Content List
1. Introduction

There is a global recognition for the need to transition from a biomedical model to a biopsychosocial (BPS) model of clinical practice that is relevant to rehabilitation and to treatment of pain and movement problems. Specific to pain, numerous national and international organizations including the International Association of Study of Pain (IASP), the World Health Organization (WHO), the International Olympic Committee (IOC), and the United States Department of Defense Veterans Affairs have made clear in their mission statements that there is a need for unified language regarding the basic understanding of pain mechanisms and the integration of BPS approaches in healthcare for the treatment of pain.1-3

The current biomedical model and the educational frameworks which support all major professional healthcare education systems have major knowledge deficits in the mechanisms and models of pain treatment, particularly the application of the BPS model of health to pain.4-6

Beyond pain, rehabilitation professions ranging from physical therapists, occupational therapists, athletic trainers, chiropractors, psychologists, physicians, to every level of the care team, lack a coherent comprehensive clinical framework that is transdisciplinary in nature. Across the domains of orthopedics, sports medicine, neurology, oncology, pediatrics, geriatrics, cardiopulmonary, integumentary, and their numerous subdomains, no frameworks exist that are shared across disciplines or domains.

Despite recognizing these gaps in knowledge, acceptance, and integration of BPS-based models for clinical practice is virtually non-existent in both private practices and hospital-based systems.7,8 Multiple healthcare disciplines have failed to transition due to concerns of limited incentives for adoption of the BPS model with current reimbursement models, the impact of the BPS model on workload, and inadequate resource availability for developing competence in BPS care.

Due to the poor acceptance of BPS-based models, healthcare consumers and medical providers have limited options and knowledge related to finding providers who utilize the BPS model.

The BPS model is now over 40 years old and multiple concerns and considerations regarding its application have arisen during that time. Bolten & Gillett best summarized some fundamental concerns associated with the BPS model in a recent review.9

“Engel’s biopsychosocial model has long been criticized for having various kinds of limitations, along with suggestions for improvements. Increasingly, however, there have been more radical criticisms. Such radical criticisms are of two main types: first, that the model lacks specific content, is too general and vague; and second, that it lacks scientific validity and philosophical coherence. Given the popularity of the biopsychosocial model and its presumed status as an overarching framework for medicine and healthcare, such radical criticisms signal significant underlying theory problems.”

The Human Rehabilitation Framework (HRF) was specifically developed with an acute awareness of the difficulties presented by the BPS model in both its understanding and application. The HRF development process began by first addressing the challenges of philosophical coherence that arises in understanding and applying the BPS model. A lack of coherence arises when there is a lack of consistent adherence to a defined philosophy of science built on a clearly defined worldview and its truth criterion assumptions.

In developing the HRF, a pragmatic scientific philosophy of functional contextualism was chosen and committed to. Functional contextualism defines its truth criterion as “successful working.” This truth criterion was derived from the contextualism worldview defined in Stephen C. Pepper’s book, World Hypotheses: A Study in Evidence.10 This book presents the argument that humans possess limited ways of “cognitizing” despite the appearance of countless numbers of “schools of thought” traditionally presented in the eclectic tradition of philosophy. In his book, he discusses 7-8 (depending on how you read it) ways of seeing the world, but of these, there are only four relatively adequate philosophical theories or ways of creating world hypotheses that are unlimited in scope. These world hypotheses are derived from “root metaphors,” which are common sense, yet fundamental ways of perceiving the world.

Figure 1: Scheme of adequate world hypotheses built on relative theories as defined by Stephn C. Pepper10

What is particularly helpful about Pepper’s root metaphor theory is that he removes much of the incoherent eclecticism of the tradition of philosophy arguing over ontological and epistemological debates and provides a practical way of looking at philosophy, which is particularly helpful for developing scientific philosophies. To be concise, we have presented a limited synopsis of the four worldviews suggested by Pepper. The root metaphor of contextualism was selected due to its capacity to work with known corroboration and flexibility with unknowns, to a philosophy that supports an HRF theme of developing “confident ambiguity” in clinical practice. In contrast to the two other most commonly represented world hypotheses of mechanism and organicism in application of the BPS model. Mechanism is dependent on high levels of certainty and precision, with truth specifically associated with “specific parts working together to yield specific outcomes.” Mechanism is highly prone to certainty derived combinatorial explosion. Organicism effectively sees truth as everything having meaning in the whole and everything is a part of the whole. Meaning is implied, therefore there is a risk for teleological error. The fourth relatively adequate world hypothesis, formism, focuses on truth in naming. It is the root scientific philosophical lens that led to the development of ICD and DSM diagnoses. These diagnoses are a particular area of problem in the BPS model.

Human pathologic conditions frequently encapsulate multiple concurrent ICD and DSM diagnoses for a single individual.

“…a hypothetical 79-year-old woman with osteoporosis, osteoarthritis, type 2 diabetes, hypertension, and chronic obstructive pulmonary disease should take as many as 19 doses of medication per day. Adherence to five separate sets of clinical practice guidelines for the woman’s five diseases could result in adverse interactions between her medications, or a medication for one disease could exacerbate the symptoms of another. Such guidelines might also make conflicting recommendations for the woman’s care. If she had peripheral neuropathy, guidelines for osteoporosis would recommend that she perform weight-bearing exercise, while guidelines for diabetes would recommend that she avoid such exercise.11 These situations create uncertainty for clinicians and patients as to the best course of action to pursue as they attempt to manage the treatments for multiple conditions.”12

ICD and DSM diagnoses yield interventions based on protocols for syndromes. This is a flawed approach to diagnosis and intervention because no two individuals will respond to a set protocol similarly. Multiple factors that make an individual unique must be excluded in the assumptions of a protocol intervention.

“The complexity of the U.S. healthcare system means that patients and clinicians have more information to consider and more decisions to make than ever before. Often, these decisions are neither easy nor straightforward, and they include varying options, trade-offs, benefits, and risks. Further complicating matters, patients often lack the information they need to make decisions. Fewer than half of patients receive clear information on the benefits and trade-offs of the treatments for their condition”13-15

“As clinicians’ endeavor to provide the best and most appropriate care for their patients, they also struggle with the cognitive complexities inherent in making care decisions.”16

To address this as well as many other shortcomings of the protocols for a syndromes approach, a process-based approach to diagnosis and provide interventions will be proposed which serves as the clinical foundation for the HRF.

As we attempt to address the shortcomings of the BPS model, three criteria of key qualities arise: scope, precision, and depth. Beginning with scope, a new BPS framework for rehabilitation must apply to a large range of phenomena, in fact, it would need to be universalistic in nature to cover the scope of domains of orthopedics, neurology, pediatrics, geriatrics, and beyond. A functional contextualism philosophy of science ensures a near infinite scope for the application of the BPS model.

Regarding precision, we are most interested in personalized rehabilitation. If we are to be person-first in a BPS model we cannot be so broad as to fall to general heuristics and loose metaphors, nor can we achieve a reductionistic precision without falling into combinatorial explosion. Furthermore, we run into precision challenges attempting to obtain group to individual generalizability by way of ergodic theorem.17

Finally, it’s important to address the concerns regarding a lack of specific content associated with the BPS model. We propose that existing content can be adapted through adopting a critical lens of scientific depth. Depth is the consistency and coherence that must be maintained between well-established scientific findings at different levels of analysis across multiple domains (IE: physiology, psychology, sociology, etc.). To maintain scientific depth across content, an evolutionary perspective has been selected. To quote Theodosius Dobzhansky, “nothing in biology makes sense except in the light of evolution.”18 We further expand on this with Niko Tinbergenny’s proposal that biologic behavior must be able to answer 4 central questions:19

  • What is the history (phylogeny) of the behavior?
  • What are the developmental explanations (ontogeny) of the behavior?
  • What is the function (adaptive value) of the behavior?
  • What is the mechanism(s) (causation) underlying the behavior?


Figure 2: Diagram of Tinbergen’s four questions, divided by object of study and level of questionSource: Bio 342 2012 website

While developing the HRF, several questions arose regarding whether the ICF already accounts for what the HRF looks to achieve. The simple answer to this question is they serve two completely different functions. The HRF is a universal rehabilitation framework for problem framing, clinical decision making, and clinical intervention. The HRF was not developed to be exclusive to pain but is able to expand throughout all rehabilitation as it provides practical strategies for all domains and specialties that reside in healthcare. The ICF is a measurement system used to standardize classification of function and disability with the intention of standardizing language between disciplines and professions and to be complementary to the ICD. The ICF does not provide any resources for problem framing, clinical decision making, or intervention. There are benefits to the ICF in terms of standardizing research terminology and the HRF. Future resources toward this end will be provided on this site in the future. Until then, more information about the ICF can be found through the World Health Organization.

