1.Psychological factors are commonly associated with chronic low back pain
Psychological and social factors not only affect back pain itself but also how much the pain impacts on one’s life. For example, the presence of depressive symptoms can make back pain worse and increase the disability associated with back pain [16]. People with back (or neck) pain are more likely than people without back pain to meet criteria for common mental health problems, including major depressive episodes, anxiety disorders (odds ratio vary from 2.1 to 2.8) [12]. The coexistence of mental health conditions with back pain is associated with impaired quality of life and increased risk of chronicity [5; 29; 33]. While mechanisms underlying these associations are not fully understood, treatments of chronic back pain have expanded to include relevant psychological processes.
Some well-known psychological risk factors for back pain onset and maintenance
2. Avoidance behavior in response to chronic pain may be unhelpful and contribute to pain maintenance
Many people with back pain will avoid certain movements or activities because they worry about injury or increased pain. These reactions can be helpful in response to acute injury to protect body tissues during the healing process. However, these same avoidance behaviours in response to chronic pain become unhelpful because protection and healing are no longer needed. Avoidance then becomes part of the cycle of pain maintenance [27; 41]. In turn, this avoidance can lead to cycles of increasing pain and disability, as described in the Fear Avoidance Beliefs Model (FABM) [10]. A variety of self-report questionnaires can be used to assess avoidance-related beliefs and behaviors in the context of back pain [15], and there are several treatment strategies that specifically aim to reduce fear of pain and reinjury [28].
3. Behavioral overactivity and dysfunctional persistence can also hinder healing process and increase functional limitations
Just as avoidance behaviors can lead to pain chronicity, so can the opposite patterns. It appears that behavioral overactivity and dysfunctional persistence with activities despite severe pain [2; 3] can hinder healing process and lead to increased pain and functional limitations [7; 14; 17; 18; 39; 40].
4. High levels of catastrophizing and low self-efficacy are both risk factors for development and maintenance of chronic low back pain
Pain catastrophizing is defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” [37] characterized by a preoccupation with worrying, distracting, and distressing thoughts about pain. The Pain Catastrophizing Scale (PCS) was developed as a self report questionnaire to assess this phenomenon for use in research and clinical care [38]. The PCS includes three subscales: rumination (“I can’t stop thinking about how much it works”), magnification (“I worry that something serious may happen”), and helplessness (“It’s awful and I feel that it overwhelms me”) [38].
Self-efficacy is “concerned with judgments of how well one can execute courses of action required to deal with prospective situations” [4]. This concept appears to be consistently associated with various aspects of the pain experience including severity, disability and affective distress among individuals with chronic pain (83 studies including 23 studies in low back pain) [21]. People who lack confidence in their ability to do things despite pain, or their ability to manage their own pain, are typically more disabled by it and in more pain, than those who are confident they can do things despite their pain.
5. Psychological distress is a common reaction to chronic low back pain that can in turn contribute to increased disability
Both acute and chronic back pain can be associated with psychological distress in the form of anxiety (worries, stress) or depression (sadness, discouragement). Psychological distress is a common reaction to the suffering aspects of acute back pain, even when symptoms are short-term and not medically serious [35]. In turn, this distress is associated with hormonal and neural processes consistent with protecting ourselves. Through these processes, distress usually makes pain worse over time, and increases the disability caused by pain [16; 24; 30]. This means that when people with back pain are also distressed, treating their distress should also help their back pain [42].
Selected psychological approaches in global back pain treatment
It is important to include psychosocial screening and diagnostics when assessing an individual with back pain. This can support better tailoring of treatment to patient needs. For example, the PCS scale has been used to screen patients for pain beliefs that can complicate treatment or contribute to poor outcomes [44]. Some psychological treatments for back pain management are specifically designed with the goal of reducing pain catastrophizing and improving function [32; 36].
6. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain may be considered for individuals presenting with significant psychosocial impact.
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain was found to be more effective than usual care or physical treatment alone in reducing low back pain and disability. Effect sizes are overall modest however, and there does not seem to be a dose-response effect [22]. There is no evidence that such treatment approach help prevent the transition from acute to chronic low back pain [26].
