Psychosocial factors in osteopathic practice: To what extent should they be assessed?

International Journal of Osteopathic Medicine 8 (2005) 49e59

www.elsevier.com/locate/ijosm

Review

Psychosocial factors in osteopathic practice: To what extentshould they be assessed?

Nicholas Lucas

School of Exercise & Health Sciences, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Sydney, Australia

Received 14 March 2005; received in revised form 31 March 2005; accepted 5 April 2005

Abstract

Psychosocial factors have been hypothesised to contribute causally to both acute and chronic musculoskeletal pain, and are also

considered to be obstacles to recovery. The assessment of a patient with a pain complaint comprises a standard osteopathic interviewand physical examination. During the consultation the osteopath may explore psychosocial aspects of the patients life based on theconcept that psychosocial factors may have been related to the onset of pain, the transition from acute to chronic pain, or may be

acting as factors which maintain pain and prevent a return to normal function.The main aim of this commentary is to develop a pragmatic answer to the question ‘‘to what extent should psychosocial factors

be explored in those patients who present to osteopaths with a pain complaint?’’

In order to seek an answer to this question a search for relevant articles was conducted using the National Library of MedicinePub Med Clinical Queries search function, and the Cochrane Database of Systematic Reviews. The most recent systematic reviewson psychosocial risk factors for pain are summarised. Also, the most recent systematic reviews regarding the management ofpsychosocial factors in patients with pain are summarised.

It is reported that while there is evidence that psychosocial issues are an important aspect of the pain experience, there is insufficientevidence from which to make firm conclusions about (1) which instruments should be used to measure psychosocial variables, and(2) which combination of psychosocial factors constitutes risk for specific pain syndromes. It is also reported that management

strategies such as cognitive-behavioural therapy and biopsychosocial multidisciplinary treatment are effective at improving outcomesin certain populations; however, these approaches are no more efficacious than other approaches, such as exercise therapy.

These findings suggest that osteopaths should purposely evaluate psychosocial factors in patients who present with pain, and

should address relevant issues as part of their osteopathic management of the patient. However, it is proposed that the formalmeasurement of psychosocial factors using questionnaires is unnecessary in many patients. Also, specific psychological managementor multidisciplinary treatment is not required in order to achieve meaningful outcomes for most patients.� 2005 Elsevier Ltd. All rights reserved.

Keywords: Psychosocial aspects; Musculoskeletal system; Pain; Osteopathic medicine

1. Introduction

Pain is amultifactorial experience that consists ofmorethan the sensation of pain itself.1 Pain is themost commonreason for patients to seek osteopathic treatment,2 withlumbar spinal pain constituting between 31 and 68% of

E-mail address: [email protected]

1746-0689/$ - see front matter � 2005 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijosm.2005.04.002

complaints.2,3 Pain can be temporally categorised asbeing acute, sub-acute and chronic in nature.4 Acute painis defined as the pain experienced by the patient in the first0e12 weeks. Sub-acute pain is typically defined as a painexperience that persists for between 6 and 12 weeks; andchronic pain is defined as a pain experience that persistsfor longer than 12 weeks (3 months).

However, temporality of pain as the criterion fordetermining chronicity has been questioned.4,5 Loeser

mailto:[email protected]

http://www.elsevier.com/locate/ijosm

50 N. Lucas / International Journal of Osteopathic Medicine 8 (2005) 49e59

and Melzack5 suggest that it may be the individual’sinability to restore homeostatic mechanisms that signalsthe transition to chronic pain and this may be onlypartially time dependent.

The neurobiologic mechanisms operant in those withchronic pain have been elucidated to a great extent inthe last decade.6e8 An extensive literature also informsthe role that psychological, behavioural, social andenvironmental variables play in the pain experience ofthe patient.9 However, patients who endure chronic painremain difficult to treat, and it remains difficult toidentify those in the acute phase or sub-acute phase whoare destined to develop chronicity. Indeed, in a multi-variate model of factors implicated in chronic pain,only 30% of the variance in pain is attributable topsychosocial factors, while the remaining 70% area mystery and is not explained by biomedical factors.10

The effectiveness of generic manual therapy in themanagement of chronic pain remains undetermined;however, it is reasonable to conclude from the literaturethat any therapeutic effects in those with chronic painare minor and difficult to differentiate from non-specificeffects of hands-on care.11e16 This conclusion requirescareful interpretation from an osteopathic perspective,as osteopaths typically use more than one manualtherapy technique in any given consultation and rarelyonly treat the region of pain.

It is reasonable to consider the possibility thatconclusions drawn from research investigating genericmanipulative approaches, such as used in the recentlyreported UK Back Pain Exercise and ManipulationTrial (UK BEAM Trial),17 are not generalisable to anosteopathic approach to treatment. Specific judgementsabout osteopathic treatment should be based on researchthat specifically investigates an osteopathic approach. Ina recent randomised controlled trial investigating theeffectiveness of an osteopathic approach to chronic lowback pain, Licciardone et al.18 report that there was nodifference in outcome between the osteopathic manipu-lation group and the sham manipulation group;however, both groups demonstrated improvements inpain, better physical functioning and mental health at 1month, and fewer co-treatments at 6 months whencompared to the no treatment group. This result isconsistent with the findings of systematic reviews ofmanipulation (cited above) and fails to demonstrate thata specific osteopathic approach offers benefits over othermanipulative approaches, or sham manipulation.

Given the limited benefit that manipulation aloneappears to have on those with chronic low back pain,other approaches to the management of patients inpain, especially chronic pain, need to be considered. Theosteopathic profession has a rich history of consideringthe patient as an integrated whole, with rejection of theconcept of mindebody dualism.19 Osteopaths are wellplaced to recognise and understand current concepts in

regard to the role that psychosocial factors play inpatients with pain, and the strategies that might be usedto modify these factors. It is suggested that osteopathsconsider the evidence regarding which psychosocialfactors constitute risk for developing pain or maintain-ing pain; and which of those factors are remediable.

