Psychosocial approaches to the prevention of chronic pain: the low back paradigm

doi:10.1053/berh.1999.0044

Best Practice & Research Clinical Rheumatology

Volume 13, Issue 3, September 1999, Pages 545-554

https://doi.org/10.1053/berh.1999.0044 Get rights and content

Abstract

Psychosocial factors have the potential to influence an acute musculoskeletal pain problem at three distinct phases: the onset of pain; the seeking and receiving of health care and income support; and the development of chronic pain-related disability and work loss. Clinical management that ignores psychosocial factors has done little to stem the flow of individuals from acute to chronic pain and disability. Psychosocial factors are no longer considered as mere secondary reactions to pain. We now recognize that psychosocial factors are usually the best predictors of chronicity, and that many of the learned behaviours apparent in chronic musculoskeletal pain have their genesis in the first few days and weeks of the problem. These circumstances have combined to shift an emphasis onto the early care provided for patients by primary care health professionals. The concept of Red Flags as signs of serious disease has been extended to the readily understood idea of Yellow Flags that indicate psychosocial barriers to recovery. For many individuals these issues need to be addressed so that the risk of developing long-term disability and work loss can be reduced. Doing this is not mutually exclusive with providing for the biomedical needs of patients.

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Cited by (87)

How to assess the presence of psychosocial factors in adults with chronic musculoskeletal pain in physiotherapy? (Delphi survey)
2022, Kinesitherapie
L’approche biopsychosociale est préconisée dans le cadre du traitement des patients atteints de douleurs chroniques. Cependant, il n’existe pas de recommandations sur la manière la plus adéquate pour les kinésithérapeutes de procéder à l’évaluation des facteurs psychosociaux.
Établir un consensus d’experts sur l’évaluation des facteurs psychosociaux dans le traitement de patients adultes atteints de douleurs chroniques musculo-squelettiques.
Cette étude a été réalisée selon la méthode Delphi, une méthode recommandée pour la construction de consensus. Dix-sept kinésithérapeutes, experts en douleur chronique, ont été interrogés via des questionnaires en ligne afin de définir : (1) ce que sont les facteurs psychosociaux ; (2) comment les évaluer ; (3) quels outils peut utiliser un kinésithérapeute ; (4) quel comportement le kinésithérapeute doit adopter ; (5) combien de temps est nécessaire pour l’évaluation des facteurs psychosociaux.
Le consensus obtenu fait ressortir qu’une dizaine de facteurs psychosociaux peuvent impacter la kinésithérapie : environnement familial, environnement professionnel, dépression, anxiété, catastrophisme, entourage social, kinésiophobie, croyances erronées, stratégies d’adaptations, comportements de peur-évitement. Les experts ont indiqué que l’évaluation de ces facteurs devrait se dérouler sur plusieurs séances, en utilisant des questions ouvertes, des questionnaires validés et que le comportement non-verbal du kinésithérapeute (posture, orientation, expressions faciales, hochement de tête, contact visuel) influence l’examen clinique. De plus, observer le comportement non verbal du patient est recommandé pour faciliter cette évaluation.
À notre connaissance, ce travail est le premier de ce type à se concentrer sur les modalités de réalisation de l’évaluation des facteurs psychosociaux chez les patients douloureux chroniques. Ces recommandations peuvent être appliquées sur le terrain pour guider les kinésithérapeutes dans cette démarche, tout en étant bénéfiques pour les patients.
NA.
The biopsychosocial approach is recommended in the management of patients with chronic musculoskeletal pain. However, there are no recommendations on the most appropriate way for physiotherapists to assess psychosocial factors.
To establish an expert consensus on the assessment of psychosocial factors related to chronic musculoskeletal pain in adults.
This study used the Delphi method to establish recommendations. Seventeen physiotherapists experts in chronic pain were interviewed via online questionnaires in order to define: (1) what psychosocial factors are; (2) how to assess them; (3) what tools can a physiotherapist use; (4) what behavior the physiotherapist should adopt; (5) how much time is needed to assess psychosocial factors.
The consensus obtained highlights ten psychosocial factors that can impact physiotherapy treatment: family environment, professional environment, depression, anxiety, catastrophizing, social environment, kinesiophobia, false beliefs, coping, fear-avoidance behavior. Experts have pointed out that the assessment of these factors should requires several physiotherapy sessions, in which it is recommended to use open questions and validated tools and that physiotherapist's non-verbal behavior (posture, orientation, eye contact, nod of the head, facial expression) influences the clinical examination. Finally, observing the patient's non-verbal behavior is recommended to facilitate this assessment.
To our knowledge, this study is the first to focus on how to conduct an evaluation of psychosocial factors in patients with chronic pain. These recommendations can be applied in practice to guide therapists in this process, while benefiting patients in their care.
NA.
Physical and Psychosocial Factors in the Prevention of Chronic Pain in Older Age
2018, Journal of Pain
Chronic pain is recognized as a major challenge as people age. Yet, despite growing research on chronic pain management, there is little research into chronic pain prevention. Thus there is a clear need to identify multimodal activities that could be encouraged among older adults as part of a healthy lifestyle to decrease the incidence risk of chronic pain. Using data from the English Longitudinal Study of Ageing we tracked 2,631 adults aged ≥50 years who were free from chronic pain at baseline across a decade and explore whether physical or psychosocial factors reduced the risk of developing chronic pain. In relation to physical factors, engaging in vigorous weekly activity was protective against the development of chronic pain (odds ratio 0.74, standard error 0.07, 95% confidence interval 0.62–0.89) when controlling for all identified socioeconomic, health, and social confounders. However, no effects were found for moderate weekly activity. In relation to psychosocial factors, cultural engagement was also protective against the development of chronic pain (odds ratio 0.75, standard error 0.07, 95% confidence interval 0.63–0.91), but community group participation was not. These findings extend previous work showing that physical activity and psychosocial factors such as positive affect are key factors in the long-term success of chronic pain self-management. Future interventional studies for chronic pain are encouraged.
This article explores whether physical and psychosocial activities could reduce the risk of developing chronic pain in older age. These results could potentially help clinicians to recommend multimodal activities as part of a broader healthy lifestyle for those aged ≥50 years to reduce the incidence rate of chronic pain.
