Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management

Abstract

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.

Keywords: Affordance; Biopsychosocial; Chronic pain; Ecological; Enactive.

Fig. 1

Affordances are opportunities for action that are specific to an individual's capabilities (from Vaz et al., 2017, reproduced with permission).

Fig. 2

Moving from (a) the biopsychosocial Venn diagram, to (b) a schematic of a dynamic person (the inner circle represents the organism's internal dynamics) coupled (outer circle) to a changing environment (from Stilwell & Harman, 2019, reproduced with permission).

Fig. 3

Mind Map that brings together the results of the clinician's and patient's interactive reasoning, illuminating multiple causal loops among contributing factors. Asterisks indicate most easily changeable factors identified by therapist and patient; they are entry points to intervene in the loop. For simplicity, protective factors are not represented (please see them in the vector model in Fig. 4).

Fig. 4

Vector Model showing a set of potential causal influences that dispose toward or away from the generation of pain, summarizing the Mind Map and adding protective factors. The resultant vector conveys the concept of tendency instead of necessary and sufficient causes. The effect (pain and disability) is reached when a single or combination of dispositions exceeds a threshold as different causal powers may interrupt, counteract, or intervene. Asterisks indicate most easily changeable factors identified by therapist and patient.