The Psychology of Chronic Back Pain
Psychological risk factors for chronicity and our challenge as clinicians: finding the right treatment mix.
By David J. Brunarski, DC, MSc, FCCS(C)
In 1986, Nortin Hadler commented in The New England Journal of Medicine that regional back pain had a tendency to become worse the more it was treated.1 And the Scandinavian Journal of Rheumatology quotes Aage Indahl: " The multitude of different treatments offered to patients must be regarded as pain-modulating modalities and not as cures for low back pain. There is no treatment that has been proven to be highly effective."2 A systematic review on the effectiveness of physical and rehabilitation interventions for chronic nonspecific low back pain, published this year in the European Spine Journal, concluded that "only multidisciplinary treatment, behavioural treatment, and exercise therapy should be provided as conservative treatments in daily practice in the treatment of chronic low back pain."3 A June 2011 update of a Cochrane review regarding spinal manipulative therapy for chronic low back pain stated: "[T]here was no clinically relevant difference between spinal manipulative therapy and other interventions for reducing pain and improving function in patients with chronic low-back pain."4
Back pain was "medicalized" for most of the 20th century in terms of an "injury model." Disc disease and degeneration were identified as the culprits, so victims were advised to rest, avoid strenuous activity and medicate. When that approach logically failed, surgical treatments became de rigueur for decades.
Alternative treatment, including chiropractic, became popular as education and personal wealth improved. The "wellness movement" has empowered patients to manage their own health care needs and share decisions with health care providers of their choice. Cognitive behavioural treatment (CBT) and educational approaches increasingly emphasize a "non-injury model" of back pain, which articulates "that the back is strong, that loads normally do not cause any damage despite occasional temporary pain, that reducing the focus on pain might facilitate more natural and less painful movements, and that it is beneficial to stay physically active."5
However, despite this early optimism, nearly 34 percent of individuals who suffer an episode of low back pain will continue to experience recurrent episodes.6 With so much evidence and expertise available, is the problem all in their heads? The fear-avoidance model (FAM) suggests that a unique minority of individuals do possess an exaggerated pain perception and a robust psychological avoidance strategy that often contribute additional physical and psychological layers to their original musculoskeletal complaint.7
As doctors of chiropractic, we know that even with appropriate care, some patients retain such high psychological distress that their clinical outcomes are poor. These patients demonstrate negative appraisal of their internal and external stimuli, leading to poor self-efficacy and suboptimal performance of requested tasks. These patients often exhibit pain intensity that is atypically elevated. Their escape/avoidance behaviour becomes enhanced such that their movements are intensely guarded, leading to deconditioning and disuse. The result is that the patient's physical impairments are increased and their disability prolonged.8-9 Wideman and Sullivan describe the process as a cascade of pain-related fear that devolves into pain catastrophizing, depression and long-term disability.10
The extent to which the appropriate patient receives the correct treatment mix is the new clinical challenge. Evaluating the various psychological risk factors against the patient's physical capacity for change and improvement may be enhanced through the use of validated psychological measurement tools. These tools have been found to be useful in classifying chronic pain patients into more homogenous groupings that encourage better treatment plans, outcome management and continuing care.
Dr. David Brunarski, former associate editor of DC Canada, graduated from CMCC in 1977 after completing his undergraduate educa-tion at the University of Alberta. He is president of the Ontario Chiropractic Association and practices full time in Simcoe, Ontario. To learn more, visit www.dynamicchiropractic.ca/drbrunarski.