Evidence-based practice (EBP) classically follows Gordon Paul’s famous statement of “What treatment, by whom, is most effective for this individual with that specific problem under which set of circumstances, and how does that come about?”21 Even the order to the questioning seems to have led to this explosion and predominance of protocol-based approaches that focus on quickly getting to the “treatment” process without adequately framing the problem in advance. The illusion of good clinical decision making via “differential diagnoses” and misinterpretation of Occam’s Razor led to generalized heuristics and algorithmic thinking generating a large volume of the diagnoses that ultimately became the International Classification of Disease (ICD). Effectively clinicians were taught to race to a diagnosis to initiate a protocol. Described in a different way “protocols-for-syndromes” served as precursor for the formistic diagnosis that must be swiftly found so that the clinician can rush to mechanistically “fix” the problem before the person’s meaning and role in the whole is altered in an organicism way. This approach to problem framing breeds eclecticism, and the Engels introduction of the BPS model has only complimented it.

What Paul’s statement also alludes to are the problems of certainty. It is an attempt to develop an algorithm, which is a mathematical effort to obtain certainty. The problem is, to be certain, how much of the problem do you have to scan? ALL OF IT!

Figure 3: Pie graph representing the knowledge needed required to frame the entirety of a problem.      

This is an impossible task. In the attempt to develop algorithmic approaches to problem solving, we immediately are presented with a problem of combinatorial explosion.22 To quote John Vervaeke, it becomes “cognitive suicide”.23 In clinical practice, we cannot be a machine looking for certainty. Our deductive logic is built on certainty as it is algorithmic, and this is unachievable as we cannot be comprehensively logical for countless reasons.

This problem is particularly obvious when it comes to the concept of attempting to determine a specific diagnosis related to even a “simple” pain problem. The differential diagnosis process reveals immediate combinatorial explosion even when the problem is examined purely from a biophysiological perspective as shown in the example below of attempting to differentially diagnose between two commonly used shoulder pain diagnoses:

Figure 4: Depiction of simple algorithmic reasoning to determine the mechanistic cause of shoulder pain.

In order to effectively frame a problem while minimizing combinatorial explosion, we must find a way to shrink the problem space that we are searching for important clinical information.

Figure 5: Pie graph representing the knowledge required to frame a smaller portion of a problem.      

Early attempts at utilizing algorithms in clinical problem framing in the form of Clinical Prediction Rules (CPRs) have consistently failed to demonstrate clinical value.24-26 While many proposals for problem framing are still built on algorithms despite this reality, some theorists in rehabilitation have recognized the limitations of problem framing with algorithms and pivoted to general heuristics. These include Clinical Practice Guidelines (CPGs) which also have failed to make any meaningful impact on clinical decision making or outcomes.27 Beyond these more formal attempts at general heuristics. Other attempts have included Mechanical Diagnosis Therapy (MDT), manual therapy’s “Find it and fix it” approaches, reducing complex problems to “stability” and “instability” causes, and even the best broad efforts such as the axiom “calm things down and build things up” are profoundly limited in how they can apply to human problems.

Fundamentally, the problem with heuristics is you can do all these things and still not achieve your goal. Heuristics help because they limit the problem space you need to examine, but it forces you to prejudge what you are going to select as relevant. It is where we get the term “prejudice” from, or better known as, “bias.” These biases can be helpful and even “adaptive,” but they predispose us to deceiving ourselves and our patients.

This brings us to discussing intended effects, side effects, and adverse events. While these terms are very commonly discussed in the pharmacological domain of medicine, it is nearly ignored in rehabilitation. Side effects are often confused with adverse events, as side effects can be therapeutic, and in a Process Based Approach (PBA), this includes transdiagnostic therapeutic effects that may be beneficial to any given problem. Adverse events are as the name implies, harmful, and occur acutely and chronically when associated with rehabilitation. While acute adverse events such as pneumothorax caused by the incidental event of dry needling the thorax is simple to understand, the iatrogenic effects of rehabilitation education resulting in nocebo is more nuanced. Some adverse events will always be unavoidable, but our intention is to reduce the number and severity of these occurrences.

To act without clarification of the nuances increases the risk of adverse events and the number or severity of side effects. There are always going to be side effects for every action we take, and every intervention utilized. If healthcare is supposed to be bound by the Hippocratic oath of “Do no harm,” then we must start there. By adopting a PBA for the HRF, we can assume some level of precision (personalized) specific effects in addition to a larger scope of transdiagnostic therapeutic side effects. Both this precision and scope are inseparable for depth, which is an attempt to reduce the number and the severity of adverse events. In addition, continuous curiosity that must be maintained in a PBA increases the likelihood of identifying the development of adverse side effects.

Returning to the EBP discussion, PBA asked the core question of EBP in a different way: “What core BPS processes should be targeted with this client given the goal in this situation and how can they most efficiently and effectively be changed?”28,29

With this in mind, we want to introduce PBA as a relatively new way of framing the problem space. Processes of change allow for effectively, dynamic, flexible, porous containers of multiple domains and levels of mechanisms that account for history and context, and have good scientific depth, as a way to flexibility manage combinatorial explosion in a clearly defined space. They allow you, or rather, force you to slow down and frame the problem in recognizing that some “thing(s)” is sustaining/maintaining the problem. In a PBA, these are assumed to be processes of change that are maintaining the problem in some dynamic contextually relevant manner, and that is how it operates now based on its history.

Once we frame the problem, we must commit to some measure of change occurring that is relevant to the problem. After defining the measure and the problem, then, and only then, can we work with it. This is where an intervention is selected. Selecting an intervention has a high degree of flexibility and openness, as nearly anything can be used to shift a well-defined PBA problem frame. However, it would be wise to select an intervention that most precisely fits to the specific areas of a problem frame network by way of the client and the contextual relevance. Once the intervention is chosen and used, we must measure whether change has occurred. Since the client was involved in the measure, they also must agree that change has occurred. Only then can we confirm whether the most relevant processes were selected, and the most adequate intervention was chosen to yield measurable successful progress.

In addition to core philosophical and content problems that have arisen, there are a multitude of practical scalability considerations that must be addressed. Specifically, many early attempts at stand-alone intensive multidisciplinary programs had difficulty with implementation and efficacy.30 Many of these stand-alone centers and programs have several logistic, financial, and implementation challenges. While there has been some evidence of benefit from multidisciplinary pain programs, the current healthcare climate (organizational factors, reimbursement, etc.) and the likelihood of scaling centers to meet the needs of this pain epidemic are small. Some of these shortcomings can be addressed by targeting alternative, more scalable, options to traditional standalone multidisciplinary approaches. This could include a transdisciplinary training model.31 Utilizing a transdisciplinary, and perhaps more broadly, a universalism perspective, allows for individual providers to receive cross training with key aspects of pain treatment provided by other disciplines. This would permit clinics with fewer internal disciplines to work within their network and community to allow for the flexible integration of other disciplines on an as needed basis to meet the practical, clinical, and patient needs. However, this only partially addresses the organization’s cultural and reimbursement problems previously identified. The HRF proposes potential solutions for these and other problems, but some of these will not be available in the initial white papers and publications.

“Unfortunately, these problems are not the fault of an isolated professional domain; the self-perpetuating instrumentalism of the health care system is just one example of the ways in which late modern expert systems target problems that have been defined in their terms, with little time for anything else.32 If, however, efforts to alleviate suffering remain merely instrumental they may cause unnecessary suffering, because human beings do not merely need maintenance or repair: they need to be recognized as human beings.”33

“We need approaches that make it possible to appreciate technology, professional cultures, and organizational systems as means to ends; they are not meaningful in themselves but only insofar as they serve the needs of finite—vulnerable, creative, and unique—human beings.”33

The future of research in rehabilitation and other biomedical science is likely to see a significant shift to idionomic methodology. This section will be fully developed in subsequent revisions, until then, we reference the work of Mangalam and Kelty-Stephen:34

“Growing awareness among the scientific community about lapses of reproducibility in biomedical sciences, including psychological sciences and neurosciences have inspired recent developments like the Nature series entitled “Challenges in irreproducible research,” the Reproducibility Initiative, a global project intended to identify and reward reproducible research,35 and increased transparency and data sharing practices. Although we applaud these efforts, the focus has mostly been on the fallacies of P-values, small sample size, inaccurate estimation graphics, and reporting biases. A fundamental problem pervasively linked to the lack of reproducibility in human subjects’ research—inherent in standard analytical techniques—that remains to be considered is nonergodicity, the paucity of group-to-individual generalizability. Crucially, despite the expectation that group treatments will inform individual-level interventions or outcomes, human-subjects research may take ergodicity for granted when it should not.”

