Psychological aspects of back pain

8

Psychological aspects of back pain

R O B E R T D. K E R N S M A R Y C A S E Y J A C O B

Back pain is the most common form of musculoskeletal discomfort, so common that Kahanovitz (1991) has mused that it might be abnormal n o t to experience it at some point. Steinberg (1982) reviewed the international literature on the epidemiology of low back pain, and found that in industrialized countries, the lifetime prevalence is 50-80%. The best controlled studies suggested that the most reliable estimates are in the upper half of this range, and that the point prevalence is about 10-15%. About 7% of those affected will have back pain which persists beyond 6 months (Spitzer et al, 1987).

The economic costs of chronic back pain are enormous and include direct costs such as health care costs and the purchase of prescribed and over-the- counter medications, and the indirect financial burden of underemployment, lost productivity, and disability compensation. Patients with chronic back pain utilize medical services more than those without such pain, and this holds true when comparing only people with some sort of limitation in function: back pain patients still use medical services more (Nagy et al, 1973). Low back pain costs the United States an estimated $14 billion a year, mainly in treatment and compensation (Dworkin et al, 1985). Clearly, more effective modes of treatment are needed, and patients need to be guided toward the most effective treatments currently available.

MODELS OF PAIN

Traditionally, somatic models of pain have driven treatment planning. Somatic models suggest a linear relationship between structural tissue damage and pain intensity. Unfortunately, they do not account for the documented lack of correlation between organic findings and reports of back pain (Flor and Turk, 1984). A more sophisticated understanding of the phenomenology of the back pain experience requires the recognition of the influence of a range of psychological and environmental variables. Variables that have been studied and described in the literature include 'personality' (Timmerans and Sternbach, 1974), attention and distraction (Beers and Karoly, 1979; McCaul and Malott, 1984), beliefs about pain, styles of thinking and ways of coping (Turk and Rudy, 1986; Jensen et al, 1991),

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338 R. D. KERNS A N D M. C. JACOB

mood (Saychem et al, 1984; Haythornthwaite et al, 1991), and gender and age (Kashima and McCreary, 1987; Melding, 1992).

Somatic models of chronic back pain are also inadequate bases for treatment planning because they do not account for common concomitant clinical and social problems such as affective distress, substance and alcohol abuse (Atkinson et al, 1991), marital distress and family dysfunction (Flor et al, 1987; Thomas and Roy, 1989), unemployment and underemployment (Gervais et al, 1991). The prevalence of these issues highlights the need to plan treatments with the patient as the focus, rather than pain (Fordyce, 1988).

Other models have been offered that address some of the inadequacies of somatic models. These 'central' models emphasize the roles that the central nervous system and psychological factors play in the perpetuation of back pain. Generally speaking, these models take into account peripheral nociception but emphasize the role that central factors play in determining the extent of back pain, disability, and distress. Most research, however, has been cross-sectional, and while correlates between neurobiological and psychosocial variables can be considered and relationships hypothesized, such research can not take into account the historical context in which the chronic back pain occurs. Take a few examples: relationships have been identified between chronic pain and maladaptive ways of thinking (Jensen et al, 1991), affective distress (Haythornthwaite et al, 1991), and low serotonin turnover (Magni et al, 1987). It is not known, however, whether these correlates are sequelae of chronic pain, or if they precede and possibly contribute to its development.

Kerns and Jacob (in press) have recently described a diathesis-stress model of chronic pain that integrates contemporary neurobiological and psychosocial perspectives. The model is discussed in some detail below, but briefly, it proposes that individuals who develop chronic pain may have pre-existing susceptibilities or vulnerabilities (congenital or learned) that placed them at risk for the development of the chronic pain syndrome. These vulnerabilities may exist in the cognitive (e.g. distorted thinking), affective (e.g. trait anxiety), or behavioural (e.g. always going to bed when having pain) domains, or in the individual's social milieu (few social supports). In addition to these multiple potential vulnerabilities, the experience of acute pain may include multiple challenges to the individual in the same domains. These challenges may include physical impairment, activation of central monoamine and endorphin systems, anxiety and fear, and so forth. The diathesis-stress model of chronic pain would suggest that the experience of back pain may persist and become associated with disability and distress when there is a match between a pre-existing vulnerability and a specific challenge presented by the back pain problem.

As mentioned, the vulnerabilities may be of several sorts. Cognitive vulnerabilities include the sort of dysfunctional thinking associated with depression, where perceptions of helplessness and hopelessness are common. When in the presence of back pain, such distorted thinking may encourage behavioural avoidance, and lead to further declines in attempts to cope and problem-solve, and a growing negative affective experience,

P S Y C H O L O G I C A L ASPECTS OF BACK PAIN 339

which in turn may extend secondary peripheral effects such as muscle tension and atrophy (Ahern et al, 1988), and functional disability (Turk and Rudy, 1991). Turk and his colleagues (Turk et al, 1983; Turk and Rudy, 1986; Flor and Turk, 1988) have argued that dysfunctional information processing and negative self-statements and beliefs underlie the development of the chronic pain condition. It is known, however, that not all people with chronic pain think dysfunctionally. Turk himself has identified a cluster of patients who seek treatment but also report relatively high levels of perceived self-control (Turk and Rudy, 1988, 1990). This is an excellent example of how a specific vulnerability to chronic back pain may be present in some individuals and not others. The diathesis-stress model is able to account for these individual differences.

