Take the pain away and the other problems go too? A loooooong post

There are some days I despair that the biopsychosocial model will EVER take hold in the died-in-the-wool medical interventionist strongholds.

This quote from a discussion with a colleague might help you join in my pity party…The conversation is about a case of a young woman with 18 month history of neck pain post-MVA, she has been to pain management and ‘while this has helped her understand and manage her pain better, the pain persists to the point that she is becoming increasingly frustrated, with deterioration in her work, personal and social environment.’

In my discussion with my colleague, he stated that ‘…the reasons that the patient is frustrated is that she still has pain.  Take that away (if it is possible) and the other problems go too.’ He went on to say ‘I am not trying to eliminate psychsocial factors.  They are important but it is the pain that is the underlying problem.  If it can be removed then it should be.  If not then the psychosocial issues are the only thing that can be addressed.’

His basic assumption is that the only contribution psychosocial factors have in this person’s situation are in response to her having ongoing pain. I’d be the first person to agree that having pain is incredibly stressful, and that most people will respond with frustration and eventual demoralisation.  And reducing or removing pain will almost certainly result in an improvement in mood and a reduction in distress and frustration.

Where do I start in responding to my colleague?

The whole experience of pain is psychological: until we attend to the stimulus, then interpret it as threatening, it is meaningless.  The nervous system doesn’t sit around waiting for a stimulus to reach it before reacting to it – instead, the nervous system is actively seeking out, sorting through, prioritising and selecting which stimuli it will integrate and respond to.  Remember the nervous system includes the brain, with all the social, cultural and learned experiences the person has had – and the predictions that brain within the person can make, and the meaning of what-is-happening-now to the person.

Some of our responses are ‘automatic’, much pain behaviour is based on reflex action designed to protect us, but over which we develop voluntary control.  By ‘automatic’ I mean – we don’t think about it any more, it’s habitual, probably done since we were babies.

So, our nervous system is ready and waiting and our experience of having pain is entirely about our interpretation of it – psychosocial factors are integral to having pain.  So to suggest that ‘psychosocial issues are the only thing that can be addressed’ – and only after pain cannot be relieved makes me feel he doesn’t understand that the pain experience in total is psychological.

Back to the relationship between pain and disability. Why do we work so hard to help people with pain?  It’s because having pain can be distressing, and can influence function (but not always).  Unless I’m mistaken in my reading of the literature around pain and disability, the relationship between having pain and being disabled by it (and being distressed, frustrated, seeking treatment for it, needing help for it) is not as simple and straightforward as 1 + 1 = 2.

Let’s take a look at some of the studies that show this.

  1. A study in primary care, with patients with an average of 10 days low back pain looked at the relationship between pain intensity, disability as measured on the Roland Morris Questionnaire, and Quality of LifeOn day one, simple correlation was r = 0.347 between VAS and RMQ; on day 15, simple correlation was r = 0.570 between VAS and RMQ.  VAS score explains 12% of the RMQ on Day One, while on Day 15, the VAS score explains 33% of the RMQ score.  The authors conclude:  ‘Clinically relevant improvements in pain may lead to almost unnoticeable changes in disability and quality of life. Therefore, these variables should be assessed separately when evaluating the effect of any form of treatment for low back pain.’  (Kovacs, Abraira,  Zamora, et al., 2004).
  2. A longitudinal cohort study with 6-month follow-up of 218 patients with chronic neck pain, given usual treatment by physiotherapists. A range of measures were taken of pain, disability, satisfaction with treatment, and impairment. No strong correlations were found among disability, patient satisfaction, pain, and physical impairments although the correlations tended to increase in the follow-up assessments. Moderate correlation was found between disability and pain (r range, .55–.63); a fair relationship was found between pain and patient satisfaction (r range, .43–.48), but only weak relationships were found between physical impairments and pain (r range, −.08 to −.25). The authors conclude:The findings support the suggestion that clinicians should address as many relevant aspects of a presenting clinical entity as possible in the management of chronic neck pain. (Chiu, Lam & Hedley, 2005).
  3. Just in case, here is one final paper that, although published in 2002, summarises the state of play in terms of psychosocial factors and low back pain. Written by Pincus, Vlaeyen, Kendall et al (2002), it ‘aims to outline evidence-based theories that have lead to the identification of yellow flags (psychosocial risk factors for developing long-term disability) for nonspecific LBP’. Just a snippet or two from this might help to put some of this information into perspective, particularly around the belief that psychosocial factors don’t really need to be dealt with ‘if the pain can be removed’.