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2. Overview

The HRF is a BPS process-based framework for helping clinicians work with individuals struggling with movement and pain problems. It is designed to assist movement and physical rehabilitation professionals to engage in evidence-based psychologically informed practice and to fully embrace the BPS model. Not only is the HRF practical for physical rehabilitation specialists but has the capabilities to completely revolutionize rehabilitation as whole. Its practicality can be applied throughout all domains and specialties of rehabilitation and allows for a coherent unified approach to be implemented across multiple dimensions.

It incorporates both identification and engagement of empirically researched processes associated with psychosocial flexibility, as well as a prognostic ladder based on relative psychological flexibility for developing clinical decision-making skills. This prognostic ladder is designed to be expanded to other BPS flexibility processes with future advances in research on these processes. The HRF draws on the practicality and ease of adoption offered by the six psychological flexibility processes developed for Acceptance and Commitment Therapy (ACT) and combines these with three rehabilitation specific BPS processes to comprehensively address the needs of movement and pain in physical rehabilitation. Central to the HRF is the importance that the processes and principles must first be applied by the clinician to themselves and their own problems in an ongoing manner before they can support their clients in applying them to their problems. The HRF is an ongoing work in progress that has the flexibility to adapt over the course of its development as new evidence becomes available.

More specifically, the HRF integrates the psychological flexibility processes developed for ACT, built on Relational Frame Theory (RFT), with three additional BPS processes. This develops functional analysis, skill education and development, and a prognostic ladder for advancing clinical practice.

  • There are six categories of BPS processes which make up the HRF:
    • Attentional Processes
    • Cognitive/Emotional Processes
    • Social Processes
    • Motor Behavior Processes
    • Loading Capacity Processes
    • Behavioral Processes
  • Under these categories are nine specific, process-based skills used for clinical interventions; each skill is delivered with the support of a prognostic ladder.

Figure 6: Categories of BPS Processes. 6 Categories of BPS processes with subsequent process skills.

Change processes were selected based on their ability to possess high precision, scope, and depth.

  • Depth is a core component in maintaining coherence across the HRF. Any level of analysis cannot conflict with well-established findings of another domain of science including but not limited to physiology, genetics, social/cultural factors, etc. Any clinical theories cannot conflict with well-established basic empirically studied sciences.
  • Specifically, clinical theories cannot conflict with evolutionary science.36

The HRF was created to address the gap in the working framework for training rehabilitation professionals to engage in the BPS model. To minimize the redevelopment of research that is readily available, a significant effort was made to draw on available models, theories, and processes to build the HRF. The majority of research was performed relative to pain science, motor behavior, tissue capacity, RFT, ACT, psychological flexibility, cognitive network psychology, and process-based therapy. These have all been instrumental to the development of the HRF.

The six core psychological flexibility processes of ACT, and the inflexibility processes they target, have been extensively studied in empirical research. ACT was easily and quickly deployed as demonstrated by the World Health Organization (WHO) in selecting ACT as its primary mode of intervention for help with suffering in war-torn nations.37,38 ACT makes a quick complimentary bridge for rehabilitation professionals to develop improved BPS skills. The evidence for ACT in comparison to CBT for chronic pain is equivalent, but the transdiagnostic benefit, such as concurrent improvement in depression and anxiety, is greater in ACT.39 Psychological flexibility changes account for most improvements in patient functioning with ACT interventions.40,41 Initial efforts to integrate physical therapy with ACT (PACT) demonstrated feasibility. PACT, when compared to standard physical therapy care, showed short term superiority, but not long term superiority.42 We hypothesize that some of the limitations of the PACT approach for long term effectiveness may in part be associated with coherence difficulties between standard physical therapy and ACT. Inconsistencies of worldviews in which an intervention was developed may present with problems of coherence for both the client and the clinician. We propose that a comprehensive re-evaluation of the movement strategies, in combination with psychosocial strategies, may result in more sustainable benefits and enhance transdiagnostic benefits for improving quality of life. The HRF is built on a philosophic worldview of contextualism with the pragmatic scientific philosophy of functional contextualism. It is transdisciplinary and rooted in the BPS model for health.

RFT has been formally used in the context of language and cognition.43 The HRF expands upon its content as an unofficially proposed representation of motor behavior acknowledging its relationships relative to sensory, cognitive, and emotional stimuli. Interventions associated with RFT are inherently process-based, and it draws upon the psychological flexibility and inflexibility processes developed for ACT. Finally, to ease the difficulty in merging mechanistic views of traditional physical rehabilitation into the contextual aspects of pain and movement, the HRF provides a prognostic ladder as a tool to assist with the clinical decision-making pathways to help guide treatment planning.

Figure 7: The HRF Development Network. Overview depicting the development of the HRF

3. Definitions

Hofmann & Hayes describe processes of change as the following:28


“Processes of therapeutic change are theory based, dynamic, progressive, contextually bound, modifiable, and multilevel changes or mechanisms that occur in predictable, empirically established sequences orient toward desirable outcomes.”

Alternatively, to better represent the HRF allowing it to be conceptualized easier across different professions, we have modified the definition explaining processes of change as the following:

“Processes of therapeutic change are the dynamic functional collection of overlapping and interconnecting mechanisms operating at multiple levels and dimensions that are changeable and interact in an orderly manner accounting for history, time, and the diverse contextual factors involved in a meaningful outcome.”

Simply put, as described in Learning Process-Based Therapy “A process is a sequence of events that is known to influence a person’s well-being.”44

In the HRF, the BPS Flexibility Processes have the potential to impact someone’s well-being either positively or negatively depending on the context, history, and amount of flexibility that is examined in an individual.

When defining scope, we have selected the Oxford noun definition of “the extent of the area or subject matter that something deals with or to which it is relevant.” – An adequate world hypothesis defined by Stephen Pepper is to have an infinite scope, which is large enough to have “answers” to all things of the world and otherwise. Unlimited scope is a central component to their “relative adequacy.”

When defining scope, we have selected the Oxford noun definition of “the extent of the area or subject matter that something deals with or to which it is relevant.” – An adequate world hypothesis defined by Stephen Pepper is to have an infinite scope, which is large enough to have “answers” to all things of the world and otherwise. Unlimited scope is a central component to their “relative adequacy.”

Here we must be selective in defining depth to a specific definition as “extensive and detailed study or knowledge.” For Pepper’s Root Metaphor theory, this is both in relationship to common sense knowledge and refined knowledge. In a PBA, depth means any given “knowledge” must be consistent with well-established scientific findings at different levels of analysis. Depth is the consistency and coherence that must be maintained between well-established scientific findings at different levels of analysis across multiple domains (IE: physiology, psychology, sociology, etc.) Depth can make or break any theory, but this is a topic for future discussion. In the short term, it is important to note that even when we survive not falling into eclecticism related to scope and precision, we may fall into eclecticism of scientific depth and further increase incoherence.

Like PBA for psychotherapy, we have opted to utilize current thinking in network science as an approach to problem frame the complexity of the client/patient history and context in which the problem is operating. This clinical problem framing establishes the foundation of this new form of EBP clinical decision making. A basic network is created with nodes (often processes and/or subproblems) and links (relationships between processes and problems).

Figure 8: Example of a crude network early in problem framing development.


The use of a network approach helps to prepare idionomic data for consideration of treatment kernels, follow-up questioning, and subsequent assessment of treatment utility.



Figure 9: Example of decision making that occurs when determining intervention selection based on a network analysis.

The Extended Evolutionary Meta-Model (EEMM) serves as a universal PBA translator across disciplines, domains, dimensions, and levels.

The following definitions were drawn and modified from Hoffman, Hayes, and Lorscheid’s work in Learning Process-based Therapy.44 These can be summarized in the acronym VSRCDL (pronounced ‘versatile”) representing the EEMM’s evolutionary behavioral approach.