Many psychological risk factors for the maintenance of back pain involve thinking processes (e.g., catastrophizing or self-efficacy) or behaviors (e.g., avoidance). Cognitive-behavioral therapy (CBT) is a form of psychological treatment that targets cognitive and behavioral processes assumed to underlie suffering and disability such as cognitive distortions and maladaptive behaviors. CBT has been studied in the context of many chronic pain conditions [45]. Specific to back pain, a meta-analysis showed that CBT, compared to no treatment or other guideline-based active treatments, leads to long-term improvement in many dimensions of the pain experience, including pain intensity, disability and quality of life [31].
7. A treatment approach referred to as Mindfulness-Based Stress Reduction (MBSR) may be an effective treatment option for people with chronic low back pain.
Mindfulness is regarded as an awareness or attention skill that includes being focused in the present, in a way that is open and accepting of experience and includes seeing distinctions between self and experience. In the context of pain, it includes being directly aware of pain sensations without resistance and without getting caught up in judgments about the pain. RCT evidence shows that people with chronic back pain trained in mindfulness, compared to usual care, report less disability and find their pain less bothersome immediately following treatment and one year later [8]. In this study MBSR appeared as effective as Cognitive Behavioral Therapy. Results in back pain are similar to results from meta-analyses of mindfulness-based approaches to chronic pain in general, where these approaches are found to improve pain, depression, and quality of life (38 RCTs, [19]).
Psychological protective factors
Acceptance means to engage in activities that include pain and to do so in a way that does not include resisting the pain or trying to reduce it. Experimental evidence shows that, relative to instructions to attempt to control pain, instructions to accept it lead to better performance in physical tasks [43]. Roughly, accepting pain appears to help because it allows people to do what they want to do rather than struggling with pain. We know that treatments focused on increasing acceptance are effective in chronic pain in general [20], acceptance improves during such treatments and is associated with improvements in outcomes [25; 34], and even treatments not explicitly focused on increasing acceptance show increased acceptance in those people with chronic pain who benefit most [1].
8. Self-compassion is more recently studied and may be a positive factor in adjusting to back pain particularly in relation to effects of self-criticism or blame
There are many ways for people with back pain to self-regulate during the inevitable physical, social, and emotional challenges of this condition. One of these includes treating oneself with kindness and understanding in the context of suffering, which is also called self-compassion. Preliminary uncontrolled trial evidence demonstrates that brief self-compassion training is associated with reduced pain and disability, increased self-compassion and interoceptive awareness, decreased evoked pressure pain responses, as well as significant changes on fMRI in response to pain anticipation [6]. These results are consistent with other studies that show that self-compassion is negatively associated with anxiety, depression, stress, pain interference, and work and social adjustment in people with chronic pain [9; 11; 13; 46] and with results from a systematic review of self-compassion interventions in chronic physical health conditions in general [23].
REFERENCES
[1] Akerblom S, Perrin S, Rivano Fischer M, McCracken LM. The Mediating Role of Acceptance in Multidisciplinary Cognitive Behavioral Therapy for Chronic Pain. J Pain 2015;16(7):606-615.
[2] Andrews NE, Chien CW, Ireland D, Varnfield M. Overactivity assessment in chronic pain: The development and psychometric evaluation of a multifaceted self-report assessment. Eur J Pain 2021;25(1):225-242.
[3] Andrews NE, Strong J, Meredith PJ. Overactivity in chronic pain: is it a valid construct? Pain 2015;156(10):1991-2000.
[4] Bandura A. Self-efficacy mechanism in human agency. American Psychologist 1982;37(2):122-147.
[5] Baumeister H, Hutter N, Bengel J, Harter M. Quality of life in medically ill persons with comorbid mental disorders: a systematic review and meta-analysis. Psychother Psychosom 2011;80(5):275-286.
[6] Berry MP, Lutz J, Schuman-Olivier Z, Germer C, Pollak S, Edwards RR, Gardiner P, Desbordes G, Napadow V. Brief Self Compassion Training Alters Neural Responses to Evoked Pain for Chronic Low Back Pain: A Pilot Study. Pain medicine 2020;21(10):2172-2185.
[7] Cane D, Nielson WR, Mazmanian D. Patterns of pain-related activity: replicability, treatment-related changes, and relationship to functioning. Pain 2018;159(12):2522-2529.
[8] Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of Mindfulness Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 2016;315(12):1240-1249.
