Tamar Pincus and Chris Main
WHY ARE PSYCHOLOGICAL INTERVENTIONS RELEVANT TO PEOPLE WITH SPINAL PAIN?
As technology and communication of scientific findings improve, so grows the consensus that the experience of pain needs to be understood and treated within the conceptual framework of the biopsychosocial model. This approach is supported by a plethora of studies investigating the risk of developing pain; of moving from early stages of pain to persistent disabling pain; and of poor coping and worse prognosis once pain is entrenched. There is considerable evidence to suggest that psychological factors play an important part in each of these.1 In particular, distress/depression, anxiety, catastrophic thinking and cognitions about the probable future path of the pain experience have all been shown to influence outcomes, including pain, disability, mood, health care utilization and absence from work. In addition, more recent research has focused on the role of the brain in defining the pain experience, subject to previous experiences, expectations, moods and context.2 Early assessment and screening tools have offered ways of identifying aspects of the psychological impact of pain and pain-associated distress and limitations in function, thereby assisting clinical decision-making. Since the early days, a wide range of assessment tools have been developed and validated on a range of clinical populations, in clinical and occupational contexts3 and at various stages of illness. The wide-ranging influences of psychological factors on the perception of pain and response to pain are the subject of a recent review.4 The evidence is not without contradiction, and many questions remain, especially about the finer mechanisms that are associated with the development of disability. Nonetheless, the evidence has been sufficiently persuasive to lead to a proliferation of trials using psychological techniques to address risk factors, alter cognitions and change behaviors in people with spinal pain. Some approaches have been tested more often and more thoroughly than others. In this chapter, we present the most common psychological interventions for people with spinal pain, describe their theoretical bases and summarize the evidence which supports their use.
CURRENT PSYCHOLOGICAL INTERVENTIONS FOR PAIN
Traditionally, psychological interventions have been classified according to their primary focus/theoretical alignment. In the field of pain management, the earliest interventions with an explicit psychological focus have had specific behavioral, cognitive or psychophysiological approaches.5 Historically, behavioral interventions have been based on principles of learning, such as classical conditioning, reinforcement, observational learning, etc., rather than the broader definition of behavioral intervention currently in vogue, although they share the aim of changing behavior. Cognitive approaches are more sharply focused on patients’ beliefs and thoughts, with the general aims of enhancing helpful cognitions, such as self-efficacy and adaptive coping strategies. Psychophysiological approaches attempt to enhance or establish control of physiological processes such as heart-rate or electromyography (EMG) as in the use of biofeedback.
An important early landmark was the blending of cognitive and behavioral perspectives offered by Turk and colleagues6 in their textbook on cognitive behavioral therapy (CBT) for pain. Since then there have been many developments in the understanding of psychological mechanisms underpinning the development of pain-associated disability and attempts to prevent/ameliorate it.
Types of psychological intervention have ranged from traditional face-to-face counseling, in groups or individually, principally on an out-patient basis to the incorporation of psychological techniques within interdisciplinary pain management programs.7 Interventions include delivery by general practitioners, psychologists, nurses, musculoskeletal practitioners (e.g., physical therapists) and lay people. Interventions range from a single session to over 100 hours of therapy, and trials now include online delivery, in addition to face-to-face treatment. Specific psychological techniques commonly found in pain management interventions include disclosure, cognitive restructuring, activity scheduling, relaxation and biofeedback, hypnosis and exposure interventions.7 These techniques derive primarily from mental health psychology, but require specific training and expertise, and are more commonly offered to people with severe or persistent pain problems. Frequently, they are offered as part of an interdisciplinary package of integrated care.
