Margaret Chesney, PhD, and Christine Goertz, DC, PhD
The current opioid epidemic in the United States brings long overdue attention to nonpharmacological approaches to managing pain. Among the recommended therapies for low back pain by the American College of Physicians, for example, are spinal manipulation, acupuncture, yoga and cognitive behavioral therapy.1 While it may be clear why body-based therapies such as spinal manipulation and yoga were recommended, the inclusion of a psychological approach, such as cognitive behavioral therapy, may raise some eyebrows among those who view pain as from a primarily physical or biological perspective.
It is less surprising, however, to those who have been following the science.
Over the past 40 years, it has become increasingly evident that psychological factors play an important role in the experience of chronic pain. Both the Veterans Administration and the recent draft report from the Health and Human Services Task Force on Best Practices in Pain Management2 recommend a “biopsychosocial” model of care. Recognizing the influence of psychological and social factors does not challenge those who treat pain from a physical perspective, such as doctors of chiropractic. On the contrary, recognizing the role of psychological factors in how patients respond to their pain may provide insights for DCs in tailoring their approaches, and at times, may help explain why some patients appear to be relatively resistant to treatment.
For instance, persons who have higher levels of pain-related anxiety and fear, as well as patients who engage in what psychologists refer to as “pain catastrophizing,” have been shown to benefit less from analgesics,3 surgical procedures to relieve pain4 and psychosocial approaches to pain including cognitive behavioral therapy (CBT)5 than patients without these psychological characteristics. More specifically, “pain catastrophizing” is a term used for people who focus on their pain and have a habit of negatively evaluating their ability to cope with pain. Patients with pain-related fear and anxiety, and particularly with catastrophizing, have been shown to report higher pain intensity, lower pain tolerance and higher pain-related disability,6 as well as higher risk for prescription opioid-misuse7. Research also documents that these individuals are less likely to engage in health promoting behaviors such as exercise,8 adhering to treatment appointments,9 and retuning to work.10 Given this profile, these patients may present a challenge for chiropractic care.
Conversely, persons who have higher “self-efficacy” for managing their pain are more likely to show resilience and positive adjustments to their pain and may be more responsive to treatment.6 Increases in self-efficacy and resilience over the course of treatments have been associated with treatment success in studies of CBT for chronic pain.11 Pain patients with higher self-efficacy are more confident in their ability to control or manage pain. Such patients report lower levels of distress and better treatment outcomes. Working with patients in ways that focus on enhancing their self-efficacy for managing their pain is more likely to lead to positive outcomes of pain-coping skills and self-care interventions.
Finally, it is important to note that social factors can often influence psychological responses to pain. Pain catastrophizing, for example, is associated with higher levels of caregiver support. There are those that study catastrophizing who argue that this approach represents an interpersonal effort to maintain support from others. These social factors are likely to influence response to treatment and may be important to take into consideration.
Because it is not always possible to easily identify patients who suffer from pain-related anxiety, fear or catastrophizing, it may be necessary to use reliable and valid patient reported questionnaires for this purpose, as recommended by Choosing Wisely.12 Specifically, the program — which features evidence-based recommendations that intend to help spark conversations about appropriate care between patients and their health care providers — includes the following recommendation:
Do not provide long-term pain management without a psychosocial screening or assessment. (Scroll down for the full recommendation.)
Practitioners who are sensitive to these psychological and social factors in the treatment of pain may be more likely to activate multiple channels to achieve greater therapeutic outcomes and can provide helpful information regarding when it may be necessary to make appropriate referrals. Reliable and valid questionnaires that can be used for this purpose include the PHQ-9 depression scale and the Fear Avoidance Belief Questionnaire.
Dr. Chesney is former director of the UCSF Osher Center for Integrative Medicine and the first deputy director of the NIH’s Center for Complementary and Integrative Health. Her research has focused on empowering individuals to promote health, prevent disease, and maintain optimal well-being across their lifespans, even in the face of serious health challenges.
Dr. Goertz is the chair of ACA's Committee on Quality Assurance. She is also ACA’s senior scientific advisor and CEO of the Spine Institute for Quality (Spine IQ).
Recommendation: Do not provide long-term pain management without a psychosocial screening or assessment.
There is a high probability that any person with a chronic pain syndrome has a concomitant psychological disorder, most notably depression and/or anxiety. The relationship between chronic pain and depression/anxiety is well established. The causal arrow between pain and these disorders can point in either direction and over time may form a positive feedback loop between these two elements. Screening tools are available that will aid in the detection of potential depression/anxiety, and, when indicated, a referral may be most appropriate for more extensive evaluation and treatment. In addition, lesser psychological factors such as catastrophizing and fear avoidance behavior may interfere with a patient’s recovery and should be recognized by the clinician. Recognizing indicators of patient psychosocial health behavioral factors can affect a patient’s recovery and/or compliance with treatment and may decrease the risk of developing chronic illness/pain. Tools such as StarTBack 9 screening tool, PHQ-9 depression scale and the Fear Avoidance Belief Questionnaire are examples
To learn more about Choosing Wisely recommendations, visit http://www.acatoday.org/Practice-Resources-Choosing-Wisely.
- Qaseem, A., Wilt, T.J., McLean, R. M., and Forciea, M.A., for the Clinical Guidelines Committee of the American College of Physicians, 2017. Noninvasive treatments for acute, subacute, and chronic low back pain:A clinical practice guideline from the Amercan College of Physicians, Annals of Internal Medicine, 166: 514-530.
- Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations, U.S. Department of Health and Human Services. https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html.
- Schiphorst Preuper HR, Geertzen JH, van Wijhe M, Boonstra AM, Molmans BH, Dijkstra PU, Reneman MF. 2014.Do analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT. Eur Spine J, 23, 800-806, 2014
- Vissers MM, Bussmann JB, Verhaar JA, Busschbach JJ, Bierma-Zeinstra SM, Reijman M (2012). Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review. Semin Arthritis Rheum 41, 576-588.
- Turner JA, Holtzman S, Mancl L, 2007. Mediators, moderators, and predictors of therapeutic change in cognitivebehavioral therapy for chronic pain. Pain, 127, 276-286
- Edwards RR, Dworkin RH, Sullivan MD, Turk DC and Wasan, AD. 2018. The role of psychosocial processes in the development and maintenance of chronic pain. J of Pain, 17, T70-T92.
- Martel MO, Jamison RN, Wasan AD, Edwards RR. 2014, The association between catastrophizing and craving in patients with chronic pain prescribed opioid therapy: A preliminary analysis. Pain Med, 15, 1757-1764.
- Castaneda DM, Bigatti S, Cronan TA, 1998. Gender and exercise behavior among women and men with osteoarthritis. Women & Health, 27, 33-53.
- Litt MD, Porto FB, 2013Determinants of pain treatment response and nonresponse: Identification of TMD patient subgroups. J Pain, 14, 1502-1513.
- Gauthier N, Sullivan MJ, Adams H, Standish WD, Thibault P 2006. Investigating risk factors for chronicity: The importance of distinguishing between return-to-work status and self-report measures of disability. J Occup Environ Med, 48, 312-318.
- Turner JA, Holtzman S, Mancl L 2007. Mediators, moderators, and predictors of therapeutic change in cognitive behavioral therapy for chronic pain. Pain 127, 276-286.
- Choosing Wisely, "American Chiropractic Association: 5 Things Physicians and Patients Should Question," http://www.choosingwisely.org/societies/american-chiropractic-association/.