Research Review By Dr. Demetry Assimakopoulos©

Audio:

Download MP3

Date Posted:

February 2017

Study Title:

Clinical Biopsychosocial Physiotherapy Assessment of Patients with Chronic Pain: The First Step in Pain Neuroscience Education

Authors:

Wijma AJ, van Wilgin P, Meeus M et al.

Author's Affiliations:

Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Transcare, Transdisciplinary Outpatient Treatment Centre, Groningen, The Netherlands; Pain in Motion International Research Group, Brussels, Belgium; Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Antwerp University, Belgium; Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Belgium.

Publication Information:

Physiotherapy Theory and Practice 2016; 32(5): 368-384.

Background Information:

Chronic pain is an exceedingly common global healthcare issue that affects 17-27% of the world’s population (1-3). It has huge economic and patient-related ramifications, such as increased medical costs, decreased personal income and quality of life.

Nervous system hyperexcitability, also termed non-neuropathic central sensitization (CS), has been demonstrated in chronic pain suffers (4). Strictly defined, CS is the amplification of neuronal signalling leading to somatosensory (pain) hypersensitivity, and eventually pain without nociceptive input (5, 6). Many chronic pain issues such as low back pain, lateral epicondylalgia and osteoarthritis cannot be solely explained by an organic, identifiable anatomic defect. CS has also been shown to be the predominant, underlying mechanism of fibromyalgia, chronic whiplash and irritable bowel syndrome (7, 8).

The experience of pain itself is biopsychosocial in nature. Pain catastrophizing, pain-related anxiety, trait anxiety, trait neuroticism, depression, stress, poor self-efficacy and post-traumatic stress disorder (PTSD) are present to varying degrees in patients suffering from chronic pain. Bearing this in mind, the initial chronic pain examination should take into account both somatic and psychosocial factors. Understanding these facets of one’s chronic pain experience allows the clinician to provide individualized, patient-centred pain neuroscience education. The authors of this clinical commentary sought to provide a practical guide for assessment of chronic pain using a biopsychosocial framework.

Summary:

Intake: The PSCEBSM Model

P: Type of Pain (9)

Nociceptive Pain:
  • Definition: history of damage to body tissue in the previous 6-8 weeks.
  • Pain diminishes according to the natural healing process.
  • Related to tissue damage or potential damage (i.e. ankle sprain).
  • Local pain, often presenting with signs such as edema, hematomas, skin colouration.
  • Pain is described as sharp, aching and throbbing.
Neuropathic Pain:
  • History of a nervous system lesion/disease, or post-traumatic/post-surgical nervous system damage.
  • Diagnostic examination reveals an anomaly such as sensory disruption, altered reflexes, weakness or autonomic changes.
  • Related to medical or systemic cause, such as stroke, post-herpetic neuralgia, diabetes or some form of neurodegenerative disease.
  • Pain and sensory dysfunction are neuro-anatomically logical.
  • Pain is often described as burning, shooting or prickling.
Non-Neuropathic Central Sensitization Pain:
  • Pain or disability are disproportionate to the nature of injury.
  • No history of a lesion, damage or disease of the nervous system.
  • No indications from diagnostic investigations.
  • No medical cause for pain.
  • Pain is neuroanatomically illogical and segmentally unrelated to the primary source of nociception. Several regions of hyperalgesia at sites outside and remote to the symptomatic area.
  • Pain is often described as vague and dull.
  • Hypersensitivity unrelated to the MSK system can be assessed using the Central sensitization inventory (CSI). The inventory includes hypersensitivity to light, sound, smell, taste and hypersensitive skin.
S: Somatic and Medical Factors

Other comorbid issues may have a negative impact on persistent widespread pain, such as disuse, altered movement patterns, exercise capacity, strength and heightened muscle tone during movement. Medications, either for pain, or other conditions, can have side-effects that make pain more difficult to live with (Writer’s note: An example here might be a patient who suffers from low back pain with radiculopathy, who is being pharmacologically managed with neuromembrane stabilizers for leg pain relief. In such cases, some patients may use a cane, not for pain, but for the dizziness caused by medication. In such cases, clinicians may want to encourage the patient to discuss the efficacy of their medication with the general practitioner).