The aims of this commentary are to:

1. orientate readers to the field of psychosocial researchin pain populations;

2. explore the evidence for psychosocial risk factors forpain using information from systematic reviews;

3. explore the evidence for psychosocial interventionsin patients with pain from systematic reviews;

4. develop an evidence-based answer to the question‘‘to what extent should osteopaths assess psychoso-cial factors in patients presenting with pain?’’

In order to achieve these aims, background in-formation regarding psychosocial factors in chronicpain and the psychogenic theory of pain will beintroduced. Evidence in the form of systematic reviewswill be used to discuss those factors which increase therisk of developing chronic pain and those factors thatare potentially remediable with psychosocial interven-tions. Systematic reviews were retrieved using theNational Library of Medicine Pub Med Clinical Queriesfunction (for risk factors the search terms used were:psychological, psychosocial, risk, chronic, pain; fortreatment the search terms used were: psychological,psychosocial, multidisciplinary, behavioural, treatment,pain, chronic, sub-acute, acute, musculoskeletal). Whenarticles were identified, the ‘Related Articles’ functionwas used to search for any other relevant literature. TheCochrane Database of Systematic Reviews was alsosearched using the same search terms and by browsingall systematic reviews in the Back Group, Pain,Palliative Care and Supportive Care Group, Musculo-skeletal Group and Musculoskeletal Injuries Group.

2. Psychosocial factors in chronic pain

The assessment of psychosocial factors in patientspresenting with a pain problem is based on the concept,and evidence, that psychological, behavioural, socialand environmental variables contribute to the painexperience.20e25 There remains, however, controversyregarding the exact nature and extent of this contribu-tion; and this controversy is not helped by the lack ofa convincing and substantial body of evidence regardingexactly which psychosocial factors warrant assessmentand are modifiable such that the risk of chronicity theypose is reduced.10 Certain psychosocial factors whichhave been considered to be risk factors for chronic painhave been labelled as ‘yellow flags’, and it has been

51N. Lucas / International Journal of Osteopathic Medicine 8 (2005) 49e59

advised that patients should be screened for theexistence of these proposed psychosocial risk factors.26

However, 7 years have passed since the publication ofthe first guide to assessing psychosocial yellow flags, andone might reasonably ask, on the basis of evidencepublished since that time, ‘‘Which psychosocial factorsshould be evaluated in patients presenting with pain?’’In other words, while the assessment of psychosocialfactors may have concept validity, it is important todetermine which of these have both discriminativevalidity and predictive validity. The answer to thisquestion can be sought by looking at two types ofevidence.

Initially, evidence should be sought for those factorsthat have been demonstrated in good quality pro-spective cohort studies to increase the risk of pain anddisability (discriminative validity). If such factors can bereliably identified, it seems plausible that the eliminationor reduction of such factors might benefit the patient.Secondly, therefore, evidence should be sought formanagement strategies that have been demonstrated inrandomised controlled trials to actually benefit thepatient (predictive validity). In other words, the answerto the question comes in two parts: (1) which factorsincrease the risk of chronicity and/or maintain thechronic state, and; (2) which of these factors areremediable such that the patient experiences reducedpain and improved function.

A review of the literature reveals many complexissues to consider in regard to the decision to includepsychosocial assessments as part of a standard consul-tation in all patients presenting with pain, and how tointerpret the information generated. Indeed, there arecountless psychosocial ‘factors’, which do leave the termopen to interpretation and makes the term too generic.Some psychosocial variables, such as psychosocialfactors at work, have been demonstrated to have noappreciable relationship to chronic pain and disability,27

whilst others, such as distress and coping style, havebeen found to be associated with an increased risk ofdeveloping chronic pain.28

The situation is further complicated by the fact thatmany of the questionnaires used to measure a personspsychological state may be valid for use in patients withpsychological and/or psychiatric disorders, but areconsidered biased for use in patients in whom thepresenting complaint is, or has been, pain.28 Forinstance, the Minnesota Multiphasic Personality In-ventory (MMPI) is primarily a personality test, and nota test which identifies psychosocial risk factors inpatients presenting with pain. Additionally, numerousquestionnaires contain both functional items andpsychometric items which interact and may producefalsely elevated scores, called criterion contamination.Pincus et al.28 discuss these issues and describe the useand initial validation of an outcome measure (the

Depression, Anxiety and Positive Outlook Scale eDAPOS) that has been specifically designed to assessthree mood states in patients with chronic musculoskel-etal pain; those being depression, anxiety and positiveoutlook. Of particular interest is that the DAPOS wastested for validity on patients consulting a sample ofosteopaths. Anagnostis et al.29 also discuss the issue ofcriterion contamination and describe a new psycho-metrically sound measure for chronic musculoskeletaldisorders (the Pain Disability Questionnaire e PDQ).

3. The psychogenic theory of pain

In a comprehensive review of the literature, Gamsa20

outlines the historical development of the psychogenictheory of pain: that persistent, unexplained pain may becaused by psychic disequilibrium; and that such painwould be resistant to biomedical treatments. The mainfeature of the psychogenic theory of pain is that emotionaldisturbance finds expression in pain. In a further criticalappraisal of research methodology, Gamsa21 highlightsthat much of the original research that was used tosupport the psychogenic theory of pain was methodolog-ically unsound. Also, subsequent research, that has usedrefined methodology to minimise bias and control forextraneous variables, has failed to find consistentevidence in support of the psychogenic theory of pain.

