Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients

Chronic pain syndromes such as chronic low back pain are responsible for enormous costs for health care and society. For these conditions a pure biomedical approach often proves insufficient. Numerous studies have shown that there is little direct relationship between pain and disability and suggest that the biopsychosocial approach offers the foundations for a better insight in how pain can become a persistent problem. The main assumption is that pain and pain disability are not only influenced by organic pathology, if found, but also by psychological and social factors. In this contribution, a behavioural analysis of chronic musculoskeletal pain will be discussed, with special attention to the role of pain-related fear in the development and maintenance of chronic pain disability, and the behavioural rehabilitation perspective of chronic pain management.     

Psychological approaches for the nursing management of chronic pain: part 2

Aims and objectives. The aim of this article was to present the ways that nurses can integrate psychological approaches into their management of chronic pain conditions using a biopsychosocial framework. Communication, the importance of the patient–practitioner interaction, the role of education and provision of information, reassurance and reduction of anxiety and the use of coping strategies training in the management of chronic pain are reviewed alongside the key skills of nursing. Background. This is the second part of a two‐part article. Part 1 was a discussion of psychosocial factors associated with chronic pain conditions and the psychological approaches used in the management of these conditions. Conclusions. It is identified that key nursing skills often equate to the requirements of the psychological approaches, therefore specific techniques from a cognitive‐behavioural framework can be readily applied, integrated and used by nurses in the management of chronic pain conditions. Relevance to clinical practice. Commonly utilized nursing skills are similar to those required for cognitive‐behavioural therapy. It is reasonable to assume therefore that nurses can and should be involved in effectively managing the psychological aspects associated with chronic pain conditions.     

Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model

Purpose : Since the early 1990s, numerous prospective studies have been published on the determinants of chronic disability related to low back pain (LBP) of non-specific origin whose human and financial costs are enormous. The significant contribution of psychosocial factors is being increasingly recognized. However, additional efforts are needed to clarify their role and to improve the interventions. The purpose of this theoretical paper is to propose a coherent organization of the medical and psychosocial determinants identified in prospective studies into a conceptual framework. Method : Several models available in the field of pain and disability as well as in health psychology were reviewed. Results : A recent version of the stress coping model was chosen and adapted to the problem. The adapted model suggests that stress, particularly that caused by the pain associated with LBP, could have a negative impact on the outcome either: (1) indirectly through the negative emotional responses that it produces, which can cause biological or behavioural changes; or (2) directly through the biological or behavioural changes, which can in turn negatively affect the emotional response. Conclusions : The proposed biopsychosocial model assumes that LBP-related chronic disability is possibly, in some cases, a stress-related disorder. Its empirical verification in LBP could particularly improve the understanding of the interrelationships between certain variables.     

Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model

Purpose : Since the early 1990s, numerous prospective studies have been published on the determinants of chronic disability related to low back pain (LBP) of non-specific origin whose human and financial costs are enormous. The significant contribution of psychosocial factors is being increasingly recognized. However, additional efforts are needed to clarify their role and to improve the interventions. The purpose of this theoretical paper is to propose a coherent organization of the medical and psychosocial determinants identified in prospective studies into a conceptual framework. Method : Several models available in the field of pain and disability as well as in health psychology were reviewed. Results : A recent version of the stress coping model was chosen and adapted to the problem. The adapted model suggests that stress, particularly that caused by the pain associated with LBP, could have a negative impact on the outcome either: (1) indirectly through the negative emotional responses that it produces, which can cause biological or behavioural changes; or (2) directly through the biological or behavioural changes, which can in turn negatively affect the emotional response. Conclusions : The proposed biopsychosocial model assumes that LBP-related chronic disability is possibly, in some cases, a stress-related disorder. Its empirical verification in LBP could particularly improve the understanding of the interrelationships between certain variables.     

