Psychological Factors in the Assessment and Treatment of Chronic Low Back Pain - PowerPoint PPT Presentation


PPT – Psychological Factors in the Assessment and Treatment of Chronic Low Back Pain PowerPoint presentation | free to view - id: 7e59f-ZDc1Z


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Psychological Factors in the Assessment and Treatment of Chronic Low Back Pain


The Orthopedic clinics North America, 22, 263-271. Gatchel, R. J. (2000) ... Clinical Orthopaedics and Related Research, 279, 8-20. ... – PowerPoint PPT presentation

Number of Views:541
Avg rating:3.0/5.0
Slides: 28
Provided by: jade6


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Psychological Factors in the Assessment and Treatment of Chronic Low Back Pain

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)
  • Lifetime prevalence 60 - 80
  • (Frymoyer Cats-Baril, 1991)
  • 90 recover from LBP in less than 12 weeks
  • 5 to 10 report persisting pain and disability
    after 3 months

3-4 months
2 weeks
1 month
BioPsychoSocial Models
  • The experience of pain involves
  • Biological factors -nociception, tissue damage
  • Psychological factors - cognitions, emotions
  • Social factors -family dynamics, employment

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
    pre-emptively to prevent this neural memory from

Personality Disorders
  • Not causal in the development of chronic pain
  • Compromise a patients coping skills
  • Produce poorer treatment outcomes

Clinical Examples
  • Neurotic patients worry about minor residual
  • Patients with borderline personality disorder
    demand immediate special attention and becoming
    angry or passive-aggressive when denied special
  • (Weisberg Keefe, 1999)

  • 30 to 100 of chronic pain patients suffer from
  • (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 re-injury
  • 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 ?.
  • Bogduk (in press)

Cognitive Behavioural Therapy
  • CBT is recommended by the Australian Pain Society
    as a psychological treatment for pain
  • Increasing activity levels and problem-solving
    training led to significant reductions in pain
    intensity and functional limitations in 212 CLBP
  • (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 return-to-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 one-to-one education
    session about the physiology of pain
  • Note marked reduction in activation, excepting
    primary somatosensory areas, after 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 dont want to hear about the pain.
  • I get angry when someone makes a comment about
    me being sick.
  • I feel guilty when I cant do things with the
  • I dont want them to worry about how I feel.
  • (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
  • 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

  • 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

Psychological Assessment Treatment of CLBP
  • Depression, 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
  • CBT has been shown to be an effective treatment
    for CLBP

  • Adams, N., Ravey, J., Taylor, D. (1996).
    Psychological models of chronic pain and
    implications for practice. Physiotherapy, 82,
  • Bogduk, N. (in press). Psychology and low back
    pain. International Journal of Osteopathic
  • 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,
  • 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.or
  • 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.

  • 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 Cognitive-behavioural, 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,
  • 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.