Although dated, Gamsa’s reviews provide a challengeto the concept of psychogenic pain. At the very least, thisview invites readers to consider that medically unexplain-able pain does not provide evidence of a psychogeniccause. As an example of more contemporary literatureon this issue, Raphael et al.30 report that althoughchildhood sexual and physical abuse are often viewed asimportant factors in the development and persistence ofchronic pain, the evidence for this causal association islacking. Only in very large cross-sectional studies are amild association found; however, cross-sectional studiescannot, by definition, demonstrate causality. Prospectivecohort studies are the appropriate research design toinvestigate this issue and those prospective studiesreviewed by Raphael et al.30 do not support therelationship.

The lack of evidence to support the psychogenictheory of pain is important as it removes the temptationto label patients as having pain that is ‘all in their head’.In terms of deciding the extent to which psychosocialfactors should be assessed in patients with pain, theredoes not appear to be evidence to support the notionthat osteopaths should look for psychosocial causes ofthe original onset of pain. However, as discussed above,there is ample evidence to suggest that osteopathsshould consider psychosocial variables that may increasepatients’ risk of developing chronic pain, and may


explain up to 30% of the variance in existing chronicpain conditions.

Pain can be a feature of psychiatric disorders,however, strict criteria apply when making a psychiatricdiagnosis, as outlined in the diagnostic and statisticalmanual of mental disorders (DSM-IV-TR).31 In order toensure reliable, objective diagnosis and avoid subjectivediagnoses based on personal judgement, osteopaths areencouraged to rely on the DSM criteria. In regard to theDSM-IV-TR diagnostic categories that include pain, itis clear for the majority that pain must be neither theprimary concern of the patient nor the primary reasonfor disability. Furthermore, labels such as somatisationdisorder stipulate that a patient has pain in at least fourlocations, as well as two gastrointestinal symptoms,a sexual symptom and a pseudo-neurological symptom,and is clearly an inappropriate label for those withchronic pain limited to one or two regions, e.g. neckand/or low back pain.

In the DSM-IV-TR Pain Disorder category, there aretwo labels provided for patients in whom psychosocialfactors are considered important:

1. Pain disorder associated with psychological factors;and

2. Pain disorder associated with psychological factorsand a general medical condition.

However, determining which psychological factorsare associated with pain in a particular patient remainslargely conceptual, and is based on personal opinionrather than evidence. For example, if one was to assumethat a work-related psychosocial factor had been dem-onstrated to increase the risk of developing chronic painin a population-based study, how could one look backretrospectively with an individual patient and determineif this factor played a role in the development of thatpatient’s pain?

Also, some patients in pain experience distress,anxiety and depression as a result of being in pain, inwhich case the psychological factors are subsequent tothe pain disorder. Furthermore, to say that a paindisorder is associated with psychological factors doesnot imply that psychological factors caused the paindisorder. Clearly, it is difficult to make an informed andvalid decision that a patient’s pain is associated witha psychological disorder, and it has been suggested thatmost patients with chronic pain should be labelled ashaving pain associated with a general medial condition(i.e. non-psychological cause), even if this medicalcondition is to be assumed.32

The existence of emotional and psychological re-sponses to pain does not warrant the label ‘pain disorderthat is associated with a psychological factor’, becauseeveryone who experiences pain has, by definition, anemotional experience of that pain. If the label ‘pain

disorder associated with psychological factors’ was to beapplied to everyone experiencing pain, then it wouldcease to have any discriminative validity and wouldbecome a useless label.

4. Factors that increase the risk of developing

chronic pain

It is important to note that the majority of pro-spective cohort studies examining the relationshipbetween pain and psychosocial factors has beendesigned to examine the relationship between a specificlocation of pain (such as lumbar spinal pain) andspecific psychosocial factors.22,23,25,27 The questionarises as to whether the results found in such specificstudies are then generalisable to all pain syndromes andall psychosocial variables? For instance, the findingsfrom research investigating psychosocial issues inpatients with lumbar spinal pain25,33,34 should not beextrapolated to those patients with cervical spinal pain,in whom a different profile of psychosocial risk factorsexists.35,36 Furthermore, studies examining psychosocialissues in patients with acute pain should not necessarilybe extrapolated to those with sub-acute pain, or thosewith chronic pain. Whilst theories in regard to a givenpain syndrome may be extrapolated to other syndromes(along with the limitations of theory transference), datafrom research studies should not be extrapolated.

In 2000, Hoogendoorn et al.23 published a systematicreview of psychosocial factors at work and in patientsprivate lives, as risk factors for back pain. These authorsconcluded that evidence was found for a risk associatedwith work-related psychosocial factors, but the evidencefor specific work factors was lacking. The strength ofthis finding was affected by the quality ratings given toeach of the articles, which determined their eligibility forinclusion in the systematic review, and changes in theway articles were rated affected the conclusions thatcould be drawn. For example, the authors state that‘‘None of the publications on any of the studies clearlydemonstrated, with reference to repeatability data, thatstandardised methods of acceptable quality were usedfor the assessment of psychosocial factors at work’’. Itwas also reported that there was insufficient evidence todetermine the role of private life psychosocial factors inback pain.

Four years later, in 2004, Hartvigsen et al.27 pub-lished a systematic review of prospective cohort studiesdesigned to investigate the relationship between psycho-social factors at work and low back pain, and theconsequences of low back pain. Hartvigsen et al.27

reported that many of the instruments used to collectdata on work-related psychosocial factors remained tobe validated, which threatened the internal validity ofthe original research using these instruments, and


therefore the systematic reviews based upon this re-search (such as the Hoogendoorn et al.23 review).Antinomy in this regard is evident in the findings ofHartvigsen et al.27 who, in contrast to Hoogendoornet al.23, found evidence for no association betweenpsychosocial factors at work; specifically, no associationfor low back pain and perception of work, organisa-tional aspects of work, and social support at work.