Variation: “Variation in evolution means that there are always slightly different forms available in any living system- different bodily forms, different sensitivities, different actions. Initially variation is blind (i.e., random and entirely purposeless), but because variation is so central to the successful development of complex systems, variation itself evolves and becomes controlled by context, allowing for a broader range of alternatives when they might be most needed.”44

HRF Notes: The interconnected nature of the nine processes in the HRF have revealed how nearly any imaginable intervention emphasizing a quality of variation could impact any or all of the processes that may be present in a problem. Our preliminary data shows that at least 25% of clients who have had no notable functional improvements over the course of a minimum of six other providers will show significant impacts in patient function and psychological flexibility within the first five visits of a PBA using very broad activities focusing on introducing variation to the network of processes.

Selection: “Selection means the ability for certain variants to be picked out over others. Typically, they are selected based on the apparently helpful consequences they produce (such as outright survival in the case of genetic evolution).”44

HRF Notes: There are conflicts that can occur from outcomes of short-term decisions that impact long term outcomes. Assisting a client with a decision regarding selection means helping them weigh the potential long-term side effects of their decision. Again, revisiting the combinatorial explosive nature of a selected action not only affects the outcome of the action but also the implications of combinatorial explosion of multiple side effects. A simple example could be described in the context of selecting a symptom modifying strategy vs. a behavior change strategy. Symptom modifying strategies may improve one’s experience for the moment, but how will that affect patterns of experiential avoidance and committed action in the future?

Retention: “Retention means that an individual, group, or culture repeats and strengthens selected variants over time such that they become full-grown habits or customs. In genetic evolution, selected variants are retained physically in DNA. Something like that happens in psychology too when action patterns result in changes in gene expression through epigenetics, changes in the brain based on neural connectivity, and the like. Typically, in psychology, however, positive changes are retained by practice, by building larger patterns, and by social-psychological or environmental support. There is a “use it or lose it” quality to most new habits. New learning is also more likely to be retained if it is linked to pre-existing habits or customs- what is sometimes called a “broaden and build” strategy. Arranging for social or environmental nudges can also help”44

HRF Notes: Expanding beyond the psychology domains described by Hofman et al., the HRF focuses on movement and life.44 Retention requires high volume repetition in supportive environments; therefore, we design programs and interventions that are integrated into life using the most typical functions available. Examples include sitting, standing, walking, etc. which can then be further augmented by environmental and social cues.

Context: “Context refers to the situational and historical circumstances or intervention goals that affect which behaviors an individual or group selects and retains. For example, some new forms of emotional expression may take hold only if an individual deploys this expression in the context of a loving relationship. Concerns over natural contingencies, cultural fit, connection with religious faith commitments, flexible workplaces, a supportive environment, and so on are all typical ways that practitioners speak of context in an evolutionary sense.”44

HRF Notes: We appreciate and draw from the work of Christal Ramanauskas and Bronnie Lennox Thompson on context in the Occupational Therapy space, but also generalize these concepts across disciplines, particularly in team settings, as to further reinforce retention in a transdisciplinary manner.

Dimension: “Dimension refers to which strands of events individuals are selecting and retaining. In the psychological domain, these include affect, cognition, attention, self, motivation, and overt behavior, but dimensions exist in other levels as well.” 44

HRF Notes: We have specifically added the “Movement/Postural” dimension to the HRF use of the EEMM to encompass the rehabilitation domain. Most of our motor behavior assessment and process interventions occur within this dimension.

Level: “Level means the degree of organization and complexity the targets of selection processes require. Psychological events involve the whole organism acting within a context that is considered both historically and situationally. But at the biophysiological, genetic, and epigenetic level, selection occurs sub-organismically, and at the sociocultural level. It occurs between dads and increasingly larger groups and their established rules and customs.”44

HRF Notes: We consider the therapeutic processes of loading capacity operating at the biophysiological level and social relational processes at the sociocultural level.

While we leave others to truly describe the scope of Relational Frame Theory (RFT),43,45-47 several features of RFT are important to discuss in relevance to the development of the HRF. Most importantly is Arbitrarily Applicable Relational Responding (AARR) from Derived Relational Responding (DRR).

“Arbitrarily applicable relational responding refers to responding based on relations that are arbitrarily applied between the stimuli. That is to say the relations applied between the stimuli are not supported by the physical properties of said stimuli, but for example based on social convention or social whim.[13] For example, the sound “cow” refers to the animal in the English language. But in another language the same animal is referred by a totally different sound. For example, in Dutch is called “koe” (pronounced as coo). The word “cow” or “koe” has nothing to do with the physical properties of the animal itself. It’s by social convention that the animal is named this way. In terms of RFT it’s said that the relation between the word cow and the actual animal is arbitrarily applied. We can even change these arbitrarily applied relations: Just look at the history of any language, where meanings of words, symbols and complete sentences can change over time and place.”48

In human language, A can be directly trained to be related B, C, and/or D, and without any additional training, a derived relation of B to A, C to A, D to A arises, and simultaneously B to C, C to D, and so on.

Figure 10: Representation of derived bidirectional relationships that form through relational framing.


Now if A is trained to E, we can see the start of a likely combinatorial explosion!

Figure 11: Representation of additional framing and the relationships formed through deriving another relational frame.

While we recognize we are proposing this theory based on empirical evidence,49,50 understanding AARR may be particularly helpful for understanding motor behavior as having an arbitrary quality to it.  Furthermore, it provides a theoretical model that has the potential for defining motor relationships between cognition, emotions, and other domains and dimensions. Simple clinical examples of this are motor patterns of increased tension that provide no functional use are common, they are like the “noise” of human movement and sometimes can result in maladaptive invariable motor behaviors. Effectively someone may have reports of “tension” in their upper traps which they cannot associate with thoughts or emotions in any given situation, but does not mean that at some arbitrary point, tension behaviors did not arise from derived relations with directly trained situational responses. The motor behavior of the upper traps tensioning in response to a loud noise behind someone could be related to any other stimuli present inside the person, or outside the person. This relationship between stimuli has the potential to derive multiple invariable motor behaviors in completely benign contexts by way of AARR. This is helpful with assessing possible adaptive vs maladaptive behaviors in managing tissue loads in injury. General heuristics assume that a person will offload the injured area, yet, in clinical practice we often see individuals exhibiting increased loading and weight bearing on the injured side. To speculate meaning or directly learned behaviors is questionable when investigating why the behavior occurs, therefore, it would be more useful to be open to this manifestation to minimize bias that may allow the clinician to miss a potentially maladaptive behavior that could be adjusted (IE: increasing stance time symmetry as a form of load management of an injured side.)

In RFT, the experience of self is divided into an umbrella of two parts: self-as-perspective (AKA observing mind, transcendent mind, among many other names) and “content of self.” The content of self is further divided into self-as-process and self-as-story.

Self-as-process is the “ongoing, observable process of ourselves,” such as memories, emotions, bodily sensations, and thoughts. It only exists here and now; as a result, the self-as-process is open for change. This dynamic nature of self-as-process is vital. This means memories are not always thought of or remembered in the same way, nor does sensation always feel the same, meaning our emotional state and how we interpret emotions is also variable.

Self-as-story is the “who I am” identity piece. It is built on our history, and it is important that this story is coherent and a connected whole.

The self-as-perspective, or observing self, is difficult to describe. As Hayes explains, “its borders are fuzzy.” We cannot observe it, and it is devoid of content. It is the lens through which we look that is not influenced by what it sees. The observing self is also a powerful process to engage in from a therapeutic perspective, classically emphasized in mindfulness strategies but explicitly engaged with ACT.

  • RFT Perspective Domains
    • I vs You
    • Here vs There
    • Now vs Then

Contrasting RFT’s theory of language and cognition to the 4E (Embodied, Embedded, Enactive, Extended)51 model begins with recalling that Pepper’s Root Metaphor theory recognized the relatively few ways humans can “cognitize”. This is beautifully represented in the pure synthetic and integrative theorizing that occurs in the root metaphor or organicism that represents the worldview in which 4E exists. Organicism is a worldview that wants coherence more than any other, it yearns for everything to fit together. As 4E cognition can be defined as “shaped and structured by dynamic interactions between the brain, body, and the physical and social environments of the world.” It makes assumptions for meaning and intentionality. According to the Stanford Encyclopedia of Philosophy,52 4E has three themes that are present: Conceptualization, Replacement, and Constitution. For our purpose, the HRF draws on Stanford’s definition of the Conceptualization theme as “The properties of an organism’s body limit or constrain the concepts an organism can acquire. That is, the concepts by which an organism understands its environment depend on the nature of its body in such a way that differently embodied organisms would understand their environments differently.

