Psychosocial Aspects of Pain Flashcards

Definition and Impact of Pain

• IASP Definition of Pain: The International Association for the Study of Pain (IASP) defines pain as "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."

• Low Back Pain (LBP) Prevalence:

  • Low back pain is the most widely reported musculoskeletal (MSK) disorder in the United States.

  • It is the second most common reason for seeking medical treatment, following the common cold.

  • Approximately $80\%$ of people will develop low back pain at some point during their lifetime.

• Disability and Economic Trends:

  • The prevalence of LBP is currently the same as it was $100$ years ago, yet the associated disability has increased significantly.

  • Economic impact is highly concentrated: $10\%$ of patients with low back pain account for nearly $90\%$ of the total cost.

The Biopsychosocial Model of Pain

• Foundational Concept: This model posits that pain management must consider three intersecting factors:

  • Biological factors: Anatomy, physiology, and pathology.

  • Psychological factors: Cognitions, emotions, and beliefs.

  • Social factors: Environment, work, family, and culture.

• Role of Cognitions: Cognitions are at the heart of the psychosocial portion of the model. The relative influence of each aspect varies from patient to patient.

• Model Components:

  • Anatomy and Pathoanatomy

  • Biomechanics

  • Pain Mechanisms

  • Beliefs, fears, and threats

  • Representations (how the patient views their condition)

  • "Onion Skins" (layers of complexity in pain presentation)

  • Evolutionary biology

Shifting Patient Inquiries for Persistent Pain

In cases of persistent pain, providers should help patients modify their questions to focus on prognosis and self-efficacy rather than just structural pathology:

• Structural Focus: "What is wrong with me?" vs. Functional/Biological Focus: "Why do I hurt?" or "Why do I still hurt?"

• Temporal Focus: "How long will it take?" vs. Hope-based Focus: "Is there any hope? Can this get better?"

• Actionable Focus: "What can I do for it?" and "What can you (the provider) do for it?"

• Practical Focus: "How much will it cost?"

The Flag System for Clinical Risk Assessment

• Red Flags: Indicate safety concerns and potential serious pathology needing medical referral.

• Blue Flags: Relate to occupational issues.

• Black Flags: Relate to socio-occupational issues (broader societal or financial factors).

• Orange Flags: Indicate psychiatric symptoms, such as clinical depression or personality disorders.

• Yellow Flags: Psychosocial factors that correlate to the development of persistent pain. These include:

  • Behaviors: Extended rest, withdrawal from social life, non-compliance with therapy, reporting extreme pain (e.g., $15$ on a $0-10$ Visual Analog Scale), excessive reliance on aids/appliances, sleep problems, smoking, and high intake of alcohol or medication.

  • Work: History of manual work, job dissatisfaction, problems with peers/supervisors, low educational background, low socioeconomic status, high physical demand, and working night shifts.

  • Diagnosis and Treatment: Health professionals sanctioning disability, conflicting diagnoses, diagnostic language leading to catastrophization/fear, visiting a high number of healthcare providers, expectation of a "techno-fix," and lack of treatment satisfaction.

  • Emotions: Depression, irritability, anxiety, and fear of increased pain with activity, work, or therapy.

  • Family: Overprotective spouse or punitive responses from a spouse.

  • Compensation Issues: Lack of financial incentive to return to work and a history of claims for other injuries.

Clinical Efficacy and Provider Accuracy

• PT Accuracy in Triage: In a study of $410$ Physical Therapists (PTs):

  • $53\%$ ($217$ PTs) correctly managed a patient with LBP and ectopic pregnancy (warning flag).

  • $28.5\%$ ($115$ PTs) correctly managed LBP and depression symptoms.

  • $43.2\%$ ($177$ PTs) correctly managed LBP and Fear-Avoidance Beliefs (FAB).

• Specialization Impact: PTs with specializations performed significantly better across clinical vignettes, though overall ability to manage warning flags was relatively low.

• Self-Reported Competence: Physical therapists reported the lowest competence when managing patients with high levels of distress.

• Conclusion: Valid assessment tools are essential to provide prognostic information and improve patient outcomes.

Standardized Psychosocial Assessment Tools

• Fear-Avoidance Beliefs Questionnaire (FABQ): Developed by Waddell et al. ($1993$). It uses a $0-6$ scale (Completely Disagree to Completely Agree) to assess how physical activity and work affect back pain.