[9] Costa J, Pinto-Gouveia J. Experiential avoidance and self-compassion in chronic pain. Journal of Applied Social Psychology 2013;43:1578-1591.
[10] Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain 2012;28(6):475-483.
[11] Davey A, Chilcot J, Driscoll E, McCracken L. Psychological flexibility, self-compassion and daily functionning in chronic pain. Journal of Contextual Behavioral Science 2020;17:79-85.
[12] Demyttenaere K, Bruffaerts R, Lee S, Posada-Villa J, Kovess V, Angermeyer MC, Levinson D, de Girolamo G, Nakane H, Mneimneh Z, Lara C, de Graaf R, Scott KM, Gureje O, Stein DJ, Haro JM, Bromet EJ, Kessler RC, Alonso J, Von Korff M. Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys. Pain 2007;129(3):332- 342.
[13] Edwards KA, Pielech M, Hickman J, Ashworth J, Sowden G, Vowles KE. The relation of self-compassion to functioning among adults with chronic pain. Eur J Pain 2019;23(8):1538-1547.
[14] Gajsar H, Titze C, Levenig C, Kellmann M, Heidari J, Kleinert J, Rusu AC, Hasenbring MI. Psychological pain responses in athletes and non-athletes with low back pain: Avoidance and endurance matter. Eur J Pain 2019;23(9):1649-1662.
[15] George SZ, Valencia C, Beneciuk JM. A psychometric investigation of fear-avoidance model measures in patients with chronic low back pain. J Orthop Sports Phys Ther 2010;40(4):197-205.
[16] Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M, Lancet Low Back Pain Series Working G. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-2367.
[17] Hasenbring MI, Andrews NE, Ebenbichler G. Overactivity in Chronic Pain, the Role of Pain-related Endurance and Neuromuscular Activity: An Interdisciplinary, Narrative Review. Clin J Pain 2020;36(3):162-171.
[18] Hasenbring MI, Hallner D, Klasen B, Streitlein-Bohme I, Willburger R, Rusche H. Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up. Pain 2012;153(1):211-217.
[19] Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, Colaiaco B, Maher AR, Shanman RM, Sorbero ME, Maglione MA. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine 2017;51(2):199-213.
[20] Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and Commitment Therapy (ACT) for Chronic Pain: A Systematic Review and Meta-Analyses. Clin J Pain 2017;33(6):552-568.
[21] Jackson T, Wang Y, Wang Y, Fan H. Self-efficacy and chronic pain outcomes: a meta-analytic review. J Pain 2014;15(8):800- 814.
[22] Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014;9:CD000963.
[23] Kilic A, Hudson J, McCracken LM, Ruparelia R, Fawson S, Hughes LD. A systematic review of the effectiveness of self compassion-related interventions for individuals with chronic physical health conditions. Behav Ther in press;in press.
[24] Lee HI, Hübscher M, Moseley GL, Kamper SJ, Traeger AC, Mansell G, McAuley JH. How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain 2015;156(6):988-997.
[25] Lin J, Klatt LI, McCracken LM, Baumeister H. Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: an investigation of change processes. Pain 2018;159(4):663-672.
[26] Marin TJ, Van Eerd D, Irvin E, Couban R, Koes BW, Malmivaara A, van Tulder MW, Kamper SJ. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain. Cochrane Database Syst Rev 2017;6:CD002193.
[27] Martinez-Calderon J, Flores-Cortes M, Morales-Asencio JM, Luque-Suarez A. Pain-Related Fear, Pain Intensity and Function in Individuals With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis. J Pain 2019;20(12):1394-1415.
[28] Martinez-Calderon J, Flores-Cortes M, Morales-Asencio JM, Luque-Suarez A. Conservative Interventions Reduce Fear in Individuals With Chronic Low Back Pain: A Systematic Review. Arch Phys Med Rehabil 2020;101(2):329-358.
[29] Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976) 2002;27(5):E109-120.
[30] Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, Huez JF. Psychosocial risk factors for chronic low back pain in primary care–a systematic review. Fam Pract 2011;28(1):12-21.
[31] Richmond H, Hall AM, Copsey B, Hansen Z, Williamson E, Hoxey-Thomas N, Cooper Z, Lamb SE. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PLoS One 2015;10(8):e0134192.