Neuro-orthopedic testing can be used to confirm or deny the presence of nociceptive, neuropathic or CS pain. Clinicians should also use their physical examination to determine the presence of guarding or kinesiophobia, as these signs often have a negative impact on recovery. Manoeuvres such as basic joint ROM, straight leg raise (SLR), upper limb neurodynamic testing, movement assessment, muscle strength testing and standard neurological testing can be used. While there are strict criteria for positive neuro-orthopedic testing (i.e. leg pain for SLR), other findings such as excessive rigidity, breath holding, increased tone, verbal/non-verbal signs of fear, and inconsistent movement patterns are important to recognize (Writer’s note: many clinicians will rely on Waddell’s signs and/or Hoover’s sign to determine if someone is feigning symptoms. It is important to understand that positive Waddell’s or Hoover’s tests SHOULD NOT be interpreted as malingering. Rather, they should be interpreted simply as NON-ORGANIC signs. There exists a whole spectrum of conditions that fall into this category, including malingering).

C: Cognitions/Perceptions

Cognitions and perceptions can contribute to CS-related pain by increasing pain sensitivity. Clinicians should specifically ask about the patient’s expectations for care, prognosis and their understanding of what’s causing persistent pain. Additionally, cognitive patterns such as catastrophization, perceived injustice, and perceived harm are also important to identify.

Cognitions or perceptions can be reliably measured using various psychometrics, including The Brief Illness Perception Questionnaire (Brief IPQ) or Common Sense Model of Self-Regulation. The authors recommend that patients scoring > 6 (high) on the “worrying on their pain” and < 4 (low) on “understanding their pain” on the Brief IPQ score may potentially benefit from PNE.

Catastrophization can be measured using the Pain Catastrophizing Scale (PCS). Specifically, this tool measures the patient’s tendency towards rumination, pain magnification and their perception of helplessness. The authors recommend removing the title when handing it to the patient. PNE might be helpful in patients who score > 30 (high) on the PCS.

E: Emotional Factors

Anger, fear of movement, anxiety, depressive feelings and post-traumatic stress are related to cognitions and perceptions of pain, and may increase pain sensitivity.

Both state (related to an event) and trait (across many situations) anxiety are negatively associated with pain. Clinicians can quantify anxiety levels using various psychometrics, such as the State-Trait Anxiety Inventory (STAI). A cut-off score of 39-40 is known to be suggestive of clinically significant symptoms. A higher cut off score of 54-55 has been suggested for older adults. Anxiety and its relationship to pain should be explored in the context of PNE.

Many chronic pain patients become fearful of and avoid specific movements. The Tampa-Scale of Kinesiophobia (TSK) can be used to measure patients’ beliefs about serious medical problems and activity avoidance. A cut-off score of > 37 is indicative of fear of movement. Because fear can lead to increased activity in the neuromatrix via the hypothalamic-pituitary-adrenal axis and heighten attention towards pain, anxious feelings should be explored in Pain Neuroscience Education.

Many patients who suffer injuries from motor vehicle accidents or in the workplace fail to recover and transition into chronic pain. Some patients are also dragged though lengthy lawsuits and develop a perception of injustice. Some of these individuals may consciously, unconsciously or under the advice of a lawyer, avoid active treatments for secondary gain. Perceptions of injustice can have a negative effect on pain, disability and treatment. Perceived injustice can be measured using the Injustice Experience Questionnaire (IEQ). A score > 19 is a significant finding. PNE can be helpful in these patients. Clinicians should endeavour to explain that feelings of injustice and anger act as barriers to recovery, and heighten pain sensitivity.

Chronic pain patients often suffer depression as a result of their condition. While chiropractors, physiotherapists and other manual therapists are not specifically trained in the treatment of depression, they should be aware of its existence and its role in chronic pain. Clinicians should be aware of the known bidirectional relationship between depression and pain (11). The Patient Health Questionnaire-9 is commonly recommended for clinical screening. A score > 10 on the PHQ-9 is indicative of depression. Depressed pain patients require support, acknowledgement, comfort and help, which can be provided through PNE. Clinicians could explain to patients that there is interplay between pain and depression via the neuromatrix, if they feel it would enhance the patient’s understanding of their condition.

