








































EDITORIAL 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

Improving Care for Individuals in Pain Through a Biopsychosocial 
View 
John Kiesel, PT, DPT 
Indiana State University, Terre Haute, IN  
 

 
Key Phrases 
Biopsychosocial, psychosocial factors, persistent pain, 
patient-centered care 
 
Correspondence 
Dr. John Kiesel, Indiana State University, 567 Nth 5th Street, 
Terre Haute, IN 47809. 
E-mail: John.Kiesel@indstate.edu   
 
 
Full Citation 
Kiesel J. Improving care for individuals in pain through a 
biopsychosocial view. Clin Pract Athl Train. 2021;4(2): 1-5. 
https://doi.org/10.31622/2021/0004.2.1.     
 
 
EDITORIAL 

Everyone experiences pain to some degree 

during their life.  It is a universal part of the human 
experience.  Pain can be a critical protective 
mechanism, as it warns us to change behaviors and 
move away from danger.  It can serve to protect 
an injured tissue from further damage. Pain can 
also be the source of suffering, and in cases of 
persistent pain, it can become the disease itself in 
the absence of other tissue involvement. The 
burden of pain on society is well documented and 
involves a significant economic impact.1 The 
individual impacts of suffering and distress are 
unmistakable, and the effects of pain on the 
individual do not reside there alone. Interpersonal 
relationships are often strained and societal roles 
go unfulfilled. As healthcare providers, we have 
each personally seen the burden of pain 
shouldered by our patients and sometimes our 
friends, family, and co-workers. The individual 
and subjective, yet universal nature of pain are 
what make it particularly challenging to treat.    

It has been a decade since the Institute of 
Medicine released the report Relieving Pain in 
America: A Blueprint for Transforming Prevention,  

 

Care, Education, and Research.2 This report 
outlined the multiple challenges related to 
reducing the burden of pain in the United States.  
The challenges included rising rates of chronic 
pain, increased opioid use, and inadequate 
access to treatment for the most vulnerable 
patients.2 Despite upward trends in the 
prevalence of pain, healthcare providers 
identified ongoing gaps in their education 
regarding the treatment of pain and a lack of 
confidence in their ability to care for individuals 
with more complex pain conditions. Due to these 
findings, the report called for a cultural 
transformation in the way the public and clinicians 
view pain and its treatment. The transformation 
called for a more thorough understanding of pain 
in to improve the prevention, assessment, and 
treatment of pain.2 The public health burden of 
pain along with self-reports of inadequate 
preparedness by healthcare providers to treat 
pain motivated this recommendation.  

The Institute of Medicine’s report urged clinicians 
treating patients in pain to adopt a more 
complete view of the patient. This more complete 
view incorporates aspects of culture, beliefs, 
previous experiences, knowledge, expectations, 
and values.2 This perspective aligns with a 
biopsychosocial model of pain, and it integrates 
the traditional biomedical model with its tissue 
pathology focus into a much broader view of the 
patient that includes psychosocial factors.3 The 
biopsychosocial view emphasizes the role of 
psychological and social factors play combined 
with biological factors involved in the prevention, 
assessment, and treatment of pain. This is not a 
new perspective on how to be most effective at 
caring for people in pain, but it has been slow to 
be embraced into our biomedical culture.  Engel 

https://doi.org/10.31622/2021/0004.2.1


Improving Care for Individuals in Pain Through a Biopsychosocial View 

 

 
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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 4 – Issue 2 – September 2021 
 

made a case for the biomedical model being 
outdated and lacking validity in his 1960 paper 
stating, “[on outdated models,] a disease, then, 
has substantive qualities, and the patient can be 
cured if the diseased part is removed.  That this 
often proves to be the case, as attested to by the 
successes of surgery, is actually not evidence for 
the validity of such a point of view.”4 

Traditional training for healthcare professionals 
has focused on a biomedical view of pain that 
would support the idea that a tissue-based 
pathology is the cause of pain and disability. 
Prevention, assessment, and treatment of pain 
within this biomedical view center on identifying 
the pathological tissue and promoting healing of 
the involved tissue. Limitations of the biomedical 
view include a poor ability to explain persistent 
pain and a lack of congruency with recent 
evidence highlighting the importance of 
psychosocial factors in pain and disability.5 The 
biomedical view has been increasingly challenged 
as imaging has advanced and tends to find 
pathological tissues in the majority of people. 
Unhealthy tissues are present in people who have 
never had an injury or pain in the region of the 
findings. 