  • Physical Activity items: Inclusion of thoughts that activity may harm the back or should be avoided.

  • Work items: Inclusion of concerns regarding manual labor, injury at work, compensation claims, and the timeline for return to work.

• OSPRO Yellow Flag (OSPRO-YF) Tool: A multidimensional tool available in $17$-item, $10$-item, and $7$-item versions. It identifies yellow flags across three domains:

  • Negative Mood Domain: Assesses depression (PHQ-9), state-trait anxiety (STAI), and state-trait anger (STAXI).

  • Fear Avoidance Domain: Assesses Fear Avoidance Beliefs (FABQ-W and FABQ-PA), Pain Catastrophizing (PCS), Kinesiophobia (TSK-11), and Pain Anxiety (PASS-20).

  • Positive Affect/Coping Domain: Assesses Pain Self-Efficacy (PSEQ), Self-Efficacy for Rehabilitation (SER), and Chronic Pain Acceptance (CPAQ).

Processing and Perception: Cognitive Models

• Mature Organism Model: A framework for understanding pain processing:

  • Input: Tissues, environment, culture, job, beliefs, and experiences.

  • Processing: The brain integrates input with memories and knowledge.

  • Output: The mature organism produces an output (such as pain) based on the appraisal of threat.

• Pain Neuromatrix: The primary pain map is influenced by beliefs, knowledge/logic, social context, anticipated consequences, and other sensory cues.

  • Factors affecting the neuromatrix include gender, culture (stoic vs. emotive), media, personality, socioeconomic status, and social support.

  • The end result is the brain's appraisal of the total threat to the organism.

The Fear Avoidance Model

• Definition of Fear: A distressing negative experience induced by a perceived threat.

• Persistent Pain Context: Often associated with the belief that movement will damage tissues.

• Pathways Following Injury:

  • Path A (Confrontation/Recovery): Occurs when there is "No Fear." The patient believes "I'm good," "I'll be okay," "Keep moving," or "No pain, no gain."

  • Path B (Avoidance/Disability): Triggered by Pain Catastrophizing and Negative Affectivity. This leads to Pain-Related Fear, which results in Avoidance, Disuse, Depression, and Disability.

• Cycle of Avoidance:

  • Input: Threatening illness information (e.g., "I have a bulging disc," "I will be in a wheelchair").

  • Process: Irrational thoughts lead to pulling back and doing less.

  • Outcome: Disuse leads to increased fear and further disability.

Pain Catastrophizing

• Definition: The inability to foresee anything other than the worst possible outcome.

• Characteristics:

  • Closely tied to the Fear Avoidance Model.

  • Often occurs after exposure to rigid biomedical models or education.

  • Strong correlation between increased catastrophizing and increased pain levels.

• Examples of Catastrophizing Beliefs:

  • Belief that pain is always bad.

  • Belief that all pain must be gone before resuming activity.

  • Belief that passive treatment (being "fixed" by another) is the only answer.

  • Belief that work is inherently harmful.

Mental Health and Trauma

• Prevalence in PT: $1$ in $5$ people in the US suffer from a mental, behavioral, or emotional disorder. In outpatient PT settings, $1$ in $6$ patients presents with moderate to severe depression.

• APTA Position (#P06-20-40-10): As of $2020$, it is within the professional scope of physical therapist practice to screen for and address behavioral and mental health conditions.

• Adverse Childhood Experiences (ACEs): Traumatic events (violence, abuse, neglect, instability) occurring between ages $0-17$.

  • $61\%$ of adults have experienced at least one ACE.

  • High ACE scores are associated with persistent pain and increased opioid use in adulthood.

• The Three E’s of Trauma:

  • Event: Exposure to a traumatic or stressful event.

  • Experience: The individual's unique perception of the event.

  • Effects: The long-lasting adverse consequences of the event.

Social Determinants of Health (SDOH)

• Definition: The conditions in environments where people are born, live, learn, work, play, worship, and age.

• Clinical Relevance: These factors affect health functioning and quality of life outcomes.

• Therapist Responsibilities:

  • Be aware of SDOH and its impact on clinical presentation.

  • Recognize the importance of patient self-efficacy.

  • Understand the community being served.

  • Advocate for patients in need and build trust.