Chronic musculoskeletal pain presents a significant challenge for healthcare professionals and patients alike. Traditional approaches, often rooted in the biomedical model, have focused on locating pain within damaged tissues and repairing the “broken” body. While effective in some contexts, this approach frequently neglects the broader, interconnected aspects of pain—its psychological, social, and environmental dimensions.
The biopsychosocial (BPS) model introduced an important shift, recognising that pain is influenced by a mix of biological, psychological, and social factors. However, its application in practice has often been fragmented, leaving many patients stuck in a cycle of limited progress.
In our paper, Affordance-Based Practice: An Ecological-Enactive Approach to Chronic Musculoskeletal Pain Management, we propose a different way forward. By focusing on the relationships between people and their environments, and drawing on the concept of “affordances,” we offer a fresh perspective that sees pain not just as something to fix but as something to understand within its wider context.
This blog explores the ecological-enactive approach and its potential not only to transform pain care but also to align physiotherapy with environmental contexts and a deeper connection to the world around us.
What is the Ecological-Enactive Framework?
At its core, this approach views pain as a dynamic, relational process. Instead of focusing solely on damaged tissues or internal states, it looks at how people interact with their environments and the possibilities these interactions create.
Key ideas include:
Affordances – Opportunities for action that the environment offers. For instance, a park bench may afford rest for some but feel inaccessible to others due to pain or fear.
Embodiment – Pain is experienced through the body, which connects the physical, emotional, social and environmental aspects of a person’s life.
Embeddedness – We are always situated within social and physical environments that shape our experiences.
Enaction – Pain is not static but arises through active engagement with the world.
These ideas encourage clinicians to see pain not just as a symptom but also an entanglement of a person’s ongoing relationship with their surroundings.
Pain, the Environment, and a “Stuck” Field of Affordances
People with chronic pain often describe feeling “stuck,” unable to engage with their surroundings in meaningful or enjoyable ways. Fear, unhelpful beliefs, and restrictive environments can narrow the range of actions they perceive as possible.
For example, someone with back pain might avoid gardening or walking in the park, missing out on the restorative benefits of engaging with the world.
An ecological-enactive approach seeks to expand these possibilities, helping patients rediscover what they can do and encouraging engagement with supportive environments—whether that’s exploring local green spaces or finding new ways to connect socially.
Daniela Vaz (PhD)
Professor, Federal University of Minas Gerais, Brazil
Daniela Vaz is Professor in the Department of Physiotherapy and the Graduate Program in Rehabilitation Sciences, Vice-Director of the Accessibility and Inclusion Center at the Federal University of Minas Gerais, Brazil. Works on theoretical aspects of rehabilitation and disability studies.
Matthew Low (PhD cand)
Consultant Physiotherapist at University Hospitals Dorset NHS Foundation Trust
Photo by Joseph Sharp on Unsplash
Practical Applications
The ecological-enactive approach translates into practical, person-centred strategies that are simple yet transformative:
Encouraging movement variety – Instead of prescribing rigid postures or exercises, clinicians can help patients explore different ways of moving that feel comfortable and functional.
Reconnecting with the world – Thinking beyond the clinic is paramount to not only support physical health but also promote emotional well-being and reduce stress.
Creating supportive environments – Rehabilitation spaces within and outside of the clinic can be reconsidered to create an inviting and empowering environment, offering patients a sense of safety and possibility.
Collaborative Tools – Mind maps and simple visual tools can help patients and clinicians co-create a shared understanding of pain and identify practical steps forward.
Photo by Siora Photography on Unsplash
A Broader Vision: Physiotherapy and the Environment
This framework isn’t just about improving individual care—it also has implications for how physiotherapy can engage with the environment. The ecological-enactive approach naturally aligns with the aims of the environmental physiotherapy association, emphasising our interconnectedness with the world around us.
Conclusion
The ecological-enactive approach represents a shift in how we think about and manage chronic pain. By focusing on the entanglement between people, their bodies, and their environments, it offers a richer, more connected view of health.
Read the full article here:
Vaz, D. V., Stilwell, P., Coninx, S., Low, M., & Liebenson, C. (2023). Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management. Brazilian Journal of Physical Therapy, 27(5), 100554. https://doi.org/10.1016/j.bjpt.2023.100554
Header image by Joseph Sharp on Unsplash
I really enjoyed reading this article. It reminded me of many patients I’ve worked with in physical therapy clinic, where the main issue wasn’t just physical, but rather psychological. I found that by focusing more on their environment and their mindset, rather than just the exercises, the results were much quicker and more effective. It’s amazing how much the psychological and environmental factors can influence the healing process.