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“Pain is an unpleasant sensory and emotional experience associated with actual
or potential tissue damage or described in terms of such damage.”
—International
Association for the Study of Pain, 1973
“Viewing chronic nonmalignant pain in strictly disease model terms is the
moral equivalent of kicking the refrigerator when the TV does not work.”
—Wilbert
Fordyce, Ph.D., 1994
Back pain is universal and is the leading cause of disability and absenteeism
from the workplace, yet specific causes of back pain, such as infections, tumors,
osteoporosis, spondyloarthopathies, and trauma, represent a minority of pain
syndromes.(1) Conversion of acute back pain to chronic may be in part iatrogenic
and is often strongly driven by psychological and psychosocial factors including
fear of pain and re-injury, catastrophizing, depression, anxiety and fear of
“decompensation” (loss of income or secondary gain).(2, 3, 4) Failure to address
and treat these issues in chronic back pain often leads to continued disability.
Chronic pain is a complex social problem with medical aspects and should be
assessed and treated as such. Towards such ends, a multi-disciplinary assessment
of the patient can identify important psychological and psychosocial variables
and help drive appropriate treatment. A multi-disciplinary evaluation of back
pain should include a thorough medical evaluation of the spine, surgical and
interventional consultation as appropriate, evaluation by a PT specializing
in back pain to help address fear of movement and pain as well as biomechanical
issues, and, at a minimum, a screening for perceived level of disabilityand
mood disturbance, including depression and anxiety—both are found in the literature
to contribute significantly to the perception of pain. Once these issues have
been identified, treatment can focus on reducing pain and improving mood and
function.
The natural history of low back pain is variable; however, it is clear that
the vast majority of patients recover quickly. The task of early identification
of those who may progress to a Chronic Pain Syndrome has largely been elusive.
Although recognizing a Chronic Pain Syndrome is relatively easy once it has
occurred, predicting its development has been harder. A number of personality
characteristics have been thought to predict chronicity (age, sex, specific
diagnosis, marital status, education, income, history of anxiety and depression,
and current depression), but in fact, the findings in the literature are not
consistent. When variables are identified, they account for little of the variance
when examined statistically. Once it has developed, however, a Chronic Pain
Syndrome is characterized by intractable pain along with marked changes in behavior,
affect, restrictions of daily activities and an overutilization of health care
recourses.
Simply identifying the physical factors involved in the manifestation of the
chronic pain and prescribing somatic treatments have been shown not to eliminate
eliminate these symptoms for a significant subgroup of patients. A number of
factors may contribute to the development of Chronic Pain Syndrome, and some
may include pending litigation, an avoidance of responsibility, assumption of
the sick role, avoiding an unpleasant work environment and taking on the role
of a patient. Many of these characteristics and the emotional symptomatology
found in the Chronic Pain Syndrome are amenable to behavior modification and
are treated well with cognitive behavioral therapy and psychophysiological pain
and stress management techniques, such as biofeedback, relaxation training, and
self-hypnosis. Successful rehabilitation relies on the appropriate treatment
for mood disturbance, including anti-depressant medication and psychotherapy,
as well as the reinforcement of wellness behaviors, such as activity and removal
of reinforcements for pain behaviors.
General References
1. Ehrlich GE. J Rheumatology 2003.
2. c.f. Vowles and Gross Pain 2003.
3. Hadjistavropoulos et al Behavior Research and Therapy 2000.
4. Systematic Review of Psychosocial Factors at Work and Private Life as Risk
Factors for Back Pain. Spine. 25(16):2114-2125, August 15, 2000. Hoogendoorn,
Wilhelmina E. MSc
Spinal Column, Spring 2005. Cleveland Clinic Spine Institute (CCSI).
Copyright @2005. Cleveland Clinic Foundation. All Rights Reserved.
http://cms.clevelandclinic.org/spine/documents/Spinal%20Column%20Sp05.pdf
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