This biomedical view is at odds with more complex 
pain presentations and the majority of individuals 
with persistent pain. Patients with persistent pain 
often present with minimal tissue based pathology 
or have long since healed from a tissue pathology 
but continue to experience pain and disability. 
Much of the focus of the biopsychosocial view has 
been on applying it to patients with persistent 
pain. 6 While this is valid, it does ignore the reality 
that all chronic pain begins as acute pain. 
Psychosocial factors that play a role in the 
persistence of pain are often present in acute pain 
presentations. Adopting a view of acute pain that 
incorporates psychological and social factors 
along with tissue based factors is the way to 
accepting this view for chronic pain. Many 
prognostic indicators for the progression of acute 

to chronic pain are psychological and social in 
nature.7 After a whiplash injury, for example, 
perceived injustice and pain catastrophizing are 
predictive factors for poor recovery.8 Patient 
expectations of recovery after an injury also play 
an important role in prognosis. For individuals with 
acute injuries similar in nature, those with higher 
expectations of recovery are less likely to 
develop persistent pain.9 Pain-related fear of 
movement, a common maladaptive pain behavior 
after acute injury, was the single strongest 
contributing factor to disability in a group of 
patients with foot and ankle pathology.10 We 
should not ignore that tissue pathologies more 
severe in nature take longer to heal, but the extent 
of injury alone is a poor predictor of who will 
transition to persistent pain and ongoing functional 
loss.11,12 Only a more complete accounting of a 
patient’s culture, beliefs, previous experiences, 
knowledge, expectations, and values can begin to 
account for this transition from acute pain to 
persistent pain.   

So what does this biopsychosocial view of pain 
look like? It looks a lot like compassionate, patient-
centered care. It involves a skilled interview that 
moves beyond the state of the tissue to understand 
contributing factors to the pain experience.13 It 
involves a thorough physical examination that by 
itself can reduce pain and improve the patient’s 
psychological orientation to treatment.14 It also 
involves using standardized patient self-report 
questionnaires to help you get a more complete 
understanding of the multidimensional factors that 
contribute to your patient’s pain experience.15 It 
may involve referral or collaboration of an 
interprofessional or intraprofessional nature.  
Most of all it involves compassionate care and 
building a meaningful therapeutic alliance with 
your patient.16 These are within the skill set of 
many healthcare providers, but those of us in 
rehabilitation have some specific advantages. We 
see patients repeatedly over an episode of care, 
which allows us to build a working relationship 
while we consistently reevaluate the patient’s 



Improving Care for Individuals in Pain Through a Biopsychosocial View 

 

 
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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 4 – Issue 2 – September 2021 
 

status. We spend a significant amount of training 
on developing our physical examination skills, and 
we tend to have more time with our patients than 
our physician colleagues. 

The development of new imaging techniques, less-
invasive surgeries, and novel pharmaceuticals as 
ways to treat pain have not moved the needle on 
the burden of pain in society. In some cases, as is 
often true for advanced imaging, these tools have 
resulted in increased downstream costs and 
maladaptive pain beliefs that result in harm to 
patients.17 Advanced imaging and many novel 
interventions cling to the biomedical view and are 
lacking when it comes to addressing the 
psychosocial issues related to persistent pain. 
Effective treatment for persistent pain 
incorporates the biopsychosocial view through 
graded activity, addressing maladaptive 
behaviors, and educating patients with an 
emphasis on self-management and understanding 
the individual factors that influence their pain.18,19 
Embracing the biopsychosocial view is integral to 
enhancing the role athletic trainers and other 
healthcare providers play in reducing the burden 
of pain on society. I encourage you to take a 
moment and consider your view of pain. Reflect 
on what you are doing to incorporate 
psychological and social factors into how you 
prevent, assess, and treat pain. If we are going to 
be more effective in our role treating pain, it has 
to occur one person at a time through a view that 
incorporates psychosocial aspects into our patient 
management. It must involve a change in culture 
that is long overdue. 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 4 – Issue 2 – September 2021 
 

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18. Ogston JB, Crowell RD, Konowalchuk BK. 
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