A second area of vulnerability that may exist prior to the onset of back pain is the affective domain. Both depression and anxiety/fear appear to play roles in the development of chronic pain, as well as being coexisting problems in their own right. For example, research has found a positive relationship between depression and both pain intensity and pain behaviour frequency (Keefe et al, 1986). It has been hypothesized that depression occurs after the development of chronic problem (Brown, 1990; Atkinson et al, 1991), but a body of research also suggests that some depressed chronic pain patients had a prior psychobiological or biogenetic vulnerability to depression (e.g. Blumer and Heilbronn, 1982).

The serotonin system may be one link between chronic pain and depression. Serotonin is believed to have an important role in affective disorders (DeLeon-Jones, 1982) and in pain perception (Gershon, 1986). Sternbach et al (1976) have suggested that pain depletes serotonin, and that low serotonin may then leave one vulnerable to both chronic pain and depression. The noradrenergic system (Max et al, 1992) and the endogenous opiate systems (Ward, 1990) may be involved with depression and chronic pain in similar ways or may interact with one another in the development of these disorders.

Anxiety and fear of pain and further damage are also thought to play a role in the maintenance of back pain, and the development of functional impairment and disability (Lethem et al, 1983; McCracken et al, 1992). Laboratory analogue research has found that pain-related anxiety increases reports of pain intensity (A1Absi and Rokke, 1991) and focuses attention on pain (Arntz et al, 1991). Fear of pain and further injury is hypothesized to lead to behavioural avoidance and increased pain behaviours (Lethem et al, 1983). The diathesis-stress framework suggests that pain-related anxiety and its sequelae are more likely to occur in individuals who experience trait anxiety (Spielberger et al, 1970) and who have an avoidant style of problem- solving (Heppner and Peterson, 1982) as pre-existing characteristics.

The third cluster of vulnerabilities that may play a role in the development of chronic back pain are behavioural. Chronic back pain patients generally exhibit declines in activity in most spheres of life, including work, vocational, social and recreational activities. Reduced activity may be directly related to structural pathology and neurological impairment. Indirectly, activity may decline because the patient fears the back pain might


increase or that more damage might occur, because adoption of the 'sick role' is encouraged by others, and as a result of medication side-effects. When reduced activity leads to deconditioning, musculoskeletal contri- butions to the back pain experience may increase.

The diathesis-stress model supposes that declines in activity are more likely to occur in individuals with premorbid instrumental skill deficits. For example, people in poor physical condition may be more likely than others to be emotionally comfortable with activity restrictions, and individuals with limited social lives may similarly find declines in activity less distressing than those used to being on the go.

Finally, the diathesis-stress model of chronic pain emphasizes the importance of the social and interpersonal context of the back pain experience. Variables in this domain mediate changes in cognitive, affective, and behavioural functioning that contribute to the perpetuation of back pain over time. Social interactions may directly influence the development and perpetuation of chronic pain and its sequelae (for example, overly solicitous partners may reinforce the assumption of the sick role and promote disability), or may indirectly cause negative changes in functioning that result in additional negative effects (for example, overly solicitous partners may encourage declines in activity, resulting in deconditioning and additional muscle tension-mediated peripheral nociception). Social interactions may have mixed effects as well, as when partners support inadvertently encourages pain behaviours while buffering the development of depression (e.g. Goldberg et al, in press).

Pain-contingent reward (for example, attention from others) may be a powerful reinforcer of pain behaviours for patients having limited access to other sorts of positive social interactions (Kerns and Turk, 1984; Goldberg et al, in press). This is one example of a pre-existing vulnerability in one domain (limited social activities in the behavioural domain) becoming activated in the face of acute pain and related challenge in another domain (social/interpersonal).

The social/interpersonal domain also contains positive influences. Within the diathesis-stress model of chronic pain, social support is thought to moderate the experience of pain and reduce the likelihood of disability and distress. Ongoing support, encouragement and recognition of positive coping with pain, and productive activity by family, friends, or workmates should have broad positive effects.

In summary, the diathesis-stress model of chronic pain hypothesizes that individuals may have pre-existing vulnerabilities that place them at increased risk for chronic pain and associated disability and distress. The model emphasizes the temporal and social contexts in which chronic pain develops and is explicit in proposing that the prior vulnerabilities may be specifically challenged by the experience of acute pain. Vulnerabilities may be activated by either direct challenge (for example, problem-solving skill deficits may be challenged by work problems posed by acute pain and impairment) or indirect effects (for example, poor marital communication may be challenged by increased pain-contingent attention from the spouse). Finally, the model emphasizes the likely moderating role of social support.