The metaphor for conceptualization is drawn from the work of Lakoff and Johnson indicating that the concepts of conceptualization “derive from the kinds of “direct physical experience” (1980: 57) an implication of intentional direct meaning.53,54 Regarding cognition,

“This is because we see different forms of cognition as having common features, like intentional directedness, that distinguish them from other organic processes. Thus, to say that cognition is shaped by the body that sustains it can be true without at the same time being useful. Human thoughts and squid thoughts are cognate in ways that human thoughts and squid heartbeats are not, because thoughts, unlike heartbeats, are “about” something. Moreover, as soon as we inquire into what this aboutness might mean as a phenomenon distinct from its token implementations, we find that bodies stop mattering very much at all. If thoughts are expressible and communicable, it can only be because they have some feature by virtue of which they pick out stable features of the world that can be accessed in an intersubjective way. We do not know for sure how this occurs—intentionality remains a riddle…”

“…Thus, to the extent we are interested in cognition in general, it may be that the 4E paradigm misleads us into emphasizing its incidental features over its essential ones.”55

Now let us contrast the 4E organicism perspective to RFT’s contextualistic DRR:

“By means of relational learning, things can be related to each other independent of these non-arbitrary relations. Contextual cues can establish arbitrary relations. This means that things we have not yet encountered or that lack physical links with the things we have come across can nevertheless have functions for us. These functions could be appetitive as well as aversive.”43

What this allows us to do with a PBA for problem framing is to account for knowns and unknowns; we are not bound by meaning making or things mattering at all. Human beings can make arbitrary behavioral relationships, which can include “dark side” tendencies in human language. If we are truly presenting a universal and comprehensive problem framing approach, we need to make room for arbitrary relationships. For this reason, a functional contextually coherent theory of RFT is necessary to accomplish “Successful working” in the HRF to account for unknowns. This is contrast to the growing popularity of an organicism 4E theory for supporting the BPS model providing minimal account for unknowns.

We recognize the fragmented nature of research on psychological flexibility. For the purpose of creating a construct for which the HRF could operate with, we utilize the definition recommended by Kashdan:56

“Psychological flexibility refers to a few dynamic processes that unfold over time.”

This could be reflected by how a person:

  1. Adapts to fluctuating situational demands
  2. Reconfigures mental resources
  3. Shifts perspective
  4. Balances competing for desires, needs, and life domains.

Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility must incorporate repeated transactions between people and their environmental contexts.”56

4. Additional notes
Prior to Hayes and Hoffman’s release of the EEMM, preliminary work on the HRF organized the HRF Processes of change in the following categories: Figure 6: Categories of BPS Processes. 6 Categories of BPS processes with subsequent process skills.

The previous work did not require much revision to finalize the ultimate EEMM dimensions and levels. The nine processes of change we previously organized consisted of the six psychological flexibility processes of change from ACT and an additional three rehabilitation processes of change. These quickly fall into the EEMM via Defusion in the Cognitive dimension, Expansion (Acceptance) in the Affective/Emotional dimension, Presence in the Attentional Dimension, Observing Self in the Self dimension, Values in the Motivational dimension, Committed Action in the Overt Behavior Dimension, Loading Capacity in the biophysiologic levels, and Social Relational Processes in the sociocultural levels. With our Motor Variability processes, we opted to create a new dimension of “Movement/Posture” which we will call our EEMM HRF-Modified model. This is due to the broad scope that movement/posture encompasses across evolutionary VSRCDL and increased dialogue regarding the interconnected nature of movement (including posture) across dimensions and levels.

Figure 12: An extended evolutionary meta-model of change processes (copyright Steven C. Hayes and Stefan G. Hofmann).57

Figure 13: A two-dimensional clinical representation of the EEMM inspired by the work of Christal Ramanauskas, MScOT, Assistant Teaching Professor, Department of Occupational Therapy, University of Alberta and Bronwyn Lennox Thompson PhD, Academic Lead, Postgraduate Programmes in Pain & Pain Management, University of Otago, NZ on the application of context in PBA in the Occupational Therapy space.

Figure 14: The derived current working HRF-Modified EEMM with the addition of the Movement/Posture Dimension

  • The HRF Functional Prognostic Ladder (HRF-FPL) was developed prior to publishing the current EEMM. Despite this, the HRF-FPL remains coherent with the EEMM, as it too was rooted in evolutionary principles and is easily translated to the behavioral qualities of Variation, Selection, Retention, and Context. The first two steps of Functional Understanding and Awareness are representative of Variation, Meaningful Action of Selection, True Ownership and Build of Retention, and Thrive of VSR across multiple Contexts. In application, the language can be used interchangeably for comprehension and practicality of the individual clinician and the context of the client. The visual representation of the HRF-FPL has anecdotally been well received by clients and there may be a value to retaining it in its original form.
Figure 15: The Human Rehabilitation Framework-Functional Prognostic Ladder with associated evolutionary principles representing different levels of the ladder.
  • Similar to the HRF-FPL, the Awareness Exploration Processes (AEP) can now be coherently translated into VSR. With awareness and exploration representative of variation, “processing” representative of selection, and behavior change representative of retention. While helpful and practical in early phases of the HRF development, it is likely AEP will be retired and the EEMM VSRC language be used in the HRF other than where the language may be useful in client contexts.

Our emphasis on improving functional understanding, awareness, and meaningful action during movements and positions such as sitting, standing, walking, lifting, pushing, and pulling are that these are movement behaviors present in most Activities of Daily Living (ADLs). We know clients/patients have very low adherence to HEP after discharge, let alone during the plan of care itself.58-64 Most of the benefits of clinical treatment occur alongside broad BPS processes that are more important than strength and flexibility, despite so many clinicians emphasizing these elements exclusively. Most successful outcomes can be predicted by early increases in psychological flexibility, such as what may be noted after expectation violation. We are double-dipping into researched processes for movement as well as psychosocial processes emphasized formally in ACT work. With this process-based approach, we are working on weaving skill developments into ADLs for long-term sustainable improvement. The behavioral skills we are attempting to emphasize are often self-reinforcing. For example, “If I am present and pay attention, I make better decisions and often feel better” and “When I forget or am distracted, I start to have problems.” This idea also overlaps with the literature on acute low back injuries; distraction and moving awkwardly are the primary biomechanical mechanisms driving injury, secondary to stress and depression.65,66 Additionally, distraction has been shown to be an increased hazard in the work place when investigating occupational injuries through case-crossover designs.67-70 No exercise prescription will accomplish improvement in attentional ability – only practicing attention will do so. Our working hypothesis is that diverse BPS attentional efforts combined with the development of skills to promote true ownership, sets the stage for building further BPS capacity. Ultimately, thriving in these practices will maximize the opportunity for a lifetime of improvement beyond the clinical space and redirect trajectories of disability and suffering.

Regarding the HRF-FPL, many individuals misinterpret its intentions based on the 2-dimensional drawing outlined above. A few notes regarding the HRF-FPL are documented below:   

  • The HRF Prognostic Ladder is NOT intended to serve as a mechanistic linear progression (as represented by the infinite continuum located on the far-right side of the ladder)
  • “You can skip steps, function on one step, fall down the steps, and then climb back up.”
  • The HRF prognostic ladder serves as a clinical compass to assist with relative influence and direction of the plan of care on BPS workability in a transdiagnostic paradigm.
5. Influence of Psychological Flexibility

The role of psychosocial processes in chronic pain has been well established.71 While some evidence for the prognostic representation of psychological flexibility in physical rehabilitation exists,72 the principal limitation of the HRF is the lack of research related to the prognostic ability of psychological flexibility in physical rehabilitation for pain. We have drawn extensively on the prognostic ability of psychological flexibility in multiple aspects of human health,72,73 as well as some research on psychological flexibility prediction and the role of mediation in chronic pain.74-76 Our hope is that the open-source nature of HRF will draw on the community of researchers who resonate with the proposed framework.

6. Biopsychosocial Process-Based Framework
The HRF integrates the psychological flexibility processes developed for ACT, built on the RFT, with three additional BPS processes with a target of improving BPS process workability. There are the six categories of BPS processes which make up the HRF:
  • Attentional Processes
  • Cognitive/Emotional Processes
  • Social Processes
  • Motor Behavior Processes
  • Loading Capacity Processes
  • Behavioral Processes
Figure 6: Categories of BPS Processes. 6 Categories of BPS processes with subsequent process skills.
7. Human Rehabilitation Framework Prognostic Ladder

Figure 16: The Human Rehabilitation Framework-Functional Prognostic Ladder.