In 2000, Linton22 reported the findings of a systematicreview evaluating the psychological risk factors inpatients with back and neck pain. Linton22 reports thatpsychological variables are clearly linked with neck andback pain; citing stress, distress, and anxiety as well asmood, emotions, cognitive function and pain behaviouras significant factors. Linton22 also makes the suggestionthat these factors may be linked to the aetiology of acutepain, especially in relation to the transition from acuteto chronic pain. However, Linton22 highlights that theseconclusions should be interpreted with caution given thelow methodological quality of the studies included in thesystematic review.

In 2002, Pincus et al.25 reported the findings of theirsystematic review of psychological factors as predictorsof chronic pain and disability in patients with low backpain. They report that distress (a composite of psycho-logical distress, depressive symptoms and depressivemood), somatisation, and cognitive factors (such aspraying/hoping and catastrophising) were implicatedin the transition to chronicity in patients with lowback pain. However, these findings were reported withthe caveat that further research was needed forsubstantiation.

Of interest in the Pincus et al.25 review was theiranalysis of feareanxiety, in which they found theevidence to be ‘‘surprisingly scarce’’. They report thefindings of Burton et al.37 who found that removal offeareanxiety from a multivariate model, which includedother psychological parameters, did not weaken thepredictive power the model. This review provides somecontrasts to the conclusions of Linton,22 who stated thatanxiety was a significant factor in neck and back pain.

5. Summary of recent systematic reviews e risk factors

It can be reasonably determined from the literaturereviewed to date that psychosocial factors do not playan aetiological or causative role in the onset ofpain.20,21,30 However, it does appear that work-relatedpsychosocial issues may play a role in chronic backpain,23 and that distress, anxiety, depression,22,25

somatisation,27 and certain cognitive factors25 playa role in the transition from acute back pain to chronicback pain and disability. However, these systematicreviews pertain predominantly to lumbar spinal painand not necessarily to other spinal pain syndromes, or

chronic pain and disability in general. The evaluation ofpsychosocial factors in patients presenting with pain istherefore a conceptual, pragmatic practice based moreon common sense rather than a cohesive body ofevidence.

In summarising these systematic reviews, it isapparent that there is a lack of good quality studies fromwhich to draw firm conclusions, and this explains, tosome extent, the antinomy evident in this field. It is alsoimportant to point out that as soon as a systematicreview is conducted, it readily becomes out of date, asnew additions to the primary literature might challengethe conclusions of a previously reported systematicreview. A good quality prospective cohort study shouldbe given more consideration than a systematic reviewbased on poor quality studies, even though systematicreviews are ranked more highly than prospective studiesin the hierarchy of evidence. Lastly, while the topic ofthis commentary is concerned with pain in general, themajority of systematic reviews focus on a specific painsyndrome, which reflects the focus of the primaryliterature. For these reasons it is suggested that theconclusions of the systematic reviews be interpreted withcaution rather than accepted as being conclusive.

6. Management of relevant risk factors

The reliable and valid identification of clinicallyrelevant psychosocial factors that, when present, increasethe risk of chronicity, leads one to consider which of thesefactors are remediable. If, by addressing a psychosocialfactor, patient outcomes improve, then this increases thepredictive validity of evaluating psychosocial factors. If,on the other hand, a given psychosocial factor has noeffective management strategy that results in improvedoutcomes, then the routine measurement of this factorlacks clinical utility. Nevertheless, the assessment of suchfactors may still help the osteopath understand thepatient in the context in which they experience their pain.

There are various approaches to the management ofpsychosocial issues, and these include pharmacotherapyand cognitive-behavioural therapies (CBT) nested with-in a biopsychosocial approach to pain management. Theevidence for the efficacy and/or effectiveness of behav-ioural therapy, CBT and multidisciplinary managementof certain pain conditions is discussed below. A detaileddiscussion of the evidence for the effectiveness ofpharmacological management of psychological factorswill not be presented in this article. However, it may beof interest to readers that the authors of a recentsystematic review of antidepressants in the treatment ofchronic low back pain conclude that selective serotoninreuptake inhibitors do not appear to be beneficial forpatients with chronic low back pain, whereas tricyclicand tetracyclic antidepressants appear to produce


moderate symptom reductions for patients with chroniclow back pain. However, what is interesting is that thisbenefit appears to be independent of the patient’sdepression status. The authors also conclude that thereis conflicting evidence whether antidepressants improvefunctional status of patients with chronic low backpain.38

7. Psychosocial factors that are potentially remediable

and may help prevent chronicity and disability

The main reason for evaluating psychosocial factorsis in the hope that by addressing these factors, patientsmight be prevented from developing chronic pain andhave a greater chance of recovery. While it is logical totarget risk factors in prevention, we must recognise thatif the variance explained by the risk factor is small, thenthe changes achieved by modifying those risk factorswill also be small. In the case of psychosocial factors, thevariance in pain attributable to these factors is estimatedto lie between 15 and 30%10; so, by addressing thesefactors one might hope to vary the pain by 30% at thebest. The chance of a 30% improvement is obviouslya worthwhile aim; however, ones’ expectations of theeffectiveness of psychosocial intervention should beplaced within the realm of what is likely to be possible.Further, while it is interesting to consider theoreticalpossibilities, it is far more useful to consider the actualextent to which psychosocial intervention is successful asreported in the systematic reviews discussed below. Theevidence for the effectiveness of managing psychosocialfactors with psychosocial interventions is discussedunder the headings of acute pain, sub-acute pain, andchronic pain.

7.1. Acute pain

In regard to the management of relevant psychosocialissues in those with acute pain, there is no specificevidence from which to form an opinion at this stage.More specifically, we do not yet know if addressingpsychosocial issues in those with acute pain actuallydecreases the risk of chronicity and disability. Thedevelopment of research investigating psychosocialinterventions in acute pain will be interesting to followas it is only in the acute phase that prevention ofchronicity is likely to be viable, simply because thedetection of psychosocial risk factors in patients alreadyin the chronic phase is obviously too late to preventchronicity.