The diathesis-stress model has important clinical implications for working with patients with back pain, and may serve as a guide for assessment, treatment planning and clinical interventions.

CLINICAL IMPLICATIONS

Rational theory should serve as the foundation for all aspects of clinical assessment, treatment planning, and treatment delivery. The diathesis- stress model of chronic pain has several important implications for clinical decision-making. Given that careful clinical observation and research has informed the development of the model, it is understandable that current practice often incorporates many of these suggestions.

The diathesis-stress model encourages interdisciplinary collaboration when providing services to the patient with chronic back pain. The routine involvement of multiple specialists is indicated given the multidimensional conceptualization of the problem and diversity of factors presumed to underlie the aetiology and maintenance of chronic back pain. Integrated clinical programmes that offer coordinated evaluation and intervention services are ideal, particularly for the most complex or refractory cases. Alternatively, active ongoing communication among independent prac- titioners or settings is recommended.

Several arguments for this approach can be made. First, the sophistication of different disciplines is routinely required in order to appreciate the scope and magnitude of patients' back pain, disability, and distress. With regard to the experience of back pain per se, a multifactorial model such as that proposed suggests that it is necessary to delineate the extent and nature of underlying structural pathology and disease, biomechanical and ergonometric factors, and the multiple domains of the psychosocial context (Turk and Melzack, 1992). Furthermore, there is a high co-prevalence of multiple additional clinical and social problems among chronic back pain patients. These problems include unemployment and underemployment, marital and family dysfunction, depression, alcohol and drug abuse and dependence, and other psychophysiological disorders. Assessment and treatment planning should target these and other relevant problems and concerns. Involvement of health care providers such as physicians, psychologists, social workers, vocational rehabilitation specialists, physical and occupational therapists, among other specialists, has clear advantages in this process.

Assessment of the back pain patient

The assessment process involves discipline-specific evaluations based on the particular expertise of the participating provider. Physicians representing different specialties may routinely collaborate in evaluation and treatment of individual patients. The scope of their evaluation may be expected to vary with the presenting complaint, but generally focuses on medical diagnosis and consideration of pharmacological, anaesthetic, and surgical options for

342 R. D. KERNS AND M. C. JACOB

treatment. Most consistent with chronic illness and pain management perspectives are pharmacological approaches that target the underlying disease process or presumed source of peripheral nociception. The model also accommodates the prescription of psychotropic medications that target pain relief and symptoms of psychopathology. Medications that are not associated with physiological tolerance and those that have limited abuse potential have important advantages given the chronic nature of the problem. Indications for physical exercise and conditioning programmes are also reasonable targets for medical evaluation.

Rehabilitation specialists typically emphasize further discrimination of physical impairment (that is, limits on functioning that are directly related to structural pathology and neurological deficits) and functional disability (that is, limits related to avoidance of back pain and deconditioning). Although treatment efforts that focus on somatic relief per ~e are frequently applied (e.g. manipulations, ultrasound, hydrotherapy, transcutaneous nerve stimulation), rehabilitation efforts that emphasize education related to biomechanics and energy conservation as well as conditioning are most consistent with chronic illness and self-management perspectives. Most recently, sophisticated ergonomic and simulated work evaluation and rehabilitation programmes have been developed and offer a promising approach for improving employability (Feuerstein, 1991; Feuerstein and Hickey, 1992).

Comprehensive psychological assessment is generally accepted as a critical component of the evaluation of the chronic back pain patient. Over the past 20 years, psychologists have been instrumental in the development of psychometrically sound and clinically useful strategies for the measurement of pain, pain-related disability, and related constructs. Some aspects of this work rely on minimal interpretation (e.g. pain intensity ratings) and are reasonably elicited as part of the evaluations of providers other than psychologists. Beyond these routine ratings, evaluation by a psychologist with a specific expertise in the area of chronic back pain assessment is routinely indicated.

There are several important goals of the psychologist's evaluation (Turk and Kerns, 1983, 1985; Kerns and Jacob, 1992). Psychologists rely on standardized methods that can provide reliable and quantifiable information on a number of variables relevant to the comprehensive evaluation of the patient's experience of back pain. The information is used to (1) identify potential problems and targets for intervention (e.g. chronically elevated paraspinal muscle tension); (2) identify contributors to these problems that may be additional targets for intervention (e.g. deconditioning, poor posture, chronic bracing); (3) provide a baseline for comparison at re- evaluation points. In addition to these goals related to treatment planning and evaluation, a comprehensive psychological evaluation serves to intro- duce or reinforce a multidimensional perspective on chronic back pain among patients. The evaluation process demonstrates a broad interest in and concern for the impact of back pain on the patient's life and begins a discussion about how to decrease disability and distress. This process is critical in the engagement of the patient in this broader perspective including


the focus on the chronic nature of the problem and the rationality of a multidimensional self-management approach.