Applying a biopsychosocial model to migraine: rationale and clinical implications

Migraine is a complex condition in which genetic predisposition interacts with other biological and environmental factors determining its course. A hyperresponsive brain cortex, peripheral and central alterations in pain processing, and comorbidities play a role from an individual biological standpoint. Besides, dysfunctional psychological mechanisms, social and lifestyle factors may intervene and impact on the clinical phenotype of the disease, promote its transformation from episodic into chronic migraine and may increase migraine-related disability.Thus, given the multifactorial origin of the condition, the application of a biopsychosocial approach in the management of migraine could favor therapeutic success. While in chronic pain conditions the biopsychosocial approach is already a mainstay of treatment, in migraine the biomedical approach is still dominant. It is instead advisable to carefully consider the individual with migraine as a whole, in order to plan a tailored treatment. In this review, we first reported an analytical and critical discussion of the biological, psychological, and social factors involved in migraine. Then, we addressed the management implications of the application of a biopsychosocial model discussing how the integration between non-pharmacological management and conventional biomedical treatment may provide advantages to migraine care.     

Psychological interventions for chronic pain following spinal cord injury.

Currently, no literature is available regarding the clinical efficacy and treatment outcome of psychological interventions for chronic pain among spinal cord injured (SCI) persons. The present article provides a framework for cognitive-behavioral interventions used with other pain populations and suggested application for the SCI population with chronic pain. Primary focus is upon a biopsychosocial model with patient self-management as the treatment goal. SCI rehabilitation has traditionally relied upon self-management strategies, as have recent psychological treatment approaches for chronic pain. In addition, recommendations for treatment outcome research are provided with the emphasis on using existing standardized assessment and measurement protocols.     

Analyse des caractéristiques biopsychosociales observées chez 1 832 patients consultant pour des douleurs chroniques dans le service d’algologie du CHU de Liège

This article aims to establish a “profile” of patients presenting with chronic pain in the algology service of CHU of Liège to identify possible relationships between diagnoses, psychological states and modes of pain management. Between 2005 and 2010 we monitored 1832 individual chronic pain patients who attended our pain clinic at the University Hospital of Liège. This paper presents the characteristics of these patients and their test scores before the treatment to assess their health status in a biopsychosocial perspective. Demographic and lifestyle as well as occupational factors, pain disability index, pain belief assessment, hospital anxiety and depression scale, SF-36 (Short Form Health Survey) and pain visual analogue scale are presented. The results have clinical implication; they suggest an adaptation of our therapeutic interventions based on these observations.     

Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice--challenges and opportunities

As the biopsychosocial model of health has become increasingly understood, it has become clear that there are complex, interdependent relationships between the physical and biomedical features of low back pain and the psychological and social factors that present concomitantly. Epidemiological studies have not only highlighted that psychological and social factors are associated with back pain and disability but also have shed light on the way in which these factors serve as prognostic indicators, or obstacles to recovery, predicting which patients will have a poor prognosis. Integrating the assessment of these obstacles to recovery into physical therapist practice and using this information to guide clinical decision making have the potential to improve the quality of care offered by physical therapists by improving the targeting of treatments to individuals and enhancing the therapist-patient relationship and adherence to management advice and treatment programs. In turn, such approaches may improve both patients' clinical outcomes and the efficiency and effectiveness of service provision, helping direct interventions to those who need them. This article summarizes the key challenges to embedding psychosocial perspectives within physical therapist practice for patients with low back pain and the opportunities that could be realized by doing so, and it highlights new developments in research, clinical practice, and education that are shaping future directions in this field.     