Prognostic Ladder Representation of Biopsychosocial Flexibility: Low

In adherence to a contextual philosophical worldview, the static content of knowledge or understanding is not inherently functional, but if this knowledge is used toward a pragmatic end, function is obtained. Providing “education” and expecting behavior change without consideration for an individualized relational framework will not yield functional goals. BPS processes, other than cognitive content, are responsible for behavior change; however, knowledge for the purpose of change is functional. The most important element for providing knowledge that improves a client’s functional capacity is clinician understanding. The clinician’s assessment for the additional knowledge that would improve the functional outcome for the patient is key to this process.

Recall that, in understanding RFT,43,45-47 we learned we cannot argue or replace thoughts or understanding; we can only add new knowledge which the client must determine whether it is meaningful enough to act on. Therapeutic neuroscience education (TNE), general BPS concepts, and simple analogies can be helpful added content. This helpful content provides opportunities for new relationships and networks to be formed, when the client is able to view both old and new content through a state of observing them. Tools drawn from motivational interviewing and ACT provide strategies for engaging in the process of experience oneself, specific for functional understanding.77 Engaging in the self-as-perspective toward the function of engaging in content-of-self provides an opportunity to recognize cognitive fusion and presents the opportunity for cognitive defusion. By engaging in the self-as-perspective, the process presents options, and the client now has a choice to make with the available information. To act on these options, behavioral tools, such as values and goals, can allow the knowledge to become functional. This may explain why clinicians who have seen significant client behavior shifts via “fire hydrant education,” by engaging in underlying processes that unintentionally resulted in cognitive defusion. Therefore, we propose that it would be advantageous that cognitive inflexibility processes be targeted deliberately with an effort to pivot towards flexibility processes, as necessary.

Prognostic Ladder Representation of Biopsychosocial Flexibility: Low

The scope of awareness is deliberately broad, as many BPS processes are engaged in intentional attention, allowing for an arising awareness. Attention is defined by the American Psychology Associated (APA) as a state in which cognitive resources are focused on certain aspects of the environment rather than on others and the central nervous system is in a state of readiness to respond to stimuli.78 Awareness is defined by the APA as perception or knowledge of something.78 Accurate reportability of something perceived or known is widely used as a behavioral index of conscious awareness. However, it is possible to be aware of something without being explicitly conscious of it. As these definitions clearly state, attention is independent of awareness and awareness is only relative to consciousness.79 From a pragmatic sense, there is little functional benefit from defining the two separately in the ladder. Conscious, deliberate attention is engaging in awareness. Exploration of the RFT experience of self-forms the basis for awareness in the HRF (I/You, Here/There, Now/Then). Utilizing the RFT definitions of self, previously described in the notes section, by bringing attention to the self-as-perspective and exploring the content of self, is the network forming process we are engaged with. As physical rehabilitation professionals, we may have to emphasize motor behavioral experiences rather than cognitions and emotions as our entry point for developing basic levels of awareness, despite the often arbitrary and futile nature of the effort. This, in part, is an attempt to meet the expectations of the client attending physical rehabilitation. We attempt to guide individuals to recognize resting muscular activity, the uniqueness of their own structural anatomy, and the ability to influence it. Regarding motor behavioral awareness, there are many realms of exploration of motor behavioral options and experiments which could lead to meaningful action, if so desired. Client flexibility and openness regarding engaging in deliberate psychosocial processes will vary. For example, cognitive awareness, such as knowing and observing thoughts, beliefs, memories, judgements, and predictions can influence our motor behavior and reveal relationships to our emotions. This can be accomplished through guided experiences which could be gradually introduced as the client shows openness to the concepts. Emotional awareness entails gaining insight that emotions are physically “felt” and experienced, not simply a “matter of the mind,” but that can be sensed and perceived from a biophysiological and interoceptive perspective. Awareness of values that have been lost or never identified are often vital for individuals to develop true ownership. However, this is more explicitly explored in meaningful action.

The Awareness Engagement Processes (AEP) predates the release of the EEMM and the application of evolutionary accounts of variation, selection, retention, and context. We have opted to leave the AEP in its initial form followed by its translation into the EEMM.

When we engage in awareness processes, we explore options. What this means is to explore variability across BPS domains including: movement variability through exploring ways of moving, ways of holding positions, and ways of performing actions; psychological flexibility in noticing what we think we are doing and respecting emotional and mental cues for our internal congruence; and respecting the needs of the whole person for functional capacity through the relationships of extrinsic factors in preparation for meaningful action. In this awareness, we also recognize the things that are valuable to us. Then, we use these as compasses toward a better life and the ability to thrive transdiagnostically.

For the purpose of the HRF, the “options” revealed to the client and/or the clinician during engagement with Awareness Processes will be labeled AEP. A client may be prognostically in the awareness phase of the HRF, but the action they are engaging in, relative to that phase, will be defined as AEP

Figure 17: Awareness engagement processes as it relates to the six categories of BPS Processes.

The forefront of rehabilitation has been symptom modification (e.g., modulation/ “calming”). This can be achieved through methods such as specific exercise, directional preference, manual therapy, dry needling, taping/strapping, any number of modalities, referrals related to pharmacology, and procedures. However, the value of symptom modification in long term outcomes and addressing disability is questionable. In some contexts, symptom modification, when combined with functional understanding, may have the potential for cognitive defusion, committed action, contacting values, and can potentially address thoughts about the conceptualized past and future through expectancy violation. However, it also has a strong potential to reinforce experiential avoidance, attachment to the conceptualized self, and decrease presence in the now within the physical body. It is, potentially, a risky behavioral path to focus on and has the chance of decreasing the likelihood for true ownership, building, or thriving. Symptom modification may overlap with behavior change and processing; however, more than likely, it may result in an indirect effect of these two processes. As defined above, the opportunity for cognitive defusion may still present an indirect effect on either, or both, through AEP.

The scope and scale of BPS behavioral change available to humans is broad. The AEP of behavior change is a client-led process in which a clinician presents activities that are appropriate to the client that overlap with multiple psychological flexibility processes. An example of a common first-generation activity found in the early phase of the HRF development are the acts of sitting, standing, or walking. The act of sitting, standing, or walking provides the client an open opportunity to increase sensory, cognitive, and emotional awareness while allowing them to explore options within the experiences that arise throughout the process. Pilot data collected within a single rehabilitation facility utilizing the HRF exclusively revealed clients reporting a broad range of behavior changes associated with these guided awareness practices yielded behavior changes across physical, personal, professional, and social life domains. Further, clients reported the experience of these three awareness acts being their most influential moment in their episode of care when questioned more than six- months after the guided process. Again, the individual acts are likely not as important as the AEP, and the transition of simple awareness acts toward multiple life domains is another proposed example to support the theoretical transdiagnostic ability of the HRF. Behavior change strategies presented in context have the long-term potential for increasing true ownership, building, and ultimately thriving prognostic trajectories. Behavior change may include overlap with symptom modification and processing. This is not the intent, though; rather, this is an indirect (“fuzzy”) effect of AEP.

The processing AEP is the broadest in scope with the fewest “borders.” Processing is the active engagement of awareness, including historical, cognitive, and emotional memories. It distinctly does not yield action, but requires engagement in non-action, or being, with self-as-perspective. Processing is engagement in RFT in its broadest perspective, observing the self-as-content and self-as-process. From the ACT flexibility process, it is engaging in self-as-perspective, attention to the present moment, acceptance (expansion), and defusion in the absence of values and action. In popular terminology “mindfulness” or “meditation;” however, include broader observations, such as universal connectedness, which are beyond the intent of the HRF Processing AEP. Prosocial elements, such as self in relationships and spirituality are engaged, but the primary intent is engagement in self as an experience. Processing may include overlap with symptom modification and behavior change, but once again, this is not the intent, but rather the indirect (“fuzzy”) effect of AEP.

