Background

The biomedical understanding of chronic musculoskeletal pain endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. Although the biopsychosocial approach is an important advancement, it has a limited theoretical foundation. As such, it tends to be misinterpreted in manners that lead to artificial boundaries between the biological, psychological, and social, with fragmented and polarized clinical applications.

Objective

We present an ecological-enactive approach to complement the biopsychosocial model. In this approach, the disabling aspect of chronic pain is characterized as an embodied, embedded, and enactive process of experiencing a closed-off field of affordances (i.e., shutting down of action possibilities). Pain is considered as a multi-dimensional, multicausal, and dynamic process, not locatable in any of the biopsychosocial component domains. Based on a person-centered reasoning approach and a dispositional view of causation, we present tools to reason about complex clinical problems in face of uncertainty and the absence of ‘root causes’ for pain. Interventions to open up the field of affordances include building ability and confidence, encouraging movement variability, carefully controlling contextual factors, and changing perceptions through action according to each patient's self-identified goals. A clinical case illustrates how reasoning based on an ecological-enactive approach leads to an expanded, multi-pronged, affordance-based intervention.

Conclusions

The ecological-enactive perspective can provide an overarching conceptual and practical framework for clinical practice, guiding and constraining clinicians to choose, combine, and integrate tools that are consistent with each other and with a true biopsychosocial approach.

中文翻译：

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基于可供性的实践：慢性肌肉骨骼疼痛管理的生态激活方法

背景

对慢性肌肉骨骼疼痛的生物医学理解支持有害刺激与疼痛之间的线性关系，并且通常是二元论或还原论。尽管生物心理社会方法是一个重要的进步，但它的理论基础有限。因此，它往往会被误解，导致生物、心理和社会之间人为界限，临床应用支离破碎、两极分化。

客观的

我们提出了一种生态激活方法来补充生物心理社会模型。在这种方法中，慢性疼痛的失能方面被描述为体验封闭的可供性领域（即关闭行动可能性）的具体、嵌入和活跃的过程。疼痛被认为是一个多维度、多原因和动态的过程，不能定位于任何生物心理社会组成领域。基于以人为本的推理方法和因果关系的倾向性观点，我们提出了一些工具，可以在面临不确定性和缺乏疼痛“根本原因”的情况下推理复杂的临床问题。打开可供性领域的干预措施包括建立能力和信心、鼓励运动变化、仔细控制情境因素以及根据每个患者的自我确定目标通过行动改变看法。一个临床案例说明了基于生态激活方法的推理如何导致扩大的、多管齐下的、基于可供性的干预。

结论

生态激活视角可以为临床实践提供总体概念和实践框架，指导和约束临床医生选择、组合和整合彼此一致且与真正的生物心理社会方法一致的工具。