A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain

Cervicobrachial pain is a common cervical spine disorder. It is frequently managed through non-invasive therapy. The objective of this systematic review was to assess effectiveness of non-invasive therapy for the management of cervicobrachial pain, in terms of pain, function and disability. Computerised searches were performed to January 2010. Studies were selected using pre-specified criteria. Methodological quality of included studies was assessed using PEDro and level of inter-reviewer agreement reported using Kappa values. Meta-analyses were conducted on pain scores for similar interventions using DerSimonian-Laird random-effects model to allow for heterogeneity. Effect sizes and 95% confidence intervals were reported. Qualitative analyses, based on Centre for Evidence Based Medicine levels of evidence, were conducted for function and disability. Eleven studies were included in the review. Interventions included general physiotherapy, cervical traction, manual therapy, exercise therapy, and behavioural change approaches. There was inconclusive evidence for the effectiveness of non-invasive management of cervicobrachial pain. Potential benefits were indicated in the provision of manual therapy and exercise and behavioural change approaches to reduce pain. General physiotherapy and traction were no more effective than comparators in reducing pain (level A evidence). Effects of non-invasive management on function and disability were mixed. Future studies should identify which sub-groups of cervicobrachial pain respond to specific interventions.     

Spinal cord injury‐related pain in rehabilitation: A cross‐sectional study of relationships with cognitions,mood and physical function

Although psychological aspects of SCI‐related pain have been investigated in those with chronic pain, little data is available regarding these factors in those early in the course of the injury. Using a sample admitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood, disability and both pain and SCI‐related psychological factors. The sample were largely similar to other samples of individuals with SCI‐related chronic pain in terms of mood, but were noted to be less catastrophic in their thinking about pain than a comparative pain clinic sample. They also reported SCI self‐efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI populations there were mixed findings in relation to physical disability. Consistent with previous findings in chronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptoms of anxiety and depression, and pain‐related life interference. SCI acceptance was significantly negatively associated with depression scores, pain catastrophizing was significantly positively associated with both anxiety and depression scores, and SCI self‐efficacy was significantly negatively associated with both anxiety and depression scores. SCI self‐efficacy was also significantly positively associated with physical function scores. These findings suggest that pain‐related psychological factors may have importance even early in the clinical course following SCI, but that it is important, however, to consider more general SCI‐related psychological factors alongside them. In addition, these findings suggest the possibility that early interventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabilitation programmes.     

Fibromyalgia: A ‘model’ chronic pain syndrome?

Fibromyalgia syndrome (FMS) is a poorly understood condition that results in longstanding pain, psychological distress and disability. FMS is a ‘chronic pain syndrome'. Therefore, its assessment and treatment should be approached from a multidimensional perspective. The aims of this paper are to expand upon some of the problems that therapists encounter when they treat patients with chronic pain and to argue that FMS is a good model through which the management of chronic pain can be better understood. The history, prevalence and the possible pathogenesis of FMS are addressed first, together with the difficulty of its diagnosis. Next, various management options are described, including medication, physical therapy, psychological interventions and patient education. Finally, challenges to the management of FMS and other chronic pain syndromes are briefly examined.     

Psychological Issues in the Evaluation and Treatment of Tension-Type Headache

Tension-type headache is the most common headache disorder, affecting approximately 40?% of Americans within a one-year span. Although the most common form, episodic tension-type headache, is rarely impairing, more frequent tension-type headache can occur with significant disability and psychological comorbidity. Appreciating the psychological impact, assessing the associated biopsychosocial issues, and understanding patients?? coping styles are important in forming an appropriate treatment plan and maximizing treatment outcomes. A range of psychological therapies including relaxation training, cognitive behavioral therapy, biofeedback and mindfulness have demonstrated utility in treating chronic pain conditions and reducing the associated disability. This may be particularly applicable to special populations, including pediatric patients, pregnant patients and geriatric. Psychological assessment and treatment may be done conjointly with medication management and expands treatment options. There is great need to continue researching the effects of psychological treatments, standardizing interventions and making them available to the wider population.     