The entire assessment process, but particularly the psychological evaluation, should follow an hypothesis-testing approach. The diathesis-stress model and other contemporary multidimensional models of chronic pain are based on the premise that any of several factors may interact with one another over time to contribute to the development and maintenance of chronic pain and associated disability and distress. Given this perspective, it is important to begin the assessment process by taking a broad band approach that scans for current problem areas and their possible contributors. Continued assessment should be increasingly focused, behaviourally specific, and quantitative in order to examine apparent relationships among relevant variables. The process commonly leads to identification of goals for treatment and discussions about the treatment plan. In situations or settings in which the psychologist continues to be involved in treatment delivery, the boundaries between assessment and treatment are commonly blurred.

The psychologist uses multiple methods to converge on the nature and extent of the patient's back pain, disability and distress. Behavioural interviewing, observation, questionnaires and inventories, and diary methods are commonly used to explore the cognitive, affective, behavioural, and social/interpersonal domains (Bradley et al, 1992). The use of standardized measurement strategies and reliance on more than one measure of important variables of interest increases the reliability of the information and the validity of the interpretation of the completed evaluation.

Careful interviewing is the most frequently used method of assessment and is designed to gather relevant information as well as to engage patients in collaborative discussions about their experience and possible ways to improve their condition. Interviews often include spouses or significant others in order to broaden the scope and reliability of the information gathered as well as to set the stage for including such individuals in sub- sequent treatment and rehabilitation efforts. Semi-structured interviews designed to screen for significant psychopathology are often used in addition to interview formats that focus more generally on the back pain problems and associated disability.

Questionnaires, inventories, and behavioural diaries are common components of the psychological evaluation of chronic back pain. These methods focus on quantification of pain severity, disability, and distress in addition to a range of psychosocial variables relevant to the experience of chronic back pain. Consistent with the diathesis-stress model of chronic pain, emphasis is placed on the assessment of cognitive, affective, and behavioural domains, as Well as the social context of the experience of back pain. Measures typically include those designed to assess specific aspects of the back pain experience (e.g. pain intensity or disability measures) as well as more comprehensive and multidimensional questionnaires. Among the available measures are those designed to assess specific aspects of the domains of vulnerabilities and challenges outlined in the diathesis-stress model. Patients' pain-related cognitions can be assessed using measures of beliefs about back pain, perceptions of self-control, causal attributions, and


coping (Jensen et al, 1991; DeGood and Shutty, 1992). Assessment of affective functioning can include measures of pain-related anxiety and fear. Questionnaires and diaries are commonly used to assess the behavioural domain and include measures of activity, perceived disability, and pain behaviours. Variables relevant to consideration of the social context include social support, marital and family functioning, and specific aspects of pain- related social interaction. Other commonly used strategies are standardized measures developed using other populations but that have been validated using chronic back pain patients. These include measures that assess specific constructs of interest such as depression or marital satisfaction questionnaires, and those that are multidimensional in scope such as personality inventories.

A relatively recent advance in the assessment of pain is the development of observational methods for the quantification of overt demonstrations of pain, termed pain behaviours (Keefe and Block, 1982; Keefe and Williams, 1992). The domain of pain behaviours includes verbal complaints of pain as well as non-verbal behaviours such as grimacing, bracing, and holding or rubbing the affected body part, and behaviours such as lying down, using pain medications, and visiting doctors. Several observational coding systems have been developed and an increasing volume of research supports their reliability and utility.

Psychophysiological assessment of back pain is also increasingly common (Flor and Turk, 1989; Flor et al, 1992b). Methods have historically relied on static measurement of electromyographic activity in the relevant muscle groups. More recent technological advances permit dynamic evaluation of multiple muscle sites. Most paradigms to date incorporate mental and physical challenges to identify possible muscular hyperreactivity or evidence of dysregulation at the site of the pain. Psychophysiological assessment can be particularly useful in lending credibility to the psychological assessment in the eyes of the patient, and may offer specific support for an integrated biobehavioural rationale for the treatment and rehabilitation plan. Results may have specific implications for biofeedback and muscle relaxation exercises, for physical therapy and conditioning programmes, and for efforts designed to increase work tolerance.

Treatment planning for chronic back pain

Given the involvement of multiple disciplines, it is likely that proffered rationales for treatment may differ and even conflict. Efforts to resolve differences among these perspectives before providing feedback to the patient are essential. The goal of this process is to develop an integrated understanding of the patient's problems and a plan for intervention based on this view. Successful development of a consensus among the professionals involved will offer the patient clear and consistent information about his or her problems and what to do about them. A thorough and reasonable understanding on the part of the patient can then serve as the basis for engaging the patient in the therapeutic process. Increased adherence to the recommendations and improved efficacy are likely outcomes.

