Psychological Factors in the Assessment and Treatment of Chronic Low Back Pain
Pain: Definitions
“a sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” A physical, emotional and psychological experience in which nociception is modulated by cortical input
Low Back Pain (LBP)
10%
Lifetime prevalence 60% - 80%
(Frymoyer & Cats-Baril, 1991)
20% 3-4
months 2 weeks 1 month
50%
20%
90% recover from LBP in less than 12 weeks 5% to 10% report persisting pain and disability after 3 months
BioPsychoSocial Models
Biological factors nociception, tissue damage Psychological factors cognitions, emotions Social factors family dynamics, employment
The experience of pain involves:
Biological Basis of Chronic Pain
Prolonged nociception promotes sensitisation in the peripheral and central nervous systems Pain receptors are activated by reduced levels of stimulation, even in areas outside the original injury site
Sensitization of Pain Pathways
CBT modulates vigilance, attention & stress, causing neuroplastic changes that reverse the sensitisation of pain pathways.
Chronic pain depends on the memory of the initial intensity of the pain Pain should be treated immediately or even preemptively to prevent this neural memory from forming
Personality Disorders
Not causal in the development of chronic pain Compromise a patient’s coping skills Produce poorer treatment outcomes
Clinical Examples
Neurotic patients worry about minor residual pains Patients with borderline personality disorder demand immediate special attention and becoming angry or passive-aggressive when denied special treatment
(Weisberg & Keefe, 1999)
Depression
30% to 100% of chronic pain patients suffer from depression
(Turk, Rudy, & Stieg, 1987)
Clinical Example: Depressive patients often show a hopeless, helpless attitude toward active involvement in treatment programs
Assessment & Treatment
Psychological testing & treatment are appropriate for personality and mood disorders in chronic pain patients Minnesota Multiphasic Personality Inventory and the Beck Depression and Anxiety Inventories may be used to assess personality and emotional factors respectively (Hardin, 1997) The MultiDimensional Pain Inventory (MPI) can be used to categorise patients as “dysfunctional”, “interpersonally distressed” or “adaptive copers.”
Pain-Related Fear & Disability
Level of disability is determined by fear of pain and reinjury Not determined by severity of pain Disability arises because patients try to avoid exacerbating their pain
The Fear-Avoidance Model
Figure. 1. The fear avoidance model of back pain.
Sites at which behavioural therapy might be applied are marked Ψ.
Bogduk (in press)
Cognitive Behavioural Therapy
CBT is recommended by the Australian Pain Society as a psychological treatment for pain Increasing activity levels and problemsolving training led to significant reductions in pain intensity and functional limitations in 212 CLBP patients
(Smeets et al, 2006)
Multidisciplinary Treatment
Incorporating:
Exercise
Education Relaxation
training Vocational counselling CBT
Initial positive self-evaluation of potential to return to work Decrease in subjective disability after treatment
….were the best predictors of returnto-work
(Pfingsten et al, 1997)
fMRI Case Study
Figure 1. fMRI images, taken from a single subject with chronic low back pain during a voluntary abdominal muscle task. Images shown were acquired:
A) Directly after training in the abdominal drawing-in task B) After one week of hourly practice of the task C) Directly after a 2.5 hour oneto-one education session about the physiology of pain
Note marked reduction in activation, excepting primary somatosensory areas, after education.
Education
Encourages well behaviour Increases physical performance and reduces pain-related neural activation
Behavioural Models
Pain becomes chronic because pain behaviours are positively reinforced and well behaviours are not
Pain Behaviour
Groaning Sighing Crying Avoiding movement
Reinforced by:
Attention Sympathy Care
Family Dynamics
Role tension Marital conflict Reduced sexual activity Social isolation Anger Anxiety Resentment
(Snelling, 1994)
Distress & Isolation
“People
pain.” “I get angry when someone makes a comment about me being sick.” “I feel guilty when I can’t do things with the children.” “I don’t want them to worry about how I feel.”
