while chasing “form”.  They are not playing well, they feel under pressure for their place on a team, and the whole situation might be getting on top of them a bit. They believe their body won’t let them down, so their answer is to train harder – burning the candle at both ends until…… surprise surprise something gives. The same can be said for countless farmers, manual workers, nurses and people in daily life. Initially they just want a “quick fix” and to “get back in the game”.  But, if this cycle recurs, even their initially strong body confidence may start to erode away.

So what do we do with these apparently confident, fearless people? Do we challenge them to step back and look at everything, to look at the big picture that is their life and see where their pain story fits in?  Are we intimidated by their confidence, unsure of what their reaction will be?  Are we frightened of what they will think of us – scared that they will think we are insinuating that it’s “all in their head” or imagined? (which of course it is not!)  Maybe in that situation it is just easier to go with the biomedical approach, the quick fix and off we go again until next time?

I would encourage all therapists to challenge these people to see their own big picture and really try to hear their full story.  Do this and you can often be surprised at what might be discovered.  I suppose what I’m trying to say is that, a big part of the learning curve for me in applying the bio-psycho-social model into everyday practice, has been the growing realisation that the approach comes into play with all our patients. It’s not a tool to be used exclusively for those particularly vulnerable people with poor confidence in their bodies or fearful beliefs about their structure – it is also for the super-strong athletes with confident belief in the powers of their bodies, and of course, it applies to everyone else in between.

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