Chronic low back pain is the leading cause of years lived with disability, followed closely by neck pain.
A recent article in the journal PAIN studied the mediating factors that increase the risk of disability in people with back and neck pain. This was a meta-analysis of 12 studies involving close to 3,000 subjects.
The studies used mediation analysis, a statistical method frequently used in psychological research to measure the extent to which mediating factors indirectly influence the outcome of a direct effect, to tease out important psychological risk factors for disability. In this case, the direct effect of pain on disability was influenced by three major mediators: self-efficacy, psychological distress, and fear.1
The Importance of Yellow Flags
Structural or neurological conditions that portend poor outcome for back or neck pain are sometimes called red flags.
These include neurological deficits and muscle weakness. Psychological factors that may portend poor outcomes have been called yellow flags.2 These include the psychological risk factors found in the PAIN study.1
“There is a large subset of patients with real physical pain that is not structurally based. Unless you have been asleep for the last 15 years, you will have noticed the drumbeat of evidence showing that our CT scans and MRIs often tell us nothing about back pain,” said Ira G. Rashbaum, MD, clinical professor of physical medicine and rehabilitation at New York University School of Medicine in New York City.
“Prompt diagnosis and conservative therapy is the number one intervention. But there is no question that identifying psychological mediators is also important. Addressing these factors before pain becomes deeply embedded may help prevent disability,” said Thomas J. Rostafinski, PhD, clinical associate professor of psychiatry at Loyola University Medical Center in Maywood, Illinois