Prognostic Ladder Representation of Biopsychosocial Flexibility: Moderate

Explicit identification or engagement of values is necessary for meaningful action. Values lead us toward a direction, while taking our symptoms/internal context with us. After all, we cannot keep pushing in a direction without respecting the needs of our body. For many people, our difficulties with movement and pain are significantly affected by, and are an effect of, our overextended effort. We need to learn how to pace through our values and listen to our movement needs in the context of “workability.” As traditional physical rehabilitation has had a mechanistic oriented perspective to action, the emphasis has always been based on outcomes and addressing specific impairments and dysfunction. This mechanistic orientation limits long-term opportunities for autonomy and self-guided improvement in workability. Intentional awareness and skill development is often advised as an early phase of meaningful action. These skills engage in BPS processes related to movement and pain. Using values can be paired with exercise prescription related to improving aerobic capacity or other metabolic pathways specific to meaningful activity in a client’s life. For some clients, meaningful action may also mean realizing via awareness the need to see a counselor or other provider to help with more direct guidance in psychosocial layers and processing. Often, meaningful action is also oriented around practices that improve nerve health, including neuroanatomical mobility and sensitivity, and the performance of small movement experiments (“snacks”) during the day to improve sensorimotor awareness.

Prognostic Ladder Representation of Biopsychosocial Flexibility: Moderate-High

True ownership is prognostically representative of a progression in which autonomy, psychological flexibility, and movement variability are verbally and functionally expressed by the client. It indicates familiarity in engagement with any of the flexibility processes, albeit their application may still be limited. The client has a fundamental recognition of values and committed action and has encountered some symptom flare-ups during the course of care or verbalizes readiness for the occurrence of symptoms. At this level of function, decreased clinician/client interaction is necessary. Decreased session utilization and increasing spacing between sessions should be initiated.

Prognostic Ladder Representation of Biopsychosocial Flexibility: Moderate-High

Build prognostically does not represent a higher level of psychological flexibility than True Ownership. Rather, it serves more to support the merging of the physical rehabilitation world concurrent with psychological flexibility processes associated with resilience. Emphasis on developing comprehensive loading capacity across tissues, kinetic chains, psychosocial factors, the nervous system, and the non-musculoskeletal domains is placed here. Furthermore, ongoing challenges with values and committed action are revisited and expanded on.

Prognostic Ladder Representation of Biopsychosocial Flexibility: High

Thrive functions more as a prognostic indicator of a client who is autonomous, resilient, and able to work not only with their initial presentation but take on future unknown difficulties with greater grace. Thrive is an action state of embodying all the processes and steps while acknowledging intermittent ups and downs and still having a sense of fulfillment and direction. The feeling of “thriving” is recognized as impermanent, but a desire to maintain the action of thriving. Engagement in this process will be a fluid ability to identify processes that you need to revisit.

8. Human Rehabilitation Framework Processes
Figure 6: Categories of BPS Processes. 6 Categories of BPS processes with subsequent process skills.
Figure 18: Nine HRF BPS Flexibility Process Skills organized in a nonaflex.

Figure 19: Nine HRF BPS Inflexibility Process Skills organized in a non-a-flex.
9. Attentional Processes​

The process of presence is the act of drawing attention, in a non-judgmental manner, to any sensation, thought, or emotion that occurs in the present moment. Regarding the self as described in RFT, engagement in presence processes is to observe “Self as process,” which, at its root, is to observe the physiology of one’s body and the environment in the present moment as they experience the context of now. The skill of “Self as process” includes the ability to note and describe experiences as they occur in the moment to permit value-oriented behavioral change as needed.

The process of observing one’s self comes from a purely observational state. This observational state allows one to observe “Self as Context” and “Self as Story,” as defined by RFT, in a non-judgmental manner while not attempting to control said definitions of the self. This process includes permitting perspective shifting between “I vs You,” “Now vs Then,” and “Here vs. There.” In human language, this includes the transcendental, spiritual side of the human experience. The observing self-process allows for further flexibility associated with the identity, beliefs, and other narratives of the human mind to allow the potential for value-oriented behavioral change.

10. Cognitive & Emotional Processes

The expansion skill process is the process of making room for difficult sensations, emotions, and thoughts without attempting to control, distract, or otherwise avoid the raw nature of the experience. Often, this is the process of ATTENTION vs. DISTRACTION relative to uncomfortable experiences. This helps us understand what the sensation, emotion, or thought informs us about our life and the moment, as well as what options are presented to us when we stop trying to get rid of an experience. This clarifies the moment and reveals options toward value-oriented behavioral change.

The cognitive defusion skill process is the process of creating space related to thoughts such as descriptions, rules, judgements, memories, predictions, and other private events of the human mind. With this created space, a process of “Deliteralization” occurs in which the thought is noted in a non-judgmental manner and is simply recognized as internal content that does not have specific value by itself, allowing for a decrease in the believability of the content. The less literal and less “absolute truth” the thought presents, the more an individual can decide whether the thought aligns with their values and their desire for meaningful action.

11. Motor Behavior Processes

Motor behavior variability processes serve as the most common entry point to introducing BPS flexibility processes for the rehabilitation professional. Emphasis on intentional efforts via verbal or social touch sensory interactions to promote motor variability in multiple functional contexts are within this domain. Flexible cueing and self-exploration are encouraged, with these skills and experiments oriented around meaningful, functional activities for the individual.

12. Social Processes

Social relational process skills are based on the social processes present in the interactions of individuals and groups. Rehabilitation professionals often engage in social relational processes including verbal and nonverbal communication, with a particular interest in touch. Additional non-verbal communication processes explored include gestures, eye contact, voice, and body language.

13. Load Capacity Processes

Load capacity process skills relate to engaging with a client on core processes associated with primary human biology and physiology. Many of these processes are indirectly a part of rehabilitation tradition but are specifically applied in the HRF in relationship with the eight other BPS processes defined.

Sub-classification of skill emphasis:

  • Local Tissue
  • Kinetic Chain
  • Nervous System
  • Non-Musculoskeletal
  • Psychosocial
14. Behavioral Change Processes

Values process skills involve learning and clarifying what is important to an individual and using this as a direction for meaningful action. Values trump goals, but goals do serve as signposts along the way that demonstrates whether we are moving in the direction we have chosen.

Committed action process skills involve engaging in purposeful action that is built on value-oriented directions. Goals are the subset of values that serve as targets and records of value-oriented action.

15. Administration & Resources

Leonard Van Gelder DPT, ATC, TPS, CSMT, CSCS – Creator & Lead Developer

Leonard Van Gelder is a clinician, coach, researcher, & educator. He is the founder of, and serves in leadership roles for, the Innovative Movement Development Ventures (IMDV) Group, Dynamic Movement & Recovery, Dynamic Principles, Move Better, and Dynamic Movement Frameworks.

He has been involved in the movement and rehabilitation field for over 20 years. During this time, he has studied, published research, and presented at regional and international conferences on the science of movement and pain. He has explored a diverse spectrum of manual therapy and movement approaches, and emphasizes a biopsychosocial approach to movement, manual therapy, and education in his practice.

He founded, owns, and practices clinically at Dynamic Movement and Recovery (DMR) in Grand Rapids, MI. Connect with Leonard via Twitter.

Cameron Faller, DPT – Operations Director & Co-Developer

Cameron Faller is a physical therapist, educator and the Director of Operations of Innovative Movement Development Ventures, LLC (IMDV). Through IMDV, Cameron serves people struggling with pain and movement problems within three different industries. There is the clinical entity (Dynamic Movement and Recovery) that operates as a private practice rehabilitation facility, an educational and research entity (Dynamic Principles) that teaches a transdisciplinary process-based approach to pain, and a rehab technology entity (Dynamic Movement Frameworks) that manufactures and sells products that assist with improving human movement and performance. He also is heavily involved with being an advocate for the physical therapy profession serving multiple roles within the APTA Michigan Chapter as well as the Michigan Pain SIG.

Connect with Cameron via Facebook, Instagram, or Twitter.

Keagen Hadley, OTD, OTR/L – Chief Editor

Keagen Hadley is a Doctor of Occupational Therapy, neurological and psychiatric clinical researcher, and Amazon Bestselling author. His private practice focuses on individuals who have endured a physical injury and are struggling with the mental and psychological aspects of their rehabilitation.

Carissa Montague, OTD – Editing & Content Review

Carissa is an Occupational Therapy Specialist in Grand Rapids, Michigan. She graduated with honors from Rush Medical College of Rush University in 2020 with doctoral research focusing on self-efficacy in the management of chronic migraine and other chronic pain conditions. Carissa’s 20 years of experience as a dancer and wellness professional influence her approach to occupational therapy, bringing a biopsychosocial perspective to her work with chronic pain, movement conditions, and brain injury. She is committed to individualized care that respects the patient’s lived experience and values a supportive and multidisciplinary team process. She currently works as an occupational therapist pain and movement specialist at DMR Move with interest in effective application of biopsychosocial processes in the clinical setting.

