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    Dear all,


    As the result of a recent list server discussion I have been given some useful references on the biopsychosocial model and the uses and limitations of psychosocial hazard measures. These included Wadell’s book "The Back Pain Revolution", an HSE report ("A critical review of psychosocial hazard measures"), Peter White’s book "Biopsychosocial Medicine" and a recent review article by Weiner.


    According to Waddell (1998) the area where the assessment of psychosocial factors appears to be most useful is in the rehab field for the prediction of chronic disability; a success of 84% has been claimed for some questionnaires i.e. they are twice as accurate as standard medical assessments as these are typically only 42% accurate (ibid, p 115). The bottom line that patients who have work-related back pain (or believe they have) and remain off work for 2 weeks or more is at risk of chronic pain and disability (ibid, p 116).

    The HSE published a critical review of psychosocial hazard measures in 2001 (HSE, 2001). This review found that there had been a general lack of replicated studies examining the psychometric properties of the measures used for assessing psychosocial factors (see section 6.2, "What evidence was available?", page 76). Moreover, many of the studies on this subject were found to be of limited value because of inconsistent reporting. The reasons for this typically were;

    • information about the reliability of scales was not included
    • information about correlations between scales was not included
    • information about the survey response rates was not included
    • the measures were used inconsistently (especially for demand and control)

    The review made the striking finding that the tools most commonly used in the field (such as self-report questionnaires) were tools that were actually designed for research work (see section 6.3, "What measures are available?’, page 77). The authors found that there was almost no evidence for the reliability of measures for assessing psychosocial factors (except for internal consistency). In particular evidence was lacking for their test-retest reliability, their test-retest sensitivity and inter-rater reliability (see section 6.4, "Evidence for reliability", p 7).


    One of the most significant findings was that there is very little evidence that psychosocial hazard measures have any predictive validity (ibid, page 80). This report also questioned the

    utility of psychosocial hazard measures because though they can be administered by anyone without any special training, it is difficult to interpret them for risk control because "it is very difficult to know what a score on any of these measures actually means and therefore what could and should be done in response to it" (see section 6.6, "The utility of hazard measures", page 81).

    Peter White’s book "Biopsychosocial Medicine" (2005) contains a chapter titled "The

    Biopsychosocial Approach: A Note of Caution" by George Davey Smith that is

    highly relevant to our discussion. Smith points out that; "When interventional studies have been used to examine the efficacy of a psychosocial approach the results have been disappointing." Smith goes on to say that the evidence that psychosocial factors have an

    aetiological effect is "not good".


    A recent review article (Weiner B, 2008) expressed concerns about the biopsychosocial model’s tendency to over-emphasise psychosocial factors when underlying pathology is not clearly defined, its usefulness for explanatory and predictive purposes, its effect on outcomes and its contribution to the "medicalization" of patients with back pain.


    In future we might not need to rely on theoretical pain models quite so blindly as we have to do now. Recent advances in the imaging of the brain might soon revolutionize the diagnosis of chronic pain. Brain scans show that chronic pain "engages brain regions critical for ognitive/emotional assessments" implying that "this component of pain may be a distinctive feature between chronic and acute pain" (Apkarian et al, 2005).


    Unfortunately it seems that the brain damage due to chronic pain is permanent. Some of the most recent research indicates that pain should now be considered "an altered brain state in which there may be altered functional connections or systems and a state that has components of degenerative aspects of the CNS" (Borsook et al, 2007). All the more reason why we should prevent it before it gets to that sorry pass!




    David McFarlane MAppSc (Ergonomics)

    Ergonomist, WorkCover NSW




    1. G Waddell, (1998), "The Back Pain Revolution", [Churchill Livingstone, Edinburgh]. 


    2. HSE, (2001), Contract Report RR356/2001; "A critical review of psychosocial hazard measures", [HSE, UK].


    3. P White, (2005), "Biopsychosocial Medicine: An Integrated Approach

    to Understanding Illness", [Oxford University Press, Oxford], ISBN


    See "The biopsychosocial approach: a note of caution"; a note of caution



    4. Weiner B, (2008), "Spine update: the biopsychosocial model and spine care.

    Spine", 2008 Jan 15,33, (2), pp 219-23. The abstract is at http://www.ncbi.nlm.nih.gov/pubmed/18197110?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


    5. Apkarian A, Bushnell M, Treede R, Zubieta J, (2005), "Human brain mechanisms of pain perception and regulation in health and disease", Eur J Pain, 2005 Aug, 9, (4), pp 463-84.

    http://linkinghub.elsevier.com/retrieve/pii/S1090-3801(04)00148-X  See also;
    "These machines feel your pain"



    6. Borsook D, Moulton E, Schmidt K, Becerra L, (2007), "Neuroimaging revolutionizes therapeutic approaches to chronic pain", Mol Pain, 2007 Sep 11, 3, 25.

    http://www.molecularpain.com/content/3/1/25   See also;

    "Neuroimaging revolutionizes therapeutic approaches to chronic pain"



    [private user]


    As usual its nice for me to read your notes.   I am interested in pain, and pain perception also.  Are you familiar with the work of Bruce Mcewan from Rockefeller University? He is interested in spinal cord relays.  He has several articles and a book on pain.
    Professor Bruce McEwen of Rockefeller University in New York City, an expert on the topic, has written a book called The End of Stress As We Know It.
    See what you think.

    Best wishes,
    bev burkeBeverly Burke RN CMA CIE



    Your note is most useful. I am trying to access your second reference – the HSE report – but get a message that the site isn’t there. Would you have the correct link?
    Krishna Menon




    Thanks for your feedback. I don’t have any other link but luckily I saved a copy; please contact me directly.

    The only really good example of a successful application of the biopsychosocial model out there seems to be "Lipid lowering through work stress reductionLipid lowering through work stress reduction" (Orth-Gomer et al, 1994) but its control measure strikes me as likely to be inpractical in the real world as the stressed workers were transferred out of the stressful jobs. 

    I would be interested in your comments on these. See Lipid lowering through work stress reduction.

    Regards,David McFarlaneErgonomist, WorkCover NSW

    MAppSc (Ergonomics)


    K. Orth-Gomer, I. Eriksson, V. Moser, T. Theorell and P. Fredlund, (1994), "Lipid lowering through work stress reduction", Int J Behav Med, 1, (3), pp 204-14.


    Any recommendation concerning the use or representation of a particular brand of product in this document or any mention of them whatsoever (whether this appears in the text, illustrations, photographs or in any other form) is not to be taken to imply that WorkCover NSW approves or endorses the product or the brand.




    Try this one;


    MAppSc (Ergonomics)

    Regards,David McFarlaneErgonomist, WorkCover NSW


    Any recommendation concerning the use or representation of a particular brand of product in this document or any mention of them whatsoever (whether this appears in the text, illustrations, photographs or in any other form) is not to be taken to imply that WorkCover NSW approves or endorses the product or the brand.

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