PSYCHOLOGICAL ASPECTS OF BACK PAIN 345

There are several key components of the feedback to patients that result from the interdisciplinary evaluation process. Feedback should involve discussion and collaboration that helps the patient develop a rationale for treatment that integrates the perspectives of the health care team with the patient's pre-existing beliefs about the back pain, its aetiology, and reasonable treatment. This rationale may vary in level of sophistication but should incorporate a multidimensional and developmental perspective. The rationale should encourage the patient to adopt a chronic illness model and treatment paradigm that emphasizes self-management and quality of life.

Care must be taken to validate the patient's experience of back pain and distress. Medical diagnosis and prognosis should be clarified to the extent possible, and the limits of medical intervention with regard to pain alleviation should be reviewed. However, unidimensional and overly simplistic statements about the extent of structural pathology on the basis of neurological examination and radiological information are unsatisfying to most patients. Similarly, feedback that is heard as 'you have to learn to live with your pain' is often heard as gratuitous and uncaring, and offers little that can assist the patient in managing the problem.

A positive emphasis on treatment and rehabilitation alternatives and presentation of a credible biobehavioural rationale for such interventions can open more constructive discussions that lead to the development of a viable multimodal plan for intervention. Within a chronic illness framework, both short-term and long-term goals that target pain relief, disability rehabilitation, and alleviation of distress can be considered. A systematic plan should be developed that incorporates a hierarchy of goals or targets and the notion of successive steps in the process. Collaborative discussion with the patient should serve as the basis for the development of the overall plan and individual goals. Ultimately, it is critical that each goal is realistic from the point of view of both the patient and practitioner. For example, goals for return to work among patients who are severely physically impaired or among individuals lacking reasonable vocational skill may be unrealistic as an initial goal. Alternatively, plans based on goals that can be achieved, no matter how limited in scope or impact, are preferred in order to encourage perceptions of hopefulness and mastery. The roles of different specialists in the process and the responsibilities of the patient should be clarified. Optimally, methods for continued evaluation that include specification of quantifiable goals and realistic time frames should be described.

All prescribed treatments and rehabilitation efforts should be consistent with a chronic illness management perspective. Although the chronic useof narcotics in chronic non-malignant pain remains controversial (Portenoy, 1991; Turk and Brody, 1991), few would argue for sole reliance on analgesic medication. Similarly, anaesthesiological procedures such as nerve blocks or trigger point injections that target somatic relief alone are usually inadequate given the complex and chronic nature of the problem. However, it is reasonable to expect that such treatment approaches may be efficacious and even maximized within the context of a broadly conceived treatment approach. For example, anaesthetic procedures can be used to provide the


patient with temporary relief as he or she begins a more active physical conditioning programme. Critical is the presentation of a clear and consistent rationale for each intervention in the context of the broader efforts and goals of the treatment plan.

It is similarly important to acknowledge that treatments which target a specific problem may exert effects on other domains in the diathesis-stress framework. These effects may be either positive or negative. For example, it is now apparent that antidepressant medications may have important analgesic effects (Goodman and Charney, 1985). Physical exercise and improved conditioning may lead to increased productive and pleasurable activity that may ultimately lead to improved mood and sleep (Turner et al, 1990). On the other hand, medications that target muscle relaxation and pain relief may have depressant effects. Physical therapy techniques that target somatic relief p e r se may undermine the patient's interest and confidence in self-management approaches. The diathesis-stress model provides a framework for considering these interactions and encourages development of an integrative plan that maximizes positive effects.

The comprehensive evaluation process frequently leads to diagnosis of serious psychopathology that might otherwise have been overlooked. In particular, the presence of major depressive disorder, alcohol abuse and dependence, and prescribed and illicit drug abuse and dependence are common problems among chronic back pain patients that require routine and careful assessment and treatment (Atkinson et al, 1991; Romano and Turner, 1985). In some cases, the practitioner must be prepared to arrange for alternative specialist care prior to or coincident with the introduction of more aggressive pain management therapies. In other cases, these problems can be addressed in the context of an integrated pain management plan.

In summary, several principles should guide the assessment and treatment planning process. First, this process should be based on an hypothesis- generation and testing approach that encourages the pursuit of an integrated understanding of the specific nature of the patient's problems, factors contributing to these problems, and mechanisms relevant to their aetiology and maintenance. This process should have a multidimensional focus and typically will require interdisciplinary collaboration. An initial plan for intervention should be developed through a process that emphasizes collaborative discussions with the patient. This process should include direct feedback to the patient about the results of the evaluation process and discussions that encourage the development of shared working hypotheses about the nature of the problems and mechanisms underlying their development and maintenance. Several realistic and quantifiable goals for the treatment and rehabilitation process should be established. Finally, an individually tailored multimodal and multidimensional plan for intervention should be designed to maximize the accomplishment of these mutually agreed goals rather than more global, and less likely, outcomes.