The main types of current psychological intervention can be grouped under the following headings:
Trials of educational interventions, such as Back Schools, have been found to be relatively ineffective,8 perhaps because of the major focus on peripheral mechanisms rather than obstacles to reactivation, although newer approaches to neuro-education may hold more promise.2 The importance of providing reassurance through clear explanations has been recently explored in patients consulting for low back pain,9 and uncertainty about diagnosis has been linked to higher rates of disability, anxiety and depression.10 While almost all guidelines for spinal disorders recommend reassuring patients, how to do this effectively for individual patients remains surprisingly under-researched.9
Behavioral interventions for pain were originally described by Fordyce (reviewed by Main et al.).11 The term “behavioral intervention” can refer to interventions varying widely in their focus and complexity, and the term is often used in contrast with biomedical or pharmacological interventions but have in common the targeting of identified behaviors or using behavioral methods to attempt behavioral change. Pain intervention techniques such as desensitisation and staged reactivation are extremely common. Interventions relying on the principle of exposure have also be tested, for example, in reference to avoidance of feared movements. Trials of exposure to avoided movements have shown promise against treatment as usual12 but have not demonstrated superiority to less extreme techniques of reactivation, such as graded activity.13 There is also a growing body of evidence around interventions based on behavior-change models, which aim to facilitate and encourage a shift to healthier and more adaptive patterns of behavior such as regular physical activity. To date the evidence from trials is contradictory, and the quality of trials has been criticized.
Cognitive-behavioral Programs or CBT
Sometimes described as “second wave behavioral approaches,” CBT interventions combine a specific focus on pain cognitions and an explicit focus on coping strategies.6 The approach became the main vehicle for the early pain management programs developed for people with chronic disabling pain and established interdisciplinary pain management (frequently delivered in a group format).7 The principal objectives were re-activation and re-engagement in functional activities. They have underpinned the morphing of pain relief to (psychologically-oriented) pain management, and there is evidence of their effectiveness,14 although initial claims of cost-effectiveness have not been substantiated. There is also some evidence that effective CBT requires a certain level of skill and training, and that “diluted” interventions described as using a CBT “approach” may be suboptimal, especially for groups with substantial psychological issues.15
Stress Management Programs
Stress management programs were developed in the 1970s, in response to a growing interest in the psychophysiological response to pain. Typically, they included approaches, such as biofeedback, to normalize “stress responses.” Unregulated biofeedback clinics and unsubstantiated claims about therapeutic worth followed. The use of stress reduction (often in the form of biofeedback) as one of several techniques is frequently found in pain management programs. A recent meta-analysis concluded that, for chronic back pain, biofeedback is effective in reducing pain, both as a single intervention and as an adjunctive treatment.16 Over time there has been a shift in focus from peripheral mechanisms to central mechanisms and the use of stress reduction techniques such as muscle relaxation as a front line therapeutic approach declined. However, the re-emergence of mindfulness as part of the third wave development of psychologically based approaches to pain, has rekindled interest in psychophysiology and energized a focus on the management of emotion, which was relatively neglected in second wave therapy. (Mindfulness is discussed in more detail later in this chapter).
Acceptance and Commitment Therapy (ACT) and Contextual Cognitive Behavioral Therapy (CCBT)
Over the past 15 years, there has been increasing interest in the theoretical and practical utility of Acceptance and Commitment Therapy or ACT17 in the management of chronic pain. ACT for chronic pain focuses on assisting pain sufferers to engage in a flexible and persistent pattern of values-directed behavior while in contact with continuing pain and discomfort, particularly when efforts to control or reduce pain or discomfort have failed in the past or contributed to greater difficulties over the longer term.18 ACT includes six partly overlapping therapeutic processes: acceptance, contact with the present, values-based action, committed action, self-as-context, and cognitive defusion, although recently they have been conceptualized as three pairs of response styles.19 A core mechanism/objective is the enhancement of psychological flexibility.
Fast ACT (FACT) is designed particularly for settings where time is very limited, the “behavioral analysis” interview is reduced to just four focused questions: (a) What are you seeking? (b) What have you tried? (c) How has it worked? and (d) What has it cost you?20 A closely related intervention, CCBT, has been developed specifically with pain populations in mind.21 A definitive large trial of ACT/CCBT for people with spine pain is still needed, but preliminary data from smaller trials suggest that ACT improves almost all outcomes better than treatment as usual, or no treatment, and shows large effects in reducing pain interference long term for people with chronic pain.22
Mindfulness is a technique directed at experiences, such as thoughts, mental images, urges and emotions. Its principle objective is to disrupt and modify what have become automatic, but dysfunctional, responses to pain and its effects. The principal components of mindfulness are openness, curiosity and compassion, with a focus on maintaining a connection with the present moment using such strategies. It is increasingly being used as one of the elements of ACT, although they come from different traditions: ACT from the behavior analytic side of the cognitive and behavioral therapies, which is a family of therapy approaches that are no more than 50 years old; and mindfulness from eastern spiritual practices that are about 3000 years old. Meta-analyses of mindfulness-based treatments for groups with chronic pain show significant effects in reducing pain and depression and improving sleep, but the effects are small, and they reduce in trials which compare mindfulness to other active treatments.22,23 The reviewers comment on the need for larger trials with improved methodology.