Patients who suffer from motor vehicle accidents or traumatic injuries should be assessed for PTSD. Specifically, they should be asked if they frequently relive the event, avoid situations that remind them of the event or have negative changes in beliefs and feelings since the event (Writer’s note: Patients can have features of PTSD even after seemingly innocuous motor vehicle or workplace accidents. While not overly physically traumatic, these experiences may be compounded by intense psycho-emotional trauma. Be aware that your patients may have thought they were going to die, suffer substantial physical injury or lose their livelihood. Understanding these thoughts are also undeniably important when interviewing patients who suffered from chronic pain BEFORE their accident. I encourage all clinicians who treat chronic pain to familiarize themselves with the DSM-V criteria for PTSD). Patients should also be asked about their general level of stress or whether or not psycho-emotional stress aggravates their pain.

B: Behavioural Factors

It is important to understand the patient’s conscious and unconscious behaviours as a consequence of pain. Such behaviours can be a product of cognitive and emotional reactions that occur as a result of perceived threat to health and well-being. Patient behaviour can be categorized into 3 subgroups:
  1. Healthy behaviour: In this case, pain results in no/low fear. These patients also confront their pain, and experience some level of recovery (12);
  2. Avoidance; or
  3. Persistence behaviour: In this case, patients will continue to perform painful activities until completion, in spite of the activity being too difficult. In the long term, persistence behaviour can be unhelpful, and result in overactivity-underactivity cycling. Patients should be taught how to pace activities, to avoid symptom aggravation.
Patient behaviours are often mixed in their presentation: some patients will avoid certain activities or movements, while simultaneously persist in others. This underscores the need to perform a thorough assessment, and create an individual patient-centred pain management plan. Specifically, patients should be asked about their individual work, home and recreational activities, to determine which behaviours are avoided or persisted. Additionally, they need to be asked why they avoid or persist with certain activities.

S: Social Factors

It is inherently important determine the existence of social factors that may be helpful/supportive, or unhelpful/stressful. Social factors involved in the pain experience include: one’s social environment, workplace, relationship with a partner, prior/other treatments, and the attitudes/beliefs of other healthcare professions that provided treatment in the past, or are providing concurrent treatment. Many of us have consulted on cases where a patient is told that they have awful ‘disc degeneration’ or that their ‘discs may be out of line.’ This sort of language can heighten a patient’s perception of threat, and impact their coping strategies.

Unsupportive environments can create barriers to recovery, sustain CS and worsen overall prognosis (13, 14). PNE provided in the presence of a spouse, child or loved one can improve social support.

M: Motivation

Determining motivation and readiness to change is absolutely vital to chronic pain treatment. To truly design a treatment plan, it is crucial to determine if the patient understands the cause of their persistent pain, and the patient’s treatment expectations. The relationship between pain and kinesiophobia, disability and catastrophization are largely influenced by psychological inflexibility. The Psychology Inflexibility in Pain Scale (PIPS) can be used to assess pain avoidance and cognitive fusion with pain. Specifically, the PIPS can be used to determine whether someone will optimally respond to acceptance commitment therapy (ACT).

Biopsychosocial Treatment of Chronic Pain

The first step towards self-management and recovery is to thoroughly understand the primary mechanism contributing to pain (i.e. nociception, neuropathic, CS, or a combination therein). Each distinct mechanism has its own complex neurophysiological process that can be explored through PNE, and requires a different treatment pathway (15).

PNE should also include an explanation of how and why different biopsychosocial issues such as fear, anger, social circumstances and stress participate in the pain experience. In many cases, patients will defensively revert to thinking that their clinician believes pain is all in their head. In light of this, patients should be reassured that their pain is real.

It is often helpful to structure PNE to the patient’s readiness to change. Pre-contemplative patients require more nurturing, because they can be resistant and defensive. Contemplative (or ambivalent) patients may benefit from a “Socratic teacher” who provides education on their condition. Patients falling into the preparation stage may require some experienced coaching, to help them create a game plan. For patients who fall into the action and maintenance phases, the therapist acts more like a consultant that provides expert advice and ongoing support (16). From here, clinicians help patients create goals, establish self-efficacy and restore values.

Clinical Application & Conclusions:

This article endeavours to describe a biopsychosocial assessment for patients with chronic, non-neuropathic central sensitization pain. An extensive biopsychosocial intake should be performed using the PSCEBSM model, prior to providing a PNE intervention. This type of intake is allows the clinician to identify the primary mechanism of pain, identify potential barriers to recovery, and structure a patient-centred treatment plan, which includes PNE. This whole process will help the patient navigate through the self-pain management process.