In one study that compared standard medicaltreatment with evidence-based treatment for acute lowback pain, the authors report that patients in theevidence-based treatment group had statistically signif-icant reductions in pain and the amount of ongoing

treatment, and a greater proportion were fully recoveredat 12 months.39 What is important about this study isthat included in the evidence-based treatment group,was an emphasis of dealing with patients’ fears andmisconceptions, providing confident explanations, andempowering the patient to resume normal activities.This study, therefore, primarily supports the use of theevidence-based guidelines for the management of acutelow back pain,39 and secondarily lends support to theconcept that addressing certain psychosocial issues, suchas catastrophising and fear-avoidance behaviour, mightbenefit the patient. However, this argument does notprovide specific support for the contention that psy-chosocial issues warrant formal investigation and, ifdetected, warrant specialised psychosocial interventions.Rather, it supports the argument that the managementof all patients with acute low back pain should includereassurance, education, and advice to stay active,irrespective of whether psychosocial factors are mea-sured or not.39

7.2. Sub-acute pain

In a systematic review in 2001, Karjalainen et al.40

report that biopsychosocial multidisciplinary rehabilita-tion helps patients return to work faster, decreases sickleave and alleviates disability. However, this review wasbased on only two acceptable research articles.

In another systematic review in 2002, Pengel et al.41

report that evidence was found for the efficacy of advicein those with sub-acute low back pain; however, thisevidence is based on low methodological research andshould be viewed with caution.

In 2003, Karjalainen et al.42 updated their 2001systematic review and after screening 1808 abstracts,and the references of 65 reviews still found only two lowquality RCTs that satisfied their criteria on sub-acutelow back pain. They conclude that ‘‘that there ismoderate evidence of positive effectiveness of multidis-ciplinary rehabilitation for sub-acute low back painand that a workplace visit increases the effectiveness.However, because this evidence is based on trials thathad methodological shortcomings, and several expen-sive multidisciplinary rehabilitation programmes arecommonly used for uncomplicated/non-specific sub-acute low back problems, there is an obvious need forhigh quality trials in this field.’’

7.3. Chronic pain

In 1999, Morley et al.43 report that when comparedwith the waiting list control conditions, cognitive-behavioural treatments were associated with significanteffect sizes on all domains of measurement. Comparisonwith alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater


changes for the domains of pain experience, cognitivecoping and appraisal (positive coping measures), andreduced behavioural expression of pain. Differences onthe following domains were not significant; mood/affect(depression and other, non-depression, measures), cognitivecoping and appraisal (negative, e.g. catastrophisation),and social role functioning. Morley et al.43 conclude thatactive psychological treatments based on the principle ofcognitive-behavioural therapy are effective.

In 2000, van Tulder44 reported that there is strongevidence that behavioural treatment has a moderatepositive effect on pain intensity and function in thosewith chronic low back pain. However, this effect wasnot found when behavioural treatment was added toa usual treatment program, casting doubt as to whetherbehavioural treatment is any more effective than othernon-behavioural treatments (such as exercise therapy).

In 2002, Guzman et al.45 report in their systematicreview that only an intensive multidisciplinary approachto chronic low back pain with a functional restorationapproach (unavailable to most osteopaths in privatepractice) resulted in clinically useful outcomes, and thatless intensive outpatient psycho-physical treatments didnot improve pain, function or vocational outcomeswhen compared with non-multidisciplinary outpatienttherapy or usual care.

In 2005, Ostelo et al.46 report in their systematic reviewthat ‘‘combined respondent-cognitive therapy and pro-gressive relaxation therapy are more effective thanwaiting list controls on short-term pain relief. However,it is unknown whether these results sustain in the longterm.No significant differences could be detected betweenbehavioural treatment and exercise therapy. Whetherclinicians should refer patients with chronic low backpain to behavioural treatment programmes or to activeconservative treatment cannot be concluded from thisreview.’’

In 2003 Karjalainen et al.47 published their updatedsystematic review on multidisciplinary biopsychosocialrehabilitation for neck and shoulder pain among workingage adults and conclude that there appears to be littlescientific evidence for the effectiveness of multidisciplinarybiopsychosocial rehabilitation compared with otherrehabilitation facilities for neck and shoulder pain.

In 2003 Eccleston et al.48 report the findings of theirsystematic review evaluating psychological therapiesfor the management of chronic and recurrent pain inchildren and adolescents. The main findings of thisreview pertain to chronic headache, as this representedthe majority of the primary literature in children andadolescents, in contrast to those studies on adults whichtend to focus on low back pain. Eccleston et al.48 reportthat there is evidence that psychological treatments,principally relaxation and cognitive-behavioural therapy,are effective in reducing the severity and frequency ofchronic headache in children and adolescents. However,

due to a lack of primary literature, there is at present noevidence for the effectiveness of psychological therapiesin attenuating pain in conditions other than headache.

Lastly, in 2000 Karjalainen et al.49 report the findingsof their systematic review concerning multidisciplinaryrehabilitation for fibromyalgia and musculoskeletal painin working age adults. The authors discuss that of theRCTs that were relevant, none were of high methodo-logical quality. They conclude that there is littlescientific evidence for the effectiveness of multidisciplin-ary rehabilitation for these musculoskeletal disorders.

8. Summary of recent systematic reviews e management

Multidisciplinary biopsychosocial interventions, be-havioural therapy, and cognitive-behavioural therapyhave been evaluated for efficacy in those with sub-acuteand chronic pain. While some positive benefits arisefrom the application of these approaches, the recentsystematic reviews discussed above do not provideconvincing evidence that these approaches offer betteroutcomes than those already existing biomedical andrehabilitative approaches. For example, while behav-ioural therapy for chronic low back pain is better thanno therapy, and better than placebo, it is not better thanexercise therapy.44,50 Similarly, while intensive multidis-ciplinary biopsychosocial rehabilitation (with functionalrestoration) improves function and reduces pain, lessintensive outpatient multidisciplinary biopsychosocialrehabilitation did not show improvement in pain,function or vocational outcomes when compared withusual care.45,50 In support of this, Pincus et al.51

conclude in their report of cognitive-behavioural ther-apy and psychosocial factors in low back pain that‘‘In the treatment of psychological factors, the role ofclinicians in primary care remains unclear. Furtherevidence is needed to identify specific psychological riskfactors, primary care tools for their identification needdeveloping, and interventions at different stages of lowback pain by different professionals need to be tested.’’