Culture and musculoskeletal pain: strategies,challenges, and future directions to develop culturally sensitive physical therapy care

BackgroundPain experience has a multidimensional nature. Assessment and treatment recommendations for pain conditions suggest clinicians use biopsychosocial approaches to treat pain and disability. The current pain research is overwhelmingly skewed towards the study of biological and psychological factors including interventions, whereas, cultural factors are often ignored.ObjectiveThe aims of this Masterclass is threefold: (1) to discuss cultural influences on pain, (2) to provide strategies for delivering appropriate pain education and exercises in culturally diverse people with chronic pain, and (3) to present challenges and future directions to clinicians and researchers.DiscussionCultural factors have a relevant influence on the way individuals experience and manage health and illness. Thus, people with different cultural experience perceive, respond, communicate and manage their pain in different ways. In this aspect, the contents of pain education should be presented using different culturally appropriate examples, metaphors, images, and delivery methods that may enhance the impact of the message. Efforts should be made to produce and spread culturally adapted evidence-based materials and resources. In addition, a culturally sensitive approach may help to introduce patients to graded activities, so that they can apply these strategies in culturally acceptable and meaningful ways. Future studies should investigate the effectiveness of culturally-adapted interventions in pain-related outcomes in different pain conditions in patients with different cultural backgrounds.     

Etiological theories and treatments for chronic back pain. II. Psychological models and interventions

This is the second part of an extended review of the etiology and treatment of chronic back pain (CBP). The first paper dealt with somatic factors and interventions, this paper will examine psychological theories on the etiology of CBP and psychological treatments for CBP. Finally common problems of both the somatic and the psychological approaches will be discussed and suggestions for treatment and research will be made.     

The Relation Between Pain-Related Fear and Disability: A Meta-Analysis

Within a biopsychosocial framework, psychological factors are thought to play an important role in the onset and progression of chronic pain. The cognitive-behavioral fear-avoidance model of chronic pain suggests that pain-related fear contributes to the development and maintenance of pain-related disability. However, investigations of the relation between pain-related fear and disability have demonstrated considerable between-study variation. The main goal of the current meta-analysis was to synthesize findings of studies investigating cross-sectional associations between pain-related fear and disability in order to estimate the magnitude of this relation. We also tested potential moderators, including type of measure used, demographic characteristics, and relevant pain characteristics. Searches in PubMed and PsycINFO yielded a total of 46 independent samples (N = 9,579) that reported correlations between pain-related fear and disability among persons experiencing acute or chronic pain. Effect size estimates were generated using a random-effects model and artifact distribution method. The positive relation between pain-related fear and disability was observed to be moderate to large in magnitude, and stable across demographic and pain characteristics. Although some variability was observed across pain-related fear measures, results were largely consistent with the fear-avoidance model of chronic pain.     

Integrative pediatric pain management: Impact & implications of a novel interdisciplinary curriculum

ObjectivesObjectives of this paper are to: 1) Describe a novel interdisciplinary, integrative pain curriculum for pediatric residents. 2) Describe changes in residents’ understanding of pain epidemiology, physiology, and management; application of the biopsychosocial model in pain management; and understanding and application of non-pharmacologic approaches to pain management.Design, settingThis study was done in a pediatric residency program within an urban pediatric teaching hospital. It employed both anonymous, Likert-scale surveys administered via Qualtrics, as well as open-ended, free response questions.InterventionsWe provided a multidisciplinary pain education curriculum to pediatric residents with a focus on pain neuroscience, a history of pain management, the biopsychosocial model of care, and exposure to non-pharmacologic interventions to pain management over six hours of instruction conducted in two blocks of three hours each.Outcome measuresSelf-identified changes via survey measuring resident physician knowledge, comfort, approach, and management of pediatric pain through an interdisciplinary pain curriculum.ResultsPrior to this training, many residents were not confident in their understanding of pain neuroscience, the biopsychosocial model of care, and non-pharmacologic interventions. At completion of training, residents indicated positive changes in knowledge of, and comfort with, all of the domains taught. Ninety percent of residents indicated that the curriculum changed the way they conceptualized, approached, and/or managed pain, and reported thinking more holistically about pain management. Nearly all residents indicated they would like to have more training (98 %, N = 57) in integrative modalities.ConclusionsPediatric resident physicians are receptive to training in an interdisciplinary, integrative, pediatric pain management education intervention, and subsequently show positive changes in knowledge and comfort levels. There is a need and desire for additional pain education in resident training programs.     