[32] Schütze R, Rees CE, Smith A, Slater H, Campbell JM, O’Sullivan P. How can we best reduce pain catastrophizing in adults with chronic noncancer pain? A systematic review and meta-analysis. Journal of Pain 2018;19(3):233-256.
[33] Scott KM, Von Korff M, Alonso J, Angermeyer MC, Bromet E, Fayyad J, de Girolamo G, Demyttenaere K, Gasquet I, Gureje O, Haro JM, He Y, Kessler RC, Levinson D, Medina Mora ME, Oakley Browne M, Ormel J, Posada-Villa J, Watanabe M, Williams D. Mental-physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys. Psychol Med 2009;39(1):33-43.
[34] Scott W, Hann KE, McCracken LM. A Comprehensive Examination of Changes in Psychological Flexibility Following Acceptance and Commitment Therapy for Chronic Pain. J Contemp Psychother 2016;46:139-148.
[35] Shaw WS, Hartvigsen J, Woiszwillo MJ, Linton SJ, Reme SE. Psychological Distress in Acute Low Back Pain: A Review of Measurement Scales and Levels of Distress Reported in the First 2 Months After Pain Onset. Arch Phys Med Rehabil 2016;97(9):1573-1587.
[36] Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 2006;7(4):261-271.
[37] Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 2001;17(1):52-64.
[38] Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: Development and Validation. Psychological Assessment 1995;7(4):524-532.
[39] Titze C, Fett D, Trompeter K, Platen P, Gajsar H, Hasenbring MI. Psychosocial subgroups in high-performance athletes with low back pain: eustress-endurance is most frequent, distress-endurance most problematic! Scand J Pain 2021;21(1):59-69.
[40] Titze C, Hasenbring MI, Kristensen L, Bendix L, Vaegter HB. Patterns of Approach to Activity in 851 Patients With Severe Chronic Pain: Translation and Preliminary Validation of the 9-item Avoidance-Endurance Fast-Screen (AEFS) Into Danish. Clin J Pain 2021;37(3):226-236.
[41] Trinderup JS, Fisker A, Juhl CB, Petersen T. Fear avoidance beliefs as a predictor for long-term sick leave, disability and pain in patients with chronic low back pain. BMC Musculoskelet Disord 2018;19(1):431.
[42] Valjakka AL, Salantera S, Laitila A, Julkunen J, Hagelberg NM. The association between physicians’ attitudes to psychosocial aspects of low back pain and reported clinical behaviour: A complex issue. Scand J Pain 2013;4(1):25-30.
[43] Vowles KE, McNeil DW, Gross RT, McDaniel ML, Mouse A, Bates M, Gallimore P, McCall C. Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behav Ther 2007;38(4):412-425.
[44] Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review. Spine J 2014;14(11):2639-2657.
[45] Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020;8:CD007407.
[46] Wren AA, Somers TJ, Wright MA, Goetz MC, Leary MR, Fras AM, Huh BK, Rogers LL, Keefe FJ. Self-compassion in patients with persistent musculoskeletal pain: relationship of self-compassion to adjustment to persistent pain. Journal of pain and symptom management 2012;43(4):759-770.
ACKNOWLEDGEMENTS
MG Pagé is a Junior 1 research scholar from the Fonds de recherche du Québec en santé.
AUTHORS
Lance M. McCracken,PhD, Professor of clinical psychology, Department of Psychology, Uppsala University, Uppsala, Sweden, [email protected]
Steven Linton, PhD, Post retirement professor, School of Law, Psychology and Social Work, Orebro University, Orebro, Sweden, [email protected]
William Shaw, PhD, Associate professor and Division chief, Division of Occupational and Environmental Medicine, Departments of Medicine and Public Health Sciences, University of Connecticut Health Center, Farmington, CT, United States; [email protected]
Gabrielle Pagé*, PhD, Assistant professor and research scholar, Department of Anesthesiology and Pain Medicine, Faculty of Medicine, & Department of Psychology, Faculty of Arts and Science, University of Montreal, Montreal, QC, Canada; [email protected]
REVIEWERS
Lorimer Moseley AO
Chair in Physiotherapy
UniSA Allied Health & Human Performance
University of South Australia
Australia
Prof. Dr. Monika I Hasenbring
Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Germany
Faculty of Health Science, University of Southern Denmark, Odense, Denmark
[email protected]