9. Discussion

This overview of recent systematic reviews regardingthe relationship between psychosocial factors and painsets the background for the justification of the extent towhich psychosocial factors should be routinely exploredin osteopathic practice (Box 1). Psychosocial factorsmay primarily increase the risk of chronic pain anddisability and may be potentially remediable witha view to reducing risk of chronic pain and disabilityand improving rehabilitation outcomes; however, thisapproach remains largely conceptual.10 Also, the decisionto evaluate psychosocial factors in a patient will be


Box 1. A suggested outline of the extent to which psychosocial factors should be assessed in patientspresenting with pain

Acute pain� Address the following concerns:

» I hurt» I can’t move» I can’t work» I’m scared

� Make informal enquiries as to:» Beliefs that pain is harmful or potentially disabling» Fear-avoidance behaviours (physical, domestic, social, and vocational)» Tendency to low mood and withdrawal from social interaction» An expectation that passive treatments rather than active participation will help

Sub-acute pain� As for acute pain, however added emphasis on each of these points is provided as determined on

a case-by-case basis� Re-assess, if necessary� Consider using a formal questionnaire, such as the DAPOS.*

Chronic pain� As for sub-acute pain� Consider using a formal questionnaire, such as DAPOS.*

*Recognising that such questionnaires provide some type of formal quantification of psychosocialissues, but are still being developed and improved.

influenced by whether they have acute, sub-acute orchronic pain.

In patients with acute pain, it is proposed that theosteopath should make initial enquires regardingrelevant psychosocial factors, with a view to implement-ing further and more detailed enquiry if the patient’ssymptoms do not improve before they enter the sub-acute phase. The main reason for this is to make an earlyidentification of relevant psychosocial issues in thosepatients who are progressing toward sub-acute pain andchronicity. However, it should be noted that of thosepatients with acute low back pain, only 2e7% developchronic pain,52 and so it is in these 2e7% of patientswho develop sub-acute pain (6e12 weeks duration) thatpsychosocial factors become increasingly relevant. Inpatients with chronic pain, psychosocial issues should bemore formally assessed, however, it may be consideredthat since chronicity has already occurred, assessmentfor psychosocial issues ceases to be for preventativepurposes, and becomes important for the wholisticmanagement of an existing condition in order to meetpatients’ physical and emotional needs.

It is important to consider the possibility that patientswith chronic pain do not necessarily have psychosocialfactors that either increased their risk of developing

chronic pain or are maintaining their present status. Infact, as discussed above, regression models of chronicpain and associated features show that psychosocialvariables only account for between 15 and 30% of thevariance.10 Those factors which explain the remaining70% are a mystery in populations, and even more so inindividual patients. It should be acknowledged thatpatients in chronic pain do not automatically havechronic pain because of psychosocial factors. Thefollowing four a priori possibilities highlight this fact:

1. An individual patient with chronic pain may have nopsychosocial issues.

2. An individual patient with chronic pain may havepsychosocial issues, but which are not important intheir pain condition.

3. An individual patient with chronic pain may havepsychosocial issues as a result of being in chronicpain, but which may, or may not, be maintaining thepain.

4. An individual with chronic pain may have developedchronic pain because of relevant psychosocialfactors that were present during the acute phase,and which increased their risk of developing chronicpain.


For example, a patient may present with pain, but isactually expressing dissatisfaction with their marriage;and each of these constitute two separate problems(point 2 above), each of which is worthy of manage-ment. This is different from having pain that is eitherdue to, or is being maintained by, psychosocial issues(point 4 above). Given these possibilities, it is clear thatthe symptom of chronic pain is not pathognomonic forthe diagnosis of psychological or social problems and, atpresent, no tool or measure exists by which to reliablydistinguish between these individual groups. It should beclearly understood that it is inappropriate to labelpatients as having psychosocial problems simply on thebasis that the patient has chronic pain.

Bogduk and McGuirk10 present the strategy ofobserving and listening for relevant psychosocial factorsduring the standard medical interview, and summarisethe patient’s beliefs, and also their behaviours thatpertain to (1) physical activity, (2) domestic responsibil-ities, (3) social interactions and (4) vocational matters,should be explored. It is suggested that practitioners lookfor26:

� Beliefs that pain is harmful or potentially disabling;� Fear-avoidance behaviours (physical, domestic, so-cial, and vocational);

� Tendency to low mood and withdrawal from socialinteraction;

� An expectation that passive treatments rather thanactive participation will help.

The administration of questionnaires in acute painpatients is perhaps too intrusive, whereas an explorationof patients’ fears, beliefs and work issues through informalconversation during the consultation is considered to bea satisfactoryapproach.10 Inorder toelicit this informationit is suggested that practitioners phrase questions like26:

� What do you understand is the cause of your pain?� What are you expecting will help you?� How is your employer responding to your backpain? Your family? Your co-workers?

� What are you doing to cope with your pain?� Do you think that you will return to work?