The diathesis-stress model of chronic pain offers a broad perspective in which to consider many of the contemporary notions of back pain management. Cutting across all intervention strategies is an interest in maintaining the integrity of self-management and rehabilitation perspectives. Within


this framework patients are consistently encouraged to adopt a flexible problem-solving style with regard to their experience of pain that emphasizes self-control and personal mastery. Specific rationales for each component of the intervention plan are discussed with the patient in an effort to foster active engagement in the therapeutic efforts, increased adherence, and improved outcomes. Rationales for specific treatment components either hypothesize direct effects on one of the key problem domains (i.e. structural pathology and peripheral nociception, pain intensity, disability, or affective distress and associated symptoms) or emphasize learned control and self-management of pain and/or its impact in the patient's life. Regardless, acute illness notions that imply cure or elimination of symptoms are actively discouraged.

Consistent with an approach that targets specific problem areas and the accomplishment of quantifiable goals for improvement, the following discussion of intervention strategies will focus on several specific problem domains and offer examples of integrated treatment efforts. It will become clear that there is a high degree of overlap in the specific interventions as well as in their conceptualization across problem areas. Development of an integrated plan that draws upon these commonalities can maximize the overall effectiveness and efficiency in service delivery. Attention to possible negative interactions among these treatment options should also help reduce these effects and improve effectiveness.

Interventions for patients with back pain

Pain relief

The single commonality among almost all chronic low back pain patients is their desire for pain relief. Outcome studies that examine either specific treatment modalities or multidimensional treatment efforts routinely docu- ment reductions in reported pain (Flor et al, 1992a). Virtually all treatment modalities applied in the context of pain management efforts have anticipated direct or indirect effects on reported pain intensity.

Medical diagnostic efforts serve to identify possible reversible pathology and may lead to specific surgical, medical, or rehabilitation medicine interventions that target the pathology per se. Alternatively, these efforts may assist in decisions about appropriate pharmacological and anaesthetic interventions that target hypothesized peripheral and central pain mechanisms. Specific indications and contraindications for chronic use of narcotic analgesics and benzodiazepines remain unclear and continued controversy pervades the clinical and empirical literatures (Portenoy, 1991; Turk and Brody, 1991). A similar state of affairs exists for psychotropic medications such as tricyclic antidepressants and anticonvulsants. For example, despite the presence of over 60 studies that appear to support the efficacy of antidepressant medications as analgesics for use with heterogeneous groups of chronic pain patients, recent meta-analytic reviews challenge their beneficial effects (Goodkin and Guillion, 1989). However, these medications


appear to be more generally accepted, and are increasingly among the first pharmacological alternatives to narcotics to be considered, probably as a function of their presumed low potential for abuse. Empirical efforts to manage back pain via medical, anaesthetic and rehabilitation medicine approaches continues to be the state of the art. Optimally, medical efforts that are consistent with the chronic illness and active rehabilitation perspectives encouraged by the diathesis-stress model should be applied and efforts that target somatic relief alone are to be avoided (Deyo et al, 1990).

Multiple psychological approaches have been demonstrated to have positive effects in reducing reports of pain among chronic back pain patients. These include specific techniques such as progressive muscle relaxation (Linton and Melin, 1983), biofeedback (Keefe et al, 1981), hypnosis (Hilgard and Hilgard, 1975), and meditation (Kabat-Zinn et al, 1985), as well as individual (Merskey, 1986) and group (Kerns and Hegel, 1990) psychotherapies. Two broad perspectives have been particularly influential in the field of pain management and deserve specific attention. These are the operant conditioning approach (Fordyce, 1976) and the cognitive behavioural perspective (Turk et al, 1983). Both approaches are compatible with the diathesis-stress model of chronic pain, and their critical features have been incorporated into it.

Operant conditioning approach to chronic pain. As early as 1968, Wilbert Fordyce (Fordyce et al, 1968) at the University of Washington proposed that chronic pain could be viewed as a behavioural disorder identified by a set of observable 'pain behaviours'. These behaviours included excessive time spent reclining, excessive pain medication intake, verbal complaints of pain, protective behaviours such as limping and bracing, and so forth. Fordyce (1976) suggested that, although these behaviours may initially be expressed as a direct function of acute pain, over time, as function of social con- tingencies (e.g. attention from doctors and family members, escape from aversive work situations) these behaviours may be maintained by their environmental consequences rather than by some structural pathology and continued nociception. Fordyce and his colleagues provided the initial demonstrations of the efficacy of an intervention that applied behavioural strategies to alter environmental consequences of pain (Fordyce et al, 1968, 1973). These reports documented dramatic recoveries in previously treatment-refractory chronic pain patients.