Clinical Commentary: One cannot belittle how important taking a full biopsychosocial history is for the management of chronic pain. A large part of conservative chronic pain management is convincing the patient that their behaviours, cognitions and beliefs matter. Half the battle is decreasing the patient’s anxiety towards self-management. Remind your patients that red flags have been ruled out. Then, teach them that their nervous system can adapt. Finally, help them increase their movement capacity and load tolerance. PNE can help the patient understand the neurophysiological processes that underpin their individual pain experience, and serve to de-threaten movement. This can only be done if the clinician has a thorough understanding of the patient’s own, individual biopsychosocial framework.

Study Methods:

This was a clinical commentary. No statistical measures or article search strategy were described.

Study Strengths / Weaknesses:

Strengths:
  • The authors provided a comprehensive overview of an intake and assessment strategy for a chronic pain patient, in which they were up front about the fact that certain subjects have not been studied adequately, as well as which recommendations were based solely, or mostly, on expert opinion.
  • They provided readers with information about how to interpret different psychometrics. Often, psychometrics are published and validated without scores to stratify severity, for instance.
Weaknesses:
  • The authors did not provide examples of how to move someone through the stages of changes using education. How do you help someone self-manage pain, if they are not ready to be educated and expect a miracle cure from a clinician? These are the most difficult cases.

Additional References:

  1. Merskey H, Bogduk N. International Association for the Study of Pain. Task Force on Taxonomy. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, 2nd edn. 1994. The University of Michigan, IASP Press.
  2. European Pain Federation (EFIC). EFIC’s declaration on pain as a major health problem, a disease in its own right. 2010 http://www.efic.org/index.asp?sub=724B97A2EjBu1C
  3. Blyth FM, March LM, Brnabic AJ et al. Chronic pain in Australia: A prevalence study. Pain 2001; 89: 127–134.
  4. Koltzenburg M, Torebjork HE, Wahren LK et al. Nociceptor modulated central sensitization causes mechanical hyperalgesia in acute chemogenic and chronic neuropathic pain. Brain 1994; 117: 579–591.
  5. Woolf CJ & Salter MW. Neuronal plasticity: Increasing the gain in pain. Science 2000; 288: 1765–1769.
  6. Coombes BK, Bisset L & Vicenzino B. Thermal hyperalgesia distinguishes those with severe pain and disability in unilateral lateral epicondylalgia. Clinical Journal of Pain 2012; 28: 595–601.
  7. Nijs J, Meeus M, Van Oosterwijck J et al. In the mind or in the brain? Scientific evidence for central sensitisation in chronic fatigue syndrome. European Journal of Clinical Investigation 2012; 42: 203–212.
  8. Staud R. Evidence for shared pain mechanisms in osteoarthritis, low back pain, and fibromyalgia. Current Rheumatology Reports 2011; 13: 513–520.
  9. Nijs J, Torres-Cueco R, van Wilgen CP et al. Applying modern pain neuroscience in clinical practice: Criteria for the classification of central sensitization pain. Pain Physician 2014; 17: 447–457.
  10. Lee MC, Zambreanu L, Menon DK et al. Identifying brain activity specifically related to the maintenance and perceptual consequence of central sensitization in humans. Journal of Neuroscience 2008; 28: 11642–11649.
  11. Kroenke K, Wu J, Bair MJ, Krebs EE. Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care. Journal of Pain 2011; 12: 964–973.
  12. Crombez G, Eccleston C, Van Damme S. Fear-avoidance model of chronic pain: The next generation. Clinical Journal of Pain 2012; 28: 475–483.
  13. DeLongis A, Holtzman S. Coping in context: The role of stress, social support, and personality in coping. Journal of Personality 2005; 73: 1633–1656.
  14. Nijs J, Inghelbrecht E, Daenen L et al. Long-term functioning following whiplash injury: The role of social support and personality traits. Clinical Rheumatology 2011b; 30: 927–935.
  15. Nijs J, Torres-Cueco R, van Wilgen CP et al. Applying modern pain neuroscience in clinical practice: Criteria for the classification of central sensitization pain. Pain Physician 2014; 17: 447–457.
  16. Prochaska JO, Norcross JC. Stages of change. Psychotherapy: Theory, Research, Practice, Training 2001; 38: 443–448.