It is in patients who do present with sub-acute painthat it is most important to more formally assess forrelevant psychosocial issues. This involves a re-assess-ment of those psychosocial factors listed above. Such re-assessment can be conducted verbally, or a questionnairecan be administered. However, the problem with usingquestionnaires is deciding which one to use? Given thatthe literature does not provide an adequate answer tothat question as yet, it becomes a personal choice. Ithas not been an aim of this commentary to discuss speci-fic questionnaires, but to consider their usefulness in

general for osteopaths in private practice. Informationregarding questionnaires is widely available and a briefsummary of commonly used questionnaires can befound in Bogduk and McGuirk’s text.10

Having conducted an assessment of psychosocialfactors in an individual patient, and made the decisionthat certain psychosocial factors are present andrelevant to the pain condition, the osteopath is left toconsider the appropriate management of these factors.

10. Conclusions

It is clear from the literature that a patient’s tendencyto catastrophise may increase their risk of chronicity.Further, catastrophisation and distress resulting frombeing in pain interacts in some way with patients’ beliefsand behaviours, as well as their coping strategies, whichalso interacts with how they engage in their work andsocial lives. In those patients who do develop chronicpain, this complex mix of variables may have anassociation with the transition of pain from the acutestage to the chronic stage.

Most patients do not go on to develop chronic painand disability, so it could be argued that an in-depthassessment of psychosocial factors in all acute painpatients is not warranted. However, it is equally importantto try and identify those patients in whom psychosocialfactors represent a risk of developing chronic pain anddisability, such that these factors can bemodified with theintention of preventing chronicity and disability.

In answer to the question, ‘‘to what extent shouldosteopaths assess psychosocial factors in patients pre-senting with pain?’’ a pragmatic and sensible approach isto informally, yet consistently, make an assessment ofpsychosocial factors during the medical interview andensuing conversation and to include reassurance, educa-tion, and advice to stay active in acute pain patients.39 Inthose with sub-acute pain, it is important to focus on andmake a re-assessment of those psychosocial factors thatwere considered during the acute stage. This can beachieved verbally during the course of conversation, orcould be more formally assessed using a questionnaire(such as the DAPOS28). In patients who have alreadydeveloped chronic pain, it is important to identify thepresence of psychosocial factors that may have contrib-uted to their current chronicity with a view to helping thepatient manage their symptoms. The most effectivemanagement of psychosocial factors in sub-acute andchronic pain is difficult to determine from the evidence.

Given the limitations of the current literature toinform practitioners about the specific roles that psycho-social assessment and psychosocial intervention have invarious pain syndromes, it would be wise to stay attunedto developments in this area, as new, good qualityresearch is likely to clarify current understanding.


References

1. Keefe FJ, Bradley LA, Main CJ. Psychological assessment of the

pain patient for the general clinician.Pain 1999e an updated review.

Refresher course syllabus. Seattle: IASP Press; 1999. p. 219e230.2. Mcllwraith B. A survey of 1200 osteopathic patients in the United

Kingdom. J Osteopath Med 2003;1:7–12.

3. Burton AK. Back pain in osteopathic practice. Rheumatol Rehabil

1981;20:239–46.

4. Merskey H, Bogduk N. Classification of chronic pain. Definitions of

chronic pain syndromes and definition of pain terms. 2nd ed. Seattle:

IASP Press; 1994.

5. Loeser JD,Melzack R. Pain: an overview. Lancet 1999;353:1607–9.

6. Basbaum AI. Spinal mechanisms of acute and persistent pain. Reg

Anesth Pain Med 1999;21:59–67.

7. Julius D, Basbaum AI. Molecular mechanisms of nociception.

Nature 2001;413:203–10.

8. Warfield CA, Bajwa ZH editors. Principles and practice of pain

medicine. 2nd ed. New York: McGraw-Hill; 2004. p. 121–4.

9. Ad Hoc Committee OT/PT Pain Curriculum. Pain curriculum

for students in occupational therapy or physical therapy. IASP

newsletter. Seattle: International Association for the Study of Pain;

1994.

10. Bogduk N, McGuirk B. Psychosocial assessment. In: Bogduk N,

McGuirk B editors. Medical management of acute and chronic low

back pain. Edinburgh: Elsevier; 2002.

11. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Does

spinal manipulative therapy help people with chronic low back

pain? Aust J Physiother 2002;48:277–84.

12. Pengel HM, Maher CG, Refshauge KM. Systematic review of

conservative interventions for subacute low back pain. Clin Rehabil

2002;16:811–20.

13. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.

Spinal manipulative therapy for low back pain. A meta-analysis

of effectiveness relative to other therapies. Ann Intern Med 2003;

138:871–81.

14. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG.

Efficacy of spinal manipulative therapy for low back pain of less

than three months’ duration. J Manipulative Physiol Ther 2003;26:

593–601.

15. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.

Spinal manipulative therapy for low back pain. Cochrane Database

Syst Rev 2004;1. CD000447.

16. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal

manipulation and mobilization for low back pain and neck pain:

a systematic review and best evidence synthesis. Spine J 2004;4:

335–56.

17. UK BEAM Trial Team. United Kingdom back pain exercise and

manipulation (UK BEAM) randomised trial: cost effectiveness of

physical treatments for back pain in primary care. BMJ 2004;

10.1136/bmj.38282.669225.AE.

18. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W,

et al. Osteopathic manipulative treatment for chronic low back

pain: a randomized controlled trial. Spine 2003;28:1355–62.

19. Nash K, Tyreman S. An account of the development of the

conceptual basis of osteopathy course at the British School of

Osteopathy. Int J Osteopath Med 2005; 8, 29e37.20. Gamsa A. The role of psychological factors in chronic pain. I. A

half century of study. Pain 1994;57:5–15.

21. Gamsa A. The role of psychological factors in chronic pain. II. A

critical appraisal. Pain 1994;57:17–29.

22. Linton SJ. A review of psychological risk factors in back and neck

pain. Spine 2000;25:1148–56.

23. Hoogendoorn WE, van Poppel MNM, Bongers PM, Koes BW,

Bouter LM. Systematic review of psychosocial factors at work and

private life as risk factors for back pain. Spine 2000;25:2114–25.