don’t want to hear about the
(Smith & Friedman, 1999)
Societal & Environmental Influences
Patients who applied for a pension did not return to work
(Pfinsten et al, 1997)
Psychosocial predictors of return to work in LBP patients:
occupational stability co-worker support responses of the employer and workers’ compensation system
(Schultz et al, 2004)
Alternative Treatment Options
Patients with less active coping skills had better outcomes than “adaptive copers” Active Physical Treatment (APT), and CBT and APT together were equally efficacious as CBT
Conclusions
Pain Behavior Suffering Pain
Nociception
Chronic Low Back Pain is influenced by biological, psychological and social factors Important psychological factors include fear-avoidance beliefs, anger, guilt, anxiety, depression, personality disorders, and reinforcement of pain behaviour
Psychological Factors in CLBP
Are very important in the assessment and treatment of chronic low back pain Can determine level of disability Modulate the neural/biological aspects of chronic pain
Psychological Assessment & Treatment of CLBP
anxiety, marital or family problems and personality disorders are common mental health issues associated with CLBP and can be assessed using current psychological tests and methods CBT has been shown to be an effective treatment for CLBP
Depression,
References
Adams, N., Ravey, J., & Taylor, D. (1996). Psychological models of chronic pain and implications for practice. Physiotherapy, 82, 124-129. Bogduk, N. (in press). Psychology and low back pain. International Journal of Osteopathic Medicine. Brannon, L., & Feist, J. (2004). Health Psychology: An introduction to behaviour and health (pp. 170). Belmont, CA: Wadsworth / Thomson Learning. Frymoyer, J.W., & Cats-Baril, W.L. (1991). An overview of the incidences and causes of low back pain. The Orthopedic clinics North America, 22, 263-271. Gatchel, R. J. (2000). How practitioners should evaluate personality to help manage patients with chronic pain. In R.J. Gatchel, & J.N. Weisberg (Eds.), Personality characteristics of patients with pain. (pp. 241-257). Washington, DC, US: American Psychological Association. McCracken, L.M., Zayfurt, C., & Gross, R.T. (1992). The Pain Anxiety Symptoms Scale: Development and validation of a scale to measure fear of pain. Pain, 50, 67-73. Merse, K., & Boag, L. (2002). The role of the psychologist in the management of persistent pain. Australian Pain Society, http://www.apsoc.org.au/public.html. Moseley, G.L. (2005). Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Australian Journal of Physiotherapy, 51, 49-52.
References
Smeets, R., Vlaeyen, J., Hilling, A., Kester, A., van der Heijden, G., van Geel, A., & Knottnerus, J. (2006). Active rehabilitation for chronic low back pain: Cognitivebehavioural, physical or both? First direct post-treatment results from a randomized controlled trial. BMC Musculoskeletal Disorders, 7, 5. Nachemson, A.L. (1992). Newest knowledge of low back pain: A critical look. Clinical Orthopaedics and Related Research, 279, 8-20. Pfinsten, M., Hildebrandt, J., Leibing, E., Franz, C., & Saur, P. (1997). Effectiveness of multimodal treatment program for chronic low back pain. Pain, 73, 77-85. Snelling, J. (1994). The effect of chronic pain on the family unit. Journal of Advanced Nursing, 15, 771-776. Song, S.O., & Carr, D.B. (1999). Pain and memory. Pain Clinical Updates, 7, 1-4. Turk, D.C., Rudy, T.E., Stieg, R.L. (1987). Pain and depression: I. "Facts." Pain Management, 1, 17-26. Turner, J.A., & Chapman, R.C. (1982). Psychological interventions for chronic pain: A critical review. II. Operant conditioning, hypnosis and cognitive-behavioural therapy. Pain, 12, 23-46. Van Der Hulst, M., Vollenbroek-Hutten, M, & IJzerman, M.J. (2005). Back school treatment outcome in patients with chronic low back pain: A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation. Spine, 30, 813-825. Weisberg, J.N., & Keefe, F.J. (1999). Personality, individual differences and psychopathology in chronic pain. In R.J. Gatchel & D.C. Turk (Eds.), Psychological factors in pain: Critical perspectives (pp. 56-73). New York: Guildford Press.