A Qualitative Study of Doctors of Chiropractic in a Nova Scotian Practice-based Research Network: Barriers and Facilitators to the Screening and Management of Psychosocial Factors for Patients With Low Back Pain
2018, Journal of Manipulative and Physiological Therapeutics
This study aimed to assess chiropractors’ awareness of clinical practice guidelines for low back pain and to identify barriers and facilitators to the screening and management of psychosocial factors in patients with low back pain.
This qualitative study used semi-structured interviews informed by the Theoretical Domains Framework with 10 Nova Scotian chiropractors who were members of a practice-based research network.
The participants correctly identified what the guidelines generally recommend and described the value of psychosocial factors; however, none of the participants could name specific clinical practice guidelines for low back pain. We identified 6 themes related to barriers and facilitators for chiropractors screening and managing psychosocial factors. The themes revolved around the participants’ desire to fulfill patients’ anatomy-focused treatment expectations and a perceived lack of training for managing psychosocial factors. Participants had concerns about going beyond the chiropractic scope of practice, and they perceived a lack of practical psychosocial screening and management resources. Social factors, such as the influence of other health care practitioners, were reported as both barriers and facilitators to screening and managing psychosocial factors.
The participants in this study reported that they mostly treated with an anatomical and biomechanical focus and that they did not always address psychosocial factors identified in their patients with low back pain. Although these findings are limited to Nova Scotian chiropractors, the barriers identified appeared to be potentially modifiable and could be considered in other groups. Low-cost interventions, such as continuing education using evidence-informed behavior change techniques, could be considered to address these barriers.
‘I need to do another course’ - Italian physiotherapists' knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain
2017, Musculoskeletal Science and Practice
Psychosocial factors play an important role in the development and subsequent recovery of individuals suffering from chronic low back pain (CLBP). The study explored physiotherapists' personal beliefs and knowledge about the biopsychosocial model and the different ways they assess and manage psychosocial factors in patients presenting with CLBP.
Qualitative research design using semi-structured interviews and a constructivist grounded theory approach to data collection and analysis. A purposive sample of eight physiotherapists practicing in Italy and having experience with patients presenting chronic musculoskeletal problems were recruited from private clinics.
Three main categories were constructed: 1) conceptions of the biopsychosocial model and its role in CLBP; 2) evaluation and management of PS factors; 3) barriers in the assessment and treatment.
Physiotherapists showed a basic knowledge of the biopsychosocial model and partially recognised social, emotional, cognitive and psychological factors in chronic low back pain patients, and their contribution in the individual patient's pain and disability. Physiotherapists highlighted the presence of barriers in the evaluation and treatment of people with CLBP, and some participants displayed a lack of skills to overcome these barriers. Physiotherapists perceived limited education and training to successfully address psychosocial factors in the management of patients with chronic low back pain, indicating the need to incorporate the biopsychosocial model in the daily practice and improve the training and education of the psychosocial assessment and management.
Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study
2016, Journal of Physiotherapy
Question: What are physiotherapists’ perspectives on managing the cognitive, psychological and social dimensions of chronic low back pain after intensive biopsychosocial training? Design: Qualitative study design using semi-structured interviews to explore physiotherapists’ perceptions of their identification and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive Functional Therapy (CFT) training. Participants: Thirteen qualified physiotherapists from four countries who had received specific CFT training. The training involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive descriptive analysis was performed using a qualitative software package. Results: Four main themes emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in professional practice; altered scope of practice; and increased confidence and satisfaction. Participants described increased understanding of the nature of pain, the role of patient beliefs, and a new appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in communication, and adoption of a functional approach. Since undertaking CFT training, participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors. Conclusion: Physiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training, so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case. [Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K (2016) Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study. Journal of Physiotherapy 62: 215–221]
"We're all in this together": A qualitative study of predominantly low income minority participants in a yoga trial for chronic low back pain
2016, Complementary Therapies in Medicine
Citation Excerpt :
Chronic low back pain (cLBP) is a complex condition.1 Psychosocial factors may play a significant role in how well a person with low back pain (LBP) functions and copes with their pain.2,3 Socioeconomic disparities can often exacerbate the severity of cLBP and limit access to treatment.4–9
To explore the experiences of low-income minority adults taking part in a yoga dosing trial for chronic low back pain.
Individual semi-structured interviews were conducted with nineteen participants recruited from a randomized yoga dosing trial for predominantly low-income minority adults with chronic low back pain. Interviews discussed the impact of yoga on low back pain and emotions; other perceived advantages or disadvantages of the intervention; and facilitators and barriers to practicing yoga. Interviews were audio taped and transcribed, coded using ATLAS.ti software, and analyzed with inductive and deductive thematic analysis methods.
Boston Medical Center, Boston, MA, USA.
Participants viewed yoga as a means of pain relief and attributed improved mood, greater ability to manage stress, and enhanced relaxation to yoga. Overall, participants felt empowered to self-manage their pain. Some found yoga to be helpful in being mindful of their emotions and accepting of their pain. Trust in the yoga instructors was a commonly cited facilitator for yoga class attendance. Lack of time, motivation, and fear of injury were reported barriers to yoga practice.
Yoga is a multidimensional treatment for low back pain that has the potential to favorably impact health in a predominantly low-income minority population.