24. Gatchel RJ. A biopsychosocial overview of pretreatment screening

of patients with pain. Clin J Pain 2001;17:192–9.

25. Pincus T, Burton K, Vogel S, Field A. A systematic review of

psychological factors as predictors of chronicity/disability in

prospective cohorts of low back pain. Spine 2002;27:E109–20.

26. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial

yellow flags in acute low back pain: risk factors for long-term

disability and work loss. Wellington, New Zealand: Accident

Rehabilitation and Compensation Insurance Corporation of New

Zealand and the National Health Committee; 1997.

27. Hartvigsen J, Lings S, Leboeuf-Yde C, Bakketeig L. Psychosocial

factors at work in relation to low back pain and consequences of

low back pain; a systematic, critical review of prospective cohort

studies. Occup Environ Med 2004;61:e2.

28. Pincus T, Williams de C AC, Vogel S, Field A. The development

and testing of the depression, anxiety, and positive outlook scale

(DAPOS). Pain 2004;109:181–8.

29. Anagnostis C, Gatchel RJ, Mayer TG. The Pain Disability

Questionnaire: a new psychometrically sound measure for chronic

musculoskeletal disorders. Spine 2004;29:2290–302.

30. Raphael KG, Chandler HK, Ciccone DS. Is childhood abuse

a risk factor for chronic pain in adulthood? Curr Pain Headache

Rep 2004 Apr;8:99–110.

31. DSM-IV-TR. Diagnostic and statistical manual of mental disorders.

Text revision. 4th ed. Washington DC: American Psychiatric

Association; 2000.

32. Bogduk N. Diagnostic and statistical manual of mental disorders.

Encyclopedia of pain. Springer-Verlag; in press.

33. Linton SJ. Occupational psychological factors increase the risk for

back pain: a systematic review. J Occup Rehabil 2001;11:53–66.

34. Truchon M, Fillion L. Biopsychosocial determinants of chronic

disability and low back pain: a review. J Occup Rehabil 2000;10:

117–42.

35. Radanov BP, Stefano G, Schnidrig A, Ballinari P. Role of

psychosocial stress in recovery from common whiplash. Lancet

1991;338:712–5.

36. Borchgrevink GE, Stiles TC, Borchgrevink PC, Lereim J. Person-

ality profile among symptomatic and recovered patients neck

sprain injury, measured by MCM-I acutely and 6 months after car

accidents. J Psychosom Res 1997;42:357–76.

37. Burton AK, Tillotson KM, Main C, Hollis S. Psychosocial

predictors of outcome in acute and sub chronic low back trouble.

Spine 1995;20:722–8.

38. Staiger TO, Gaster B, Sullivan MD, Deyo RA. Systematic review

of antidepressants in the treatment of chronic low back pain. Spine

2003;28:2540–5.

39. McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety,

efficacy, and cost effectiveness of evidence-based guidelines for the

management of acute low back pain in primary care. Spine 2001;

26:2615–22.

40. Karjalainen K, Malmivaara A, van Tulder M, Roine R,

Jauhiainen M, Hurri H, et al. Multidisciplinary biopsychosocial

rehabilitation for subacute low back pain in working-age adults:

a systematic review within the framework of the Cochrane

Collaboration Back Review Group. Spine 2001;26:262–9.

41. Pengel MH, Maher CG, Refshauge KM. Systematic review of

conservative interventions for subacute low back pain.Clin Rehabil

2002;1:811–20.



rehabilitation for subacute low back pain among working age

adults. Cochrane Database Syst Rev 2003;2. CD002193.

43. Morley S, Eccleston C, Williams A. Systematic review and meta-

analysis of randomized controlled trials of cognitive behaviour

therapy and behaviour therapy for chronic pain in adults,

excluding headache. Pain 1999;80:1–13.


44. van Tulder MW, Ostelo RW, Vlaeyen JW, Linton SJ, Morley SJ,

Assendelft WJ. Behavioural treatment for chronic low back pain.

Cochrane Database Syst Rev 2000;2. CD002014.

45. Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E,

Bombardier C. Multidisciplinary bio-psycho-social rehabilitation

for chronic low back pain. Cochrane Database Syst Rev 2002;1.

CD000963.

46. Ostelo R, Tulder M, Vlaeyen J, Linton S, Morley S, Assendelft W.

Behavioural treatment for chronic low-back pain. Cochrane

Database Syst Rev 2005;1. CD002014.



rehabilitation for neck and shoulder pain among working age

adults. Cochrane Database Syst Rev 2003;2. CD002194.

48. Eccleston C, Yorke L, Morley S, Williams AC, Mastroyanno-

poulou K. Psychological therapies for the management of chronic

and recurrent pain in children and adolescents. Cochrane Database

Syst Rev 2003;1. CD003968.


Jauhiainen M, Hurri H, et al. Multidisciplinary rehabilitation

for fibromyalgia and musculoskeletal pain in working age adults.

Cochrane Database Syst Rev 2000;2. CD001984.

50. Bogduk N. Management of chronic low back pain. Med J Aust

2004;180:79–83.

51. Pincus T, Vlaeyen JWS, Kendall NAS, Von Korff MR,

Kalauokalani DA, Reis S. Cognitive-behavioral therapy and

psychosocial factors in low back pain: directions for the future.

Spine 2002;27:E133–8.

52. Nachemson AL, Waddell G, Norlund AI. Epidemiology of neck

and low back pain. In: NachemsonAL, Jonsson E, editors.Neck and

back pain: the scientific evidence of causes, diagnosis and treatment.

Philadelphia: Lippincott Williams & Wilkins; 2000. p. 165–88.

Psychosocial factors in osteopathic practice: To what extent should they be assessed?

Documents

Transcript of Psychosocial factors in osteopathic practice: To what extent should they be assessed?