David Schwarz DPT, NCS, LMT, BBA – Co-Creator & Co-Developer

David J. Schwarz has education and experience in physical therapy, massage therapy, and administration. As a multi-faceted professional, he has over 10 years of healthcare experience in multiple service settings and capacities with a passion for facilitating healthy aging, caring for persons with persisting conditions, improving quality of life for people with physical and mental health issues, and utilizing manual therapy techniques for recovery and functional improvements. He has been involved in multiple areas of the Michigan Physical Therapy Association, including the MPTA Oncology Rehab SIG, MPTA Pain SIG, and is a board certified Neurologic Clinical Specialist (NCS). He practices clinically in home health.

Leonard Van Gelder DPT, ATC, TPS, CSMT, CSCS
David Schwarz DPT, LMT, BBA
Justin Borman, PTA
Carissa Montague, OTD
Cameron Faller, DPT
Brant Satala, PTA
Alexis Manzanares, CPT, 500-RYT
Benjamin Krull, DPT
Sarah Pipher, DPT
Megan Dickerson, OTR/L

Leonard Van Gelder DPT, ATC, TPS, CSMT, CSCS 

Leonard Van Gelder is a clinician, coach, researcher, & educator. He is the founder of, and serves in leadership roles for, the Innovative Movement Development Ventures (IMDV) Group, Dynamic Movement & Recovery, Dynamic Principles, Move Better, and Dynamic Movement Frameworks.

He has been involved in the movement and rehabilitation field for over 20 years. During this time, he has studied, published research, and presented at regional and international conferences on the science of movement and pain. He has explored a diverse spectrum of manual therapy and movement approaches, and emphasizes a biopsychosocial approach to movement, manual therapy, and education in his practice.

He founded, owns, and practices clinically at Dynamic Movement and Recovery (DMR) in Grand Rapids, MI. 

Cameron Faller, DPT

Cameron Faller is a physical therapist, educator and the Director of Operations of Innovative Movement Development Ventures, LLC (IMDV). Through IMDV, Cameron serves people struggling with pain and movement problems within three different industries. There is the clinical entity (Dynamic Movement and Recovery) that operates as a private practice rehabilitation facility, an educational and research entity (Dynamic Principles) that teaches a transdisciplinary process-based approach to pain, and a rehab technology entity (Dynamic Movement Frameworks) that manufactures and sells products that assist with improving human movement and performance. He also is heavily involved with being an advocate for the physical therapy profession serving multiple roles within the APTA Michigan Chapter as well as the Michigan Pain SIG.

Anna M. Quigg, PhD, BCBA-D

Anna M. Quigg, PhD, BCBA-D is a professor and research director in the Master of Science in Occupational Therapy Program at Cox College. Dr. Quigg is a licensed developmental psychologist and licensed behavior analyst (doctoral-level). She has extensive clinical experience in pediatrics and Applied Behavior Analysis. She has more than 20 years’ experience in applied research and has published peer reviewed journal articles. Dr. Quigg’s current research interests focus on ways in which Acceptance and Commitment Therapy can be used in a variety of settings to enhance people’s capacity to live a meaningful and value-driven life, even in the face of deep struggle and adversity. She continues to work clinically from her private practice which provides professional mentorship, supervision, consultation, and editing services to professionals.

Dustin Cox, DPT, PT, LSVT, CLT

Dustin Cox, DPT, PT, LSVT, CLT is a licensed physical therapist with advanced certification in therapeutic treatment for Parkinson’s and lymphedema. He received his Bachelor of Science in Biology at Evangel University and his clinical Doctorate in Physical Therapy at Southwest Baptist University and began practicing clinically in 2011. Dr. Cox is a currently attending Northern Illinois University to earn is research doctorate. Currently Dr. Cox is enrolled in the Ph.D. in Health Science program in order to increase his skill set in clinical research. Dr. Cox has practiced in a variety of settings since starting practice in 2011 and specializes in geriatrics. His clinical focus includes maximizing quality of life and function, pain, and lymphedema management, increasing balance and motor coordination, and decreasing bradykinetic movement.

Bronnie Lennox Thompson PhD, MSc, Dip OT

Bronnie Thompson has worked in the field of pain management for most of her clinical career. Her roles have included occupational therapy, pain psychology, vocational management, and policy development. Bronwyn has completed a PhD developing a theory of living well with chronic pain. She also holds a MSc (1st class hons) in Psychology from Canterbury University and a Diploma in Occupational Therapy from CIT. She teaches post-graduate papers in pain and pain management, with a particular focus on psychosocial factors, coping, and resilience. Her research skills include classical grounded theory, qualitative synthesis, single subject research design and analysis.

Paul Lagerman BSc, PG Cert, NZRP

Paul Lagerman has been involved in clinical care for persistent pain for most of his clinical career as a physiotherapist. He currently works as a clinical advisor and physiotherapist specializing in pain management services for APM Workcare across New Zealand. Paul has interests in the philosophical and phenomenological underpinnings within physiotherapy and mentoring of new graduates and physiotherapy colleagues in the UK and in NZ.

April Gamble DPT, CLT

April Gamble has been practicing and teaching full time in the Kurdistan Region of Iraq since 2017, where she founded ACR – The American Center for Rehabilitation. She collaborates with communities to strengthen equitable and just rehabilitation services for underserved populations with an emphasis on persistent pain, cancer rehabilitation, and mental health. She is the Physiotherapy Technical Coordinator at Wchan Organization for Human Rights Violations where she leads the development of interdisciplinary pain and addiction treatment services for survivors of torture and war trauma. Dr. Gamble also regularly consults with various international NGOs, including Heartland Alliance International, Humanity and Inclusion, and DIGNITY – Danish Institute Against Torture. Dr. Gamble is an active part of the Turning Point Close the Gap Initiative, which works alongside communities impacted by breast cancer to increase just access to rehabilitation, exercise, and wellness services. Additionally, she is the 2019 recipient of the International Association for the Study of Pain’s Developing Countries grant, which resulted in over 250 Kurdish physiotherapists being equipped with the skills and knowledge to treat pain from a biopsychosocial approach.

Harpreet Singh, MD

Harpreet Singh completed his Pain Medicine Anesthesiology fellowship through the Cleveland Clinic. His clinical care has been focused on chronic pain management, ranging from procedural through non-pharmacological pain management. He has an interest in developing clinical skills around the biopsychosocial model and its application in a multidisciplinary care setting.

Michael Distler, MD

Michael Distler received his bachelor’s degree in pre-medicine studies at the University of Dayton before receiving his medical doctorate at The University of Toledo College of Medicine. He went on to complete his residency training in Physical Medicine and Rehabilitation from Case Western Reserve University/Metrohealth in Cleveland, Ohio.

Jodette Rose Ed.D, MSW, CPC

Jodette Rose is a life coach, hypnotherapist, and guided meditation teacher at Sage, Moon Wellness in Dorr, MI. Jodette’s background is in social work, serving populations in domestic violence, sexual assault services, and case management. She also served as a Certified Clinical Research Coordinator, and Independent Evaluator in mental health research for Creighton University, and the VA Nebraska-Western Iowa Health Care System. Jodette earned her Doctor of Education in Organizational Leadership at Creighton University in Omaha, NE, and Master of Social Work at Wayne State University in Detroit, MI. Josette’s area of interest centers on the impact that cultural belief systems have on client experiences with emotional and physical pain, as well as their perceived efficacy of available treatments.

Janet Downey

Janet is a Life Member and Board-Certified Clinical Specialist in Pediatrics Emeritus. She received her Bachelor’s in Physical Therapy from the University of Missouri in 1972 and her Master’s in Physical Therapy from the University of Michigan in 1998. She has served the APTAMI in a variety of positions, including Speaker of the Meeting, Chief Delegate, and President and the APTA on the Nominating Committee and is currently APTAMI Archivist. She is the recipient of the APTAMI Marjorie Stamm Outstanding Member Award and the APTA Lucy Blair Service Award. Although retired, she remains very interested in pain in children and its effects on the family. She is also able to use her professional contacts to identify and share the development of pain education and management through the years.

Special thank you to Steven Hayes, Theodore Mulder, Kevin Vowles, Adriaan Louw, Rob Langhout, and Igor Tak.



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