A BROADER FOCUS OF PSYCHOLOGICAL INTERVENTIONS: INVOLVEMENT OF CARERS AND SPOUSES
Three approaches to involving spouses in behaviorally oriented treatment programs have emerged: partner-assisted behavioral treatment, partner-assisted cognitive behavioral treatment, and couples-based interventions.
Partner-assisted Behavioral Treatment
In partner-assisted behavioral treatment, the focus is on the patient with the partner's role being primarily to use social reinforcement principles (e.g., providing attention to well behaviors, minimizing attention to pain behavior) to support the patient’s behavior change efforts.24 More recently, Thieme et al.25 demonstrated the superiority of a family-assisted behavioral treatment protocol to a physical therapy intervention and found that it was as effective as cognitive-behavioral treatment in reducing pain, although improvements in physical functioning and behavioral outcomes (self-report measures of pain behavior and pain-related spouse solicitous responding) were only found in patients receiving the familyassisted treatment.
Partner-assisted Cognitive Behavioral Treatment
Having spouses assist patients undergoing cognitive-behavioral treatment can be helpful. The effects of a spouse-assisted pain coping skills based on cognitive behavioral principles were compared with a conventional pain coping skills training protocol (which only included patients) and an arthritis education protocol that involved spousal support. The patients in the spouse-assisted treatment condition showed the best outcomes and were able to maintain initial gains in selfefficacy and physical disability 12 months after treatment.26 There is also some evidence for reduced caregiver strain.
In couples-based behavioral interventions, the focus is on the couple’s relationship and how that affects pain. Patients in relationship enhancing interventions have reported significant decreases in pain and other symptoms, and improvements in relationship functioning both immediately after treatment and at one year follow up.27 However, we still know very little about which couples are most likely to benefit from this treatment.
NEW TECHNOLOGIES: REAL-TIME INDIVIDUALLY TAILORED INTERVENTIONS
The use of mobile applications such as new sensor technologies, natural language processing, and machine learning smartphone applications could make self-monitoring less burdensome and help people detect and change maladaptive behaviors and provide a more accurate basis from which to develop therapeutic interventions when direct face-to-face support is not feasible. There are now several trials delivering CBT online to populations with pain. For adolescents with chronic pain, internet CBT has been demonstrated to improve sleep and reduce activity limitations, while reducing over-protectiveness from their parents.28 Although there is limited evidence available, a recent meta-analysis of 11 randomized control trials (RCTs) in adults with chronic back pain concluded that internet CBT increased a sense of control and decreased catastrophizing in patients, although the effects on pain and disability were less clear.29 Best practices for these and other uses of technology will need to be established with research.
MOVING UPSTREAM: PSYCHOLOGICALLY INFORMED PRACTICE (PIP)
Most of the studies cited so far have been conducted on people consulting with established pain, but research has also focused on secondary prevention. Psychologically Informed Practice (PIP)30 has been advocated as a “middle way” between traditional biomedical or biomechanically focused care and the treatment of mental illness. PIP is a pain management approach in which the treatment is delivered not by mental health professionals but by other allied health professionals (AHPs), and in which identification and management of psychological factors is implemented by using the Flag system31 based on the identification of potentially modifiable obstacles to re-activation or re-engagement of various sorts. The general principles have been incorporated into a stratified approach to care in which the number of psychological risk factors identified using a simple screening tool32 is linked with tailored treatment based on the complexity of their clinical presentation33 and for which a training program was developed.34 It should be noted, however, that in the same way that red flags are indicative of the need for an urgent surgical opinion, similarly, frank psychiatric disorder (or orange flags)35 should be triaged to a mental health professional (as should happen in any event). Stratified care is discussed more comprehensively elsewhere in Section 10.
