Pain, disability and psychosocial factors

Something that can really get my goat is when people think that because someone has high disability, and they have pain, it must be the pain that ’causes’ the disability – therefore reduce the pain, and you will inevitably reduce the disability.

This can lead to over-treatment of pain with medication (to reduce the pain, often in response to the person saying that their pain is ‘getting worse’, and limited attention to the factors that are associated with the person seeking treatment or having difficulty reducing their disability. What’s worse is that while a pain reduction treatment initially reduces pain, it doesn’t address the factors that lead to a person seeking treatment or those that contribute to disability.

Now I know that I have a bias towards psychosocial factors, but to disregard these factors and to treat only the pain using pain reduction can leave some people over-treated with pain reduction interventions, but continuing to experience distress and disability because those psychosocial factors are not addressed.

I’ve come across this paper by Truchon, Cote, Fillion, Arsenault & Dionne (2007), which nicely integrates psychosocial factors associated with low back pain disability into a ‘stress process model’.

The stress process model ‘attempts to explain how individuals react to life events that are generally associated with substantial adaptations.’ While this model doesn’t attempt to explain why some people experience low back pain, it does attempt to explain low back disability. They are not the same.

From this study, using some very well-known assessment tools, the authors crunched numbers and were able to form a structural model that demonstrates what some of us have seen in our clinical work: life events and injury cognitive appraisal had a direct influence on emotional distress. The indirect contribution of life events to explain disability through emotional distress is consistent with the literature on the stress process model.

The link between cognitive appraisal in terms of harm and lack of control and emotional distress has received considerable empirical validation in the stress literature, but less so in the low back pain literature. The perception of physical activity as harmful to back health and a perceived lack of control over pain were likely to lead to the use of physical-activity-avoidance strategies.

This is critical where an individual has received a pain reduction intervention but continues to perceive that ‘structural weakness’ in the back is present. What may happen is that any fluctuation in pain intensity (after surgery or with medication), particularly any increase after a period of time when the pain has reduced, can be perceived as confirmation that ‘things are not right’, leading to activity avoidance. Alternatively, unregulated activity levels can lead to times when over-activity is then followed by under-activity dependent on pain levels. Pain levels increase after over-activity possibly because of lack of conditioning for the specific tasks…

Finally, and probably most importantly, emotional distress was directly linked to coping strategies. This signifies that the more an individual feels distress, the more he or she tends to avoid physical activity. These results suggest that addressing cognitions and distress in clinical settings [my emphasis] could increase compliance with staying active.

And finally, the combination of emotional distress and coping strategies contributed to explaining over half the variance of functional disability in the subacute stage, as measured by the Roland–Morris questionnaire.

What makes this study unusual is the inclusion of life events that may influence the general coping quality of an individual experiencing low back pain. Some of the most stressful life events include pregnancy and birth, loss of a job, relationship changes, as well as numerous ‘life hassle’s that have a cumulative effect. Maybe it’s time we assessed for life events around the time of the onset of acute low back pain, to establish whether more attention than usual should be paid to helping someone cope more effectively with back pain, rather than merely providing pain relief.

TRUCHON, M. (2007). Low-back-pain related disability: An integration of psychological risk factors into the stress process model. Pain DOI: 10.1016/j.pain.2007.10.019



  1. Great article. As a chiropractor, I see the psychosocial effects of chronic pain and disability on a regular basis. I am a strong supporter of the need for CBT in all long term disability cases. Often, its a patient’s own fear avoidance behaviours that slow recovery!

  2. Hi drdebbie
    You’ve observed what so many of us have – it’s not the pain, but the fear of pain that prevents recovery (amongst a few other things!)
    I’m glad to hear that you use CBT, it’s not the only way forward, but it does have a good deal of research evidence to support it, and it’s not just for psychologists!!
    thanks for taking the time to comment, and I hope to see you back!

  3. Googling something to do do with pain related disabilties and I get you, can’t escape you no matter how hard I try!

  4. Thanks all you experts, but no thanks. It’s not the fear of the pain that prevents recovery, it’s the structural defect. It’s not the perception of a structural defect, it’s a structural defect.

    1. Thanks for taking the time to comment on this post. Firstly I’d like to say that I’m no expert in pain – but I do work in the area, have chronic pain myself, and read widely. So I’m persuaded that pain is not as simple as a structural defect – or at least, the structural defect alone is not entirely responsible for the experience I have. And as a very wise colleague said that if it’s possible to have defective joints, defective skin, defective heart, digestive system and so on, why should the nervous system be the one system that is excluded from the possibility of also being defective?

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