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

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


1
Psychological Factors in the Assessment and
Treatment of Chronic Low Back Pain
2
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

3
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

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

5
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

6
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
    forming

7
Personality Disorders
  • Not causal in the development of chronic pain
  • Compromise a patients coping skills
  • Produce poorer treatment outcomes

8
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)

9
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

10
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.

11
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

12
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)

13
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
    patients
  • (Smeets et al, 2006)

14
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)

15
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.

16
Education
  • Encourages well behaviour
  • Increases physical performance and reduces
    pain-related neural activation

17
Behavioural Models
  • Pain becomes chronic because pain behaviours are
    positively reinforced and well behaviours are not

18
Pain Behaviour
  • Groaning
  • Sighing
  • Crying
  • Avoiding movement
  • Reinforced by
  • Attention
  • Sympathy
  • Care

19
Family Dynamics
  • Role tension
  • Marital conflict
  • Reduced sexual activity
  • Social isolation
  • Anger
  • Anxiety
  • Resentment
  • (Snelling, 1994)

20
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
    children.
  • I dont want them to worry about how I feel.
  • (Smith Friedman, 1999)

21
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)

22
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

23
Conclusions
  • 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

24
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

25
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
    methods
  • CBT has been shown to be an effective treatment
    for CLBP

26
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.or
    g.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.

27
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 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,
    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.
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