The challenges in translating a pain management approach into primary and secondary care settings were outlined recently. 36 They identify resistance among clinicians still operating on a “pain relief” mode in broadening their focus and incorporating the identification (and management) of yellow flags in their clinics. They reinforce the importance of applying cognitive-behavioral principles, beginning with the identification and clarification of the patients’ reasons for consulting and then the appraisal of core beliefs about pain and its psychological impact, with emphasis on the importance of the style and content of communication as precursors of the development of a treatment plan. They advocate an educational approach with a focus on pain neurophysiology and re-activation including the use of graded exercise/activity and exposure to feared movement and activity. They conclude with emphasising the importance of including a clear focus on the potentially modifiable obstacles to recovery which are identified at the time of initial assessment or emerge during the course of treatment.
WHAT HAVE THESE TECHNIQUES IN COMMON AND WHAT IS THEIR RELEVANCE FOR ORTHOPAEDIC PRACTICE?
For the majority of spinal practitioners, the most important feature of PIP is eliciting and addressing patients’ behaviors, beliefs and perceptions from the onset of the relationship in the first consultation, thus facilitating where possible the direct provision of appropriate care or referral to other health care professionals (HCPs) if required. This involves a shift in thinking from a narrow biomedical approach to a biopsychosocial person-centred approach. Practitioners’ decision-making can be assisted by screening tools, but these may not flag the full picture of individual patients’ pain experience and may not provide sufficient detail to permit development and delivery of an immediate treatment plan of indication of the need for onward referral, for both of which further detail of the context will be required with therapeutic options ultimately also depending on what is available to each practitioner within their specific setting. Thus, clinics differ in their location (community vs hospital); the type of clinic (clinical vs occupational vs forensic); the clinic resource (staffing, e.g., whether uni- or multi-disciplinary); availability of specialist assessment and treatment equipment (whether single-handed or part of a multidisciplinary assessment); constraints of funding(purchaser/stakeholder)and in the case-mixeswith which they deal (initial consultations vs tertiary care) all of which will affect the composition of the case-mixes and characteristics of consulters (which will influence the cost/viability of the clinic and funded activity). Regardless of the setting, using a biopsychosocial approach always involves a comprehensive assessment, to allow practitioners’ fully to elicit and appraise the patients’ needs.
RESTRUCTURING OF THE SPINAL ASSESSMENT: FOCUS, PURPOSE AND ACTION
Accurate diagnosis, clinical decision-making and the delivery of appropriate care are necessary in all consultations with chronic disabling or distressing pain conditions, but, as aforementioned, the options available for assessment and treatment will depend on the resources and professional expertise. It would seem that the majority of spinal consultations are delivered from within a biomedical or biomechanical framework. A plethora of studies, however, have documented the influence of psychosocial factors on the perception of pain, the report of pain, decision to consult and response to treatment.4 For sub-acute and chronic pain problems a biopsychosocial perspective is required not only when biomedical options have been exhausted, but from the time of the initial consultation. This necessitates reconsideration of both the content and the style of the consultation.
The core purpose of the clinical encounter by the HCP remains the delivery of optimal care, but this may require a treatment plan offering more than one element and an implementation strategy involving more than one professional. PIP requires consideration, not only of “treatment targets,” but also specifically of potentially modifiable obstacles to reactivation (thereby refashioning them as opportunities for intervention).
PIP offers a challenge to fundamental assumptions that psychosocial factors are either secondary to physical pathology and should therefore resolve with correction of the abnormality; or are simply symptomatic epiphenomena which cloud the interpretation of the physical signs on which the spinal intervention should be based. For example, while surgery properly should be focused on surgical remediable abnormalities, with chronic disabling conditions there are often not clear indications for surgery, or, in the case of more complex chronic conditions, the surgery will need to be housed within a broader rehabilitative approach. This could include both psychological preparation for surgery and psychosocially oriented post-surgical management addressing reactivation (whether in terms of re-engagement in work or restitution of participation in valued activities). However, it must be emphasized that in PIP, what is offered is not psychological therapy but a psychologically informed approach to clinical care.
