Your patient has psychosocial risk factors: what now?

Congratulations! You’re an insightful clinician who’s offered your patient a screening assessment to find out if she or he has psychosocial risk factors – and yes! they do! Well done. Now what?

Do you…

  • send your patient to the nearest psychologist?
  • spend at least one treatment session offering pain neurobiology education?
  • scramble to find a “psychologically informed physio” to send them to, because it takes really highly trained and special clinicians to work with these people
  • give your patient the same exercise prescription you were going to anyway because, after all, they still have things going on in their tissues (or is it their nervous system? I forget – whatever, they just need to move, dammit!)
  • throw your hands up in horror and say “I never wanted to deal with people in pain anyway!”

You’d have to be hiding beneath a rock to avoid learning that people with musculoskeletal pain with psychosocial risk factors such as feeling that back pain is terrible and it isn’t going to get better, believing that it’s not safe to move or exercise with back pain, having worrying thoughts going through their mind, or not enjoying things very much should have special attention when they seek help for their pain. And we’ve all read studies showing that many of our frontline clinicians who see people with musculoskeletal pain aren’t comfortable, confident or clear about what to do with people who are, frankly, scared and distressed.

Papers like Caneiro, Bunzli & O’Sulllivan’s (2021) Masterclass clearly show that messages people with pain get told include avoiding certain movements to prevent damage, being advised that special exercises ‘protect’ the body, and that clinicians believe that certain postures and movements are inherently unsafe (bending, lifting with a rounded back). At the same time, Sajid, Parkunan & Frost (2021) found that only 11.8% of people referred by GPs for musculoskeletal MRIs had their mental health problems addressed, while only 16.7% of the MRI results were correctly interpreted by GPs and in 65.4% of cases were referred for “spurious overperception of surgical targets.”

Worse, Nicola, Correia, Ditchburn & Drummond (2021) conducted a systematic review of the effects of pain invalidation on individuals – invalidation from family, friends and healthcare individuals, and the person themselves. They found five themes: not being believed, lack of compassion, lack of pain awareness and understanding, feeling stigmatised and critical self-judgement. Perceived social unacceptability of experiencing pain was found to have an impact on the emotional state and self-image of those with persistent pain. Ya think?!

If I return to the case I presented last week, Angelina, a pretty common case of someone with a neck pain who is having trouble sleeping and generally handles her pain independently, we could assume that she doesn’t have significant psychosocial risk factors. After all, she’s managing to stay working, does a bit of self-help, and she’s not depressed though she’s a bit irritable.

What would you do?

I guess my first thought is: would Angelina even get a screening assessment to see whether she has any psychosocial risk factors? Might she present superficially well enough for her therapist to think she’s fine, let’s just treat the neck?

Of all the neck pain treatments available, what would she be given? And what might she be told about the rationale for that treatment? A recent systematic review with meta-analysis pointed out that while specific exercises helped in the short to medium term, the quality of that evidence was low (Villaneuva-Ruiz, Falla, Lascurain-Aquirrebena, 2021), while a systematic review with network meta-analysis of 40 RCTs found “There is not one superior type of physical exercise for people with chronic non-specific neck pain.
Rather, there is very low quality evidence that motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises are equally effective.” (de Zoete, Armfield, McAuley, Chen, & Sterling, 2020).

More than this: would her sleep and relationship concerns be discussed? What about her safety while driving? How about how she manages her work, and her belief that perhaps her pain is happening because of a period at work where she wasn’t positioned “correctly”?

You see, at the moment in our musculoskeletal treatment literature, the focus has been almost entirely on grouped data. And this, folks, is where Steven Hayes points out that the ergodic theorum is violated. Ergodic theory is “…the idea that a point of a moving system, either a dynamical system or a stochastic process, will eventually visit all parts of the space that the system moves in, in a uniform and random sense. This implies that the average behavior of the system can be deduced from the trajectory of a “typical” point. Equivalently, a sufficiently large collection of random samples from a process can represent the average statistical properties of the entire process.” (I stole that from

Hayes, Hofmann & Ciarrochi (2020) point out that “We cannot assume that the behavior of collectives (e.g., a volume of gas) models the behavior of an individual element (e.g., a molecule of gas) unless the material involved is “ergodic” and thus all elements are identical and are unaffected by change processes.” Humans are not ergodic (only a few noble gases are…) and what this means is that “statistical techniques based on inter-individual variation cannot properly assess the contribution of given elements to phenotypic change.” In other words: humans actively respond and change to what they’re exposed to – each of us presents to treatment with our own incredibly unique range of responses and past history, and these influence how we respond to a treatment. And perhaps this explains why most of our treatments (RCTs, using grouped data and uniformly applied and consistent treatments) particularly for persistent pain problems end up showing pretty small effect sizes. We’re violating the assumptions of the ergodic theorum. What we need are more sophisticated ways to analyse the impact of any therapy, and far fewer algorithms and cookie cutter treatments.

Where does this leave us? I have loads of ideas about where to from here, but not nearly enough space today to write about them!

My first suggestion is to avoid blindly following a treatment algorithm that fails to support YOU to sensitively and reflexively offer treatments that fit for your patient.

My second is to avoid measuring the impact of what you do only at the end of treatment (or worse, not at all!). Measure often, and measure things that matter – either to how you get to the end outcome, or that the person values. Or both.

And third: Get reading outside of your profession. Dig into psychology (I especially recommend Hayes); look at sociology (try Jutel); anthropology (try Sarah Pink’s “Sensuous futures: re-thinking the concept of trust in design anthropology”); make 2022 the year that you lean into uncertainty. I know the past two years have been incredibly unsettling – but this is the perfect time to continue on this journey into new ideas, fresh concepts, and ambiguity.