Diagnosis and classification of pelvic girdle pain disorders--Part 1: a mechanism based approach within a biopsychosocial framework

The diagnosis and classification of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this field. The majority of PGP disorders have no identified pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many of these approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to benefit all. This highlights the possibility that 'non-specific' PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity. This paper examines the current knowledge and challenges some of the common beliefs regarding the sacroiliac joints and pelvic function. A hypothetical 'mechanism based' classification system for PGP, based within a biopsychosocial framework is proposed. This has developed from a synthesis of the current evidence combined with the clinical observations of the authors. It recognises the presence of both specific and non-specific musculoskeletal PGP disorders. It acknowledges the complex and multifactorial nature of chronic PGP disorders and the potential of both the peripheral and central nervous system to promote and modulate pain. It is proposed that there is a large group of predominantly peripherally mediated PGP disorders which are associated with either 'reduced' or 'excessive' force closure of the pelvis, resulting in abnormal stresses on pain sensitive pelvic structures. It acknowledges that the interaction of psychosocial factors (such as passive coping strategies, faulty beliefs, anxiety and depression) in these pain disorders has the potential to promote pain and disability. It also acknowledges the complex interaction that hormonal factors may play in these pain disorders. This classification model is flexible and helps guide appropriate management of these disorders within a biopsychosocial framework. While the validity of this approach is emerging, further research is required.     

Prevention of chronic pain after whiplash

The acute whiplash injury is a significant health burden for patients and the healthcare system. Traditional approaches to treatment fail to resolve this ever growing medicolegal and social problem. A new biopsychosocial model of whiplash disorder encourages new ways of treating and preventing of the chronic disability. This biopsychosocial model takes into account the mechanism by which acute pain becomes chronic pain, and how this can be prevented. Specific education and treatments encourage a behaviour after whiplash injury that is conducive to more rapid recovery, and provides the whiplash patient with insight into the mediators of chronic pain. The article describes in practical terms how to use education, reassurance, a more judicious use of therapy, and exercise to achieve this goal. Practical guidelines are provided on educating the patient about other symptoms that may cause concern.     

The management of atypical non-cardiac chest pain

Atypical, non-cardiac chest pain is common and disabling, and often persists despite negative medical investigations. Aetiology is disputed and management is difficult. A multi-causal model in which both psychological and physical factors play a part is helpful; a fundamental factor is continued misinterpretation of minor physical symptoms as evidence of heart disease. We report supportive evidence and describe a psychological treatment derived from the model. In a randomized trial, cognitive behavioural methods were effective in reducing chest pain, disability and use of medication, in patients both with and without psychiatric disorder. The clinical implications are discussed.     

Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients.

The purpose of the present study was to test a hypothetical model of the relationships between perceived social support, coping responses to pain, pain intensity, depressed mood, and functional disability (functional status and functional impairment) in a population of patients with chronic pain in a Spanish Clinical Pain Unit. It was postulated that social support and pain coping responses both independently influence reported pain intensity, depressed mood, and functional disability. Analyses were performed by Structural Equation Modelling. The results indicated that satisfaction with social support is significantly associated with a depressed mood and pain intensity, but not with functional disability. Although this effect is independent of the use of active coping responses by patients, there is a modest but significant relationship between social support and passive coping strategies, indicating that higher levels of perceived social support are related to less passive pain coping strategies. The findings underscore the potential importance of psychosocial factors in adjustment to chronic pain and provide support for a biopsychosocial model of pain. PERSPECTIVE: This article tested a hypothetical model of the relationships between social support, pain coping, and chronic pain adjustment by using Structural Equation Modelling. The results indicate that perceived social support and pain coping are independent predictors of chronic pain adjustment, providing support for a biopsychosocial model of pain.