What skills then are needed and what objectives can be identified for such interventions?
Keefe37 has offered a useful 4-part classification of psychological interventions in which increasing expertise in psychological management is required.
- Interview methods which include psychosocial evaluation as a core part of the assessment.
- Incorporation of general principles of illness management using a patient-centred behavioral approach characterised by a focus on re-activation rather than pain, with appropriate encouragement for self-help and recognition of progress.
- Use of specific treatment techniques such as goal setting and value-based outcomes.
- Adoption of formal psychosocial treatment programs (e.g., use of manual and a pre-determined structure.
It is not being suggested that in spinal consultations clinicians do not already grapple with psychosocial factors, but they do not seem to do so systematically. In PIP we have an approach to tackling unnecessary levels of pain-associated disability, and pain-associated distress which offers a person-centred approach to spinal care that holds the promise of a more effective and acceptable approach to the management of spinal conditions. For some patients, the orthopaedic consultation is a good place to explore psychological issues and work together to resolve them. For others, referral may be indicated towards interventions that necessitate a higher level of skill in applying psychological techniques. We suggest that regardless of their settings (including private practice), orthopaedic surgeons create trusted networks with other practitioners who deliver psychological interventions. A referral to someone known and trusted is much easier to broach with patients, and they are more likely to comply.
- All clinicians working with people with pain should familiarize themselves with the influence common problems, including distress, catastrophic thinking, fear and avoidance, and withdrawal from activities. Clinicians should be comfortable eliciting information about these and avoid applying psychiatric interpretations to normal, if unhelpful, processes associated with loss and pain. This often involves learning to stop interrupting patients.
- Clinicians’ should be able to screen for such psychological issues with a mind to triage and appropriate treatment. For some, this might include a screening tool, for others, a set of questions and follow-up prompt to ensure they elicit the full picture.
- Clinicians should be able to engage with a variety of psychological techniques, such as problem-solving, value-led goal setting and graded activation.
- When feeling out of their depth or uncomfortable, clinicians should have an established referral network of other practitioners who have additional expertise in psychological management. Clinicians should also be ready to recognize their boundaries and limitations, especially in reference to complex psychiatric co-morbidity.
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- Poquet N1, Lin CW, Heymans MW, van Tulder MW, Esmail R, Koes BW, Maher CG. Back schools for acute and subacute non-specific low-back pain. Cochrane Database Syst Rev. 2016;4:CD008325.
- Pincus T, Holt N, Vogel S, et al. Cognitive and affective reassurance and patient outcomes in primary care: a systematic review. Pain. 2013;154(11):2407-2416.
- Serbic D, Pincus T, Fife-Schaw C, Dawson H. Diagnostic uncertainty, guilt, mood, and disability in back pain. Health Psychol. 2016;35(1):50-59.
- Main CJ, Keefe FJ, Jensen MP, Vlaeyen JWS, Vowles KE(Eds). Fordyce’s Behavioral Methods for Chronic pain and Illness Republished with Invited Commentaries. Philadelphia: IASP Press (Wolters Kluwer Health), 2015.
- Goossens ME, de Kinderen RJ, Leeuw M, et al. Is exposure in vivo cost-effective for chronic low back pain? A trial-based economic evaluation. BMC Health Serv Res. 2015; 15:549.
- Leeuw M, Goossens ME, van Breukelen GJ, et al. Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial. Pain. 2008;138(1):192-207.
- Williams AC1, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:CD007407.
- Pincus T, McCracken LM. Psychological factors and treatment opportunities in low back pain. Best Pract Res Clin Rheumatol. 2013;27(5):625-635.
- Sielski R, Rief W, Glombiewski JA. Efficacy of biofeedback in chronic back pain: a meta-analysis. Int J Behav Med. 2017;24(1):25-41.
- Hayes SC, Strosahl K, Wilson KG. Acceptance and Commitment Therapy: An Experiential Approach to Behaviour Change. New York: The Guildford Press,1999.
- McCracken LM, Morley S. The psychological flexibility model: a basis for integration and progress in psychological approaches to chronic pain management. J Pain 2014;15(3):221-234.
- Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behav Res and Ther. 2006;44(1):1-25.
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