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Regular ArticlePsychosocial approaches to the prevention of chronic pain: the low back paradigm

Abstract

Archives of Physical Medicine and Rehabilitation

Behaviour Research and Therapy

Pain Forum

Pain Forum

Pain

Pain

The epidemiology of spinal disorders

The impact of spinal disorders in industry

The disabling backache: an international perspective

Spine

MMPI scale 3 as a predictor of back injury report: what does it tell us?

Clinical Journal of Pain

The role of demographic and psychosocial factors in transition from acute to chronic pain

Pain and Disability: Clinical, Behavioural, and Public Policy Perspectives

General considerations of chronic pain

Back Pain in the Workplace: Management of Disability in Nonspecific Conditions

The Back Pain Revolution

Manual therapy round—low back pain: treatment and prevention

Journal of Manual and Manipulative Therapy

Keynote address for primary care forum—low back pain: a twentieth century health care enigma

Spine

Developing outcome assessments: a step-by-step approach

New Zealand Journal of Physiotherapy

Physical Rehabilitation Outcome Measures

Conservative therapy for low back pain: distinguishing useful from useless therapy

Journal of the American Medical Association

Practice variations, treatment fads, rising disability: do we need a new clinical research paradigm?

Spine

Mitigating the dangers of pursuing cure

A pilot programme for dealing with the comorbidity of chronic pain and long-term unemployment

Journal of Occupational Rehabilitation

Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders

Spine

The Annex to the Clinical Standards Advisory Group's Report on Back Pain

Guidelines for the Management of Back-Injured Employees

Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining ‘whiplash’ and its management

Spine

Low Back Pain Evidence Review

Predicting outcome of chronic back pain using clinical predictors of psychopathology: a prospective analysis

Health Psychology

Screening for patients at risk of developing chronic incapacity

Journal of Occupational Rehabilitation

Regular Article
Psychosocial approaches to the prevention of chronic pain: the low back paradigm