Several lines of continued research support the operant conditioning model (White and Sanders, 1986; Romano et al, 1992; Turk et al, 1992), the reliable association between observed pain behaviours and reports of pain intensity (e.g. Anderson et al, 1987; Keefe et al, 1987), and the efficacy of operant conditioning treatment approaches (e.g. Kerns et al, 1986; Turner and Clancy, 1988). A treatment framework based on the operant conditioning perspective is central to many interdisciplinary chronic back pain management programmes (e.g. Deardorff et al, 1991). Goal-oriented physical exercise, conditioning, and vocational rehabilitation treatment components are broadly based in the operant learning perspective. The use


of behavioural contracting for increased productive and pleasurable activity specifically draws on this model. Efforts to involve spouses or significant others in the treatment programme is increasingly designed to reduce solicitous responding to pain behaviours and to increase support for productive activity (Radojevic et al, 1992). Whereas early work based on the operant conditioning model was largely in-patient based, recent trends encourage out-patient treatment that emphasizes home-based learning and generalization (Turner and ClancY, 1988).

Cognitive-behavioural approach to chronic pain. A more recent innovation in the field of pain control has been an extension and elaboration of Fordyce's operant conditioning model by the incorporation of cognitive- social learning theory and cognitive-behavioural intervention perspectives. Turk and his colleagues (Turk et al, 1983) have emphasized the critical role of chronic pain patients' idiosyncratic beliefs, attitudes, and coping resources in optimal pain management. In addition to modification of maladaptive behaviours and encouraging a return to an improved functional status, proponents of a cognitive-behavioural perspective emphasize the importance of fostering the development of a perception of self-control and personal mastery in relation to back pain to replace the common perceptions of helplessness, hopelessness, and uncontrollability.

The therapeutic regimen developed by Turk and his colleagues (e.g. Turk et al, 1983; Holzman et al, 1986) consists of three interrelated phases. In the initial, reconceptualization phase, the patient is offered an alternative perspective for understanding the experience of back pain that emphasizes the critical influence of thoughts and feelings on pain intensity, suffering, and disability. Training in the use of a series of cognitive and behavioural coping strategies (e.g. attention diversion, use of positive self-statements, relaxation training, activity-rest cycling) comprise the second, skills acquisition phase. A rationale for the use of these specific skills is linked to the explicit rationale for the patient's problems established as a result of the assessment and treatment planning process. The rationale is designed to reinforce developing perceptions of personal control and mastery of the back pain experience. During this phase patients are assisted in developing a personal plan for managing the idiosyncrasies of their pain experience by enlisting these new coping skills. In the final phase, patients are given the opportunity to consolidate these skills through behavioural and cognitive rehearsal and role-playing. Problem-solving discussions with the therapist are a central component of this phase of treatment.

The efficacy of the cognitive-behavioural treatment approach has been demonstrated in several well controlled studies (Turner, 1982; Kerns et al, 1986; Turner and Clancy, 1988). Particularly important are demonstrated effects in providing pain relief in addition to improvements in multiple other domains relevant to the diathesis-stress model outlined herein. The additional heuristic value of the cognitive-behavioural perspective is marked by the development of a range of reliable measures of the cognitions of chronic pain patients and demonstrations of the role that patients' beliefs, attributions, and coping may play in mediating the experience of back pain


and suffering of these patients. Increasing attention is being placed on refining cognitive-behavioural and self-management treatment approaches and the theory upon which they are based.

Disability

It has already been noted that the experience of chronic back pain is characterized by dramatic effects on the individual's overall level of functioning. Effects are often apparent in every area of the patient's life including work and work-related activities, family, marital, and sexual functioning, and social and recreational functioning. Treatments that target back pain relief per se, such as anaesthetic nerve blocks or narcotic analgesics, are presumed to have indirect benefits in terms of improved functioning and quality of life. However, rarely in the empirical literature evaluating these therapeutic approaches are such indirect effects observed. Alternatively, rehabilitation medicine and psychological approaches to back pain management more directly target disability and emphasize these effects in evaluation of their efficacy.

Generally speaking, 'rehabilitation' efforts are designed to target the broad domain of functional disability. These efforts include education in body mechanics and energy conservation, training in alternative approaches to problems of daily living that compensate for physical limitations posed by underlying structural pathology, and graded physical exercise and conditioning programmes. These latter efforts either target more general problems such as unnecessarily limited range of motion, decreased muscle tone, and physical deconditioning, or target more specific functional activity targets such as activities of daily living and/or employment. Programmes that incorporate graded physical exercise programmes and even aerobic conditioning, work hardening approaches, and approaches based on ergonometric analyses are increasingly available. Vocational rehabilitation assessment and counselling is an additional option for the unemployed or underemployed patient.

Psychological approaches based on the operant conditioning and cognitive-behavioural perspectives explicitly target improved function and satisfaction with activities relative to their emphasis on pain relief as primary goals of treatment. Behaviour change in multiple specified areas is the basis for virtually all aspects of the treatment effort. Behaviours targeted for elimination or reduction are classified as 'pain behaviours' such as use of pain medications and visits to doctors, lying in bed or reclining in a chair, and other avoidant behaviours. 'Well behaviours' are targeted for reinforcement and include physical exercise and participation in productive activity across multiple areas of functioning. Approaches applied are largely based on the operant perspective and emphasize goal setting and contingency contracting. Increasingly challenging behaviours are 'shaped' through a process of goal setting and delivery of social reinforcement for goal accomplishment. The cognitive-behavioural perspective has introduced additional strategies including relaxation and desensitization, cognitive and behavioural rehearsal, and verbal problem-solving. These approaches serve to alter


patients' cognitions hypothesized to interfere with the production of 'well behaviours'.