Caneiro, J. P., Bunzli, S., & O’Sullivan, P. (2021). Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther, 25(1), 17-29.

Nicola, M., Correia, H., Ditchburn, G., & Drummond, P. (2021, Mar). Invalidation of chronic pain: a thematic analysis of pain narratives. Disability and Rehabilitation, 43(6), 861-869.

Sarah Pink (2021) Sensuous futures: re-thinking the concept of trust in design anthropology, The Senses and Society, 16:2, 193-202, DOI: 10.1080/17458927.2020.1858655

Sajid, I. M., Parkunan, A., & Frost, K. (2021, Jul). Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Quality, 10(3).

Villanueva-Ruiz, Iker, Falla, Deborah, Lascurain-Aguirrebeña, Ion. (2021) Effectiveness of Specific Neck Exercise for Nonspecific Neck Pain; Usefulness of Strategies for Patient Selection and Tailored Exercise—A Systematic Review with Meta-Analysis, Physical Therapy, 2021;, pzab259,

de Zoete, R. M., Armfield, N. R., McAuley, J. H., Chen, K., & Sterling, M. (2020, Nov 2). Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. British Journal of Sports Medicine.


  1. Bronnie, it has been recently claimed by Meints & Edwards [2018] that catastrophizing “is the single most important risk factor that impairs the effectiveness of pain-relieving interventions” and is “a risk factor for the development of chronic pain, pain-related disability, increased healthcare costs and increased pain sensitivity (sic) for low back pain and joint pain”. (p.174)

    However, in a recent analysis, Crombez et al. [2020] reported that pain catastrophizing couldn’t be assessed by using a self-report questionnaire. In their opinion, pain catastrophizing is also dependent upon the available contextual information, and “expert judgement”. They argued for a person-centered approach, and propose to rename “pain catastrophizing” measures in line with what is better measured: “pain-related worrying”.

    If the proposal to rename the construct is agreed to by others working in the pain area, will it mean that “pain catastrophizing” is no longer to be regarded as the most important risk factor, as outlined above by Meints & Edwards [2018]?

    Will other so-called psychosocial risk factors be able survive a close analysis?


    Meints SM, Edwards RR. Evaluating psychosocial contributions to chronic pain patients. Prog Neuropsychopharmacol Biol Psychiatry 2018;87:168-182.

    Crombez G, De Paepe AL, Veirman E, et al. Let’s talk about pain catastrophizing measures: an item content analysis. Peer J 2020 Mar 4;8:e8643. doi: 10.7717/peerj.8643.

    1. Hi John, I couldn’t possibly say whether “catastrophising” will be replaced by “pain-related worrying” nor whether it will no longer be considered “the single most important risk factor that impairs the effectiveness of pain-relieving interventions”. It’s not my place to conjecture. What I will say is that I’ve not mentioned catastrophising in this post – I’ve always been clear that any thoughts/beliefs/responses to the pain experience are contextual and need to be considered in light of contextual factors such as what a person has been told (e.g. “your pain can’t be related to tissue damage because we can’t find any”; “you have the back of an old person”, “you need to be careful about heavy lifting”), their other events occurring in their life, community understanding of pain, cultural practices and so on.
      I have avoided using the term “catastrophising” for some time because I think the concept has been used pejoratively, rather than recognising that in any situation of uncertainty, humans tend to think the worst.
      BTW the conclusions are not that “catastrophising” as a construct does not exist, rather, that our measurement instruments measure something slightly different, AND that the label used for the construct in question could be replaced with a less stigmatising term.

      1. Bronnie, the contrasting views expressed in the two papers nicely illustrate your point about the dangers of applying grouped data to an individual.

        You also point out the possible negative impact upon patients exposed to the ill-considered views of some clinicians (“your pain can’t be related to tissue damage because we can’t find any”; “you have the back of an old person”, “you need to be careful about heavy lifting”).

        But, by the same token, how much harm has been done to distressed patients by clinicians who inform them that, based upon their responses to a questionnaire, they are “pain catastrophisers”?

      2. A couple of points, John.
        In process-based networks, we’re always looking at how a person arrives at the conclusions they do – for example, if a person is freaking out about their pain (my way of describing catastrophising!), the process is what I’m looking at, such as “noticing an unusual pain” leading to “worrying about the pain because it’s not something I’ve experienced before”, leading to, perhaps, “focusing on where I’m sore”, and ultimately leading to distress and enhanced noticing (attentional bias). But as I say in the blog, these are provisional relationships that need to be tested.
        I’m sure there is plenty of harm experienced by people who are told, essentially, that they’re over-estimating the impact of their pain. It’s not something I advocate, as I mentioned – the construct has relevance in terms of our understanding of contributors to distress and disability, and the “threat value” of the experience we call pain, but I am cautious about how it’s being used in some settings. By the same token, we know that if we are able to help someone develop a more hopeful appraisal of their situation, perhaps become more positive about how they can help themselves, then outcomes are better and the “pain catastrophising” measurements we currently take do show reductions. We are not mistaken about how sore we are, but we can be mistaken about the impact and our prognosis, and it’s part of our responsibility as clinicians to firstly not add to the sense of despair and distress, and secondly to support the person to explore ways to move forward and be who they want and need to be.

  2. Hello and thank you for this insightful post!

    I am currently writing my masters in osteopathy dissertation (in the rather progressive form of an evidence-based blog) exploring psychologically-informed practice in the treatment of non-specific chronic low back pain. It is a broad and confusing topic, but I believe that these concepts are essential to our work. Your post has given some great references which I cannot wait to read… I look forward to reading your future posts too.

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