‘At least three stages can be identified in which psychosocial factors have the potential to influence low back problems.The first is during the preonset period (before symptomatic back pain develops), the second is at the time of seeking help (health care, support, and/or compensation), and the third is during the development of chronicity. This final stage is more thoroughly researched and understood than the former two.’ (my highlights)

‘It is necessary to differentiate between factors that lead to the onset of back pain, and those that lead to reporting and seeking health-care and other forms of support.’ These authors note studies in which it has been found that people who are already distressed are more likely to seek help/treatment than those who are not distressed, and these people are more likely to go on to experience chronic disability from their pain. ‘The point at which an individual seeks help is mediated by a complex mixture of medical, work-related beliefs and behavior, and a variety of psychosocial factors.’ These factors haven’t been studied well, neither have the factors that lead a person to NOT persist with seeking help.

A study based in primary care in Israel included not only the patients’ perceptions of worry, coping, limitations, expectation of pain relief, and pain interference, but also those of their clinicians. This information independently and in combination with each other were found to predict outcome up to 12 months later. … the focus on long-term and stable characteristics of patients as risk factors (such as premorbidity, high levels of depression, and catastrophizing) might overlook important and immediate predictors, such as patients [and clinicians – my insertion] perceptions and expectations.

Before we can suggest that a certain treatment to abolish pain ‘works’, particularly to reduce disability, we need to have a good, hard look at the type of patient who seeks treatment – and the type of clinicians who provide it. Several studies were provided to me to support the use of interventions for facet joint pain (see below). Although the methodology is sound, we can’t generalise from the findings in these studies to all people experiencing neck or back pain. Quite apart from the duration of pain, we need to know much more about whether these patients ‘look like’ the people we see in daily practice.

I admit I see more complex patients with more disability than someone working in an acute or sub-acute clinic, but unless my colleague and others like him ensure their patients ‘look like’ the ones in the studies they’re referring to (which means they would have to take some sort of measures to assess the risk factors), I’m not sure their patients are that different. After all, there is a complex interplay between the patient, the referrer, the clinicians, and even the funder and employer and community, that all influence who looks for treatment and who doesn’t.

I know I’m beating my head against a wall to try change a dogmatic viewpoint  – and yet I have read the literature and just don’t think the picture is quite that simple. And maybe the years I’ve worked in the biopsychosocial model, researching the psychosocial factors involved in pain and disability mean I have a more complex and perhaps sophisticated understanding of the relationship between these factors.  Is it worth my while trying to provide evidence to clinicians who have a much simpler but perhaps less accurate view of the world? I wonder what others think?

Chiu TT, Lam T-H, Hedley AJ. (2005). Correlation among physical impairments, pain, disability, and patient satisfaction in patients with chronic neck pain. Archives of Physical Medicine & Rehabilitation, 86(3), 534-540.

Kovacs, Abraira, Zamora, Gil del Real,  Llobera, Fernandez,; the Kovacs-Atencion Primaria Group. (2004).
Correlation between pain, disability, and quality of life in patients with common low back pain. Spine. 29(2):206-210.

Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, & Reis S (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine, 27 (5) PMID: 11880850
Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital nerve headache: a prevalence study. J Neurol Neurosurg Psychiatry 1994;57:1187-1190.

Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20:20-26.

Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21:1737-1745.


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