Both approaches encourage the inclusion of spouses or significant others throughout the intervention. Specific patterns of communication that either solicit or serve to reinforce 'pain behaviours' are targeted for elimination. Partners are educated in the rationale for treatment that emphasizes increased activity, decreased dependence, and increased satisfaction and quality of life. Consistent with these purposes they are encouraged to foster more adaptive coping and participation in enjoyable and productive activity. Communication training that emphasizes assertiveness, planning and negotiation, and positive reward is often incorporated in the overall intervention effort.

Affective distress

There is a strong intuitive appeal to theoretical models that hypothesize a reciprocal relationship between the experiences of negative affects such as anger, depression, and anxiety and chronic pain. On the one hand, it may be argued that affective distress influences pain perception and the development of chronic back pain. Melzack and Wall (1965), for example, have proposed that motivational and affective factors play a central role in determining the perception of pain. Substantive theories also propose that chronic pain may evolve as a function of a pervasive tendency to inhibit the expression of negative affects, particularly anger (Beutler et al, 1986), as a function of chronic anxiety and associated sympathetic arousal, particularly heightened muscle tension (Flor et al, 1985), and as an alternative means of expressing an underlying depressive disorder (Blumer and Heilbronn, 1982). Conversely, it has been argued that affective distress may be a sequel of chronic pain. In the case of depression, for example, the presence of pervasive sadness and associated depressive symptoms is reported to occur only after the development of a chronic pain problem by the vast majority of such patients. Empirical support for models of depression as a sequel to chronic pain has recently been provided (Rudy et al, 1988; Brown, 1990).

As a function of the apparent interrelationship between chronic back pain, disability, and affective distress, the intervention strategies that successfully relieve either pain or disability are presumed to have positive indirect effects on mood and associated symptoms. Pharmacological and psychological therapies that specifically target symptoms of depressive and anxiety disorders are also commonly applied. Antidepressants, in particular, are frequently prescribed and target sleep dysfunction alone or additional symptoms of depression. Cognitive (Beck, 1976) and interpersonal psychotherapies (Klerman and Weissman, 1982) are similarly applied to target these symptoms. Stress and anxiety management techniques are often incorporated in the therapeutic plan. Strategies that specifically target behavioural avoidance as a function of fear of pain and fear of injury have been employed (Lethem et al, 1983). Other strategies focus on more general social skills training including emphases on anger management and assertiveness training (Fedoravicius and Klein, 1986).


Future research in both the neurobiological and psychosocial domains will be necessary to tease apart the complex interrelationship between chronic back pain and other negative emotions and associated symptoms of distress. A specific area of distress common among chronic back pain patients that requires attention is marital and family dysfunction (Thomas and Roy, 1989). Research has documented significant problems in these areas, but these concerns have only begun to be addressed explicitly in more comprehensive back pain management efforts. Conjoint, and even family therapies, may be indicated in situations in which more severe dysfunction is identified. Given demonstrations of a strong relationship between marital distress and more personal distress (Kerns and Turk, 1984), such efforts may further contribute to an alleviation of depression or other negative mood states.

CONCLUSION

This chapter makes note of the need for integrating contemporary psychological and neurobiological models of chronic back pain. A diathesis-stress model of chronic pain is presented. The application of the model to clinical assessment, treatment planning, and intervention in a multidisciplinary context is discussed.

The diathesis-stress model of chronic pain proposes that individuals may have pre-existing vulnerabilities which place them at risk for developing the chronic back pain syndrome. The vulnerabilities may exist in some or all of the cognitive, affective, behavioural and social/interactional domains. These vulnerabilities interact with one another, and with peripheral nociception. The vulnerabilities may be challenged by specific stressors inherent in the experience of acute pain, such as physical impairment, activation of central monoamine and endorphin systems, and anxiety and fear. Chronic back pain may develop in association with disability and distress when there is a match between a vulnerability and a specific challenge offered by the pain problem.

Given the diversity of factors presumed to underlie the development and maintenance of chronic back pain, the clinical application of the diathesis- stress model of chronic pain requires the participation of clinicians from multiple disciplines. Assessment consists of discipline-specific evaluations targeting disease, pain, disability, affective distress, and the psychosocial context. Treatment planning requires clinicians to integrate their various findings and to develop a rationale for treatment which accommodates both the perspectives of the health care team and the patient's pre-existing beliefs about back pain. The rationale should emphasize a rehabilitation, self-management perspective. Treatment interventions will generally incorporate modalities from various clinical perspective. Ongoing communication among members of the clinical team is imperative to facilitate treatment decisions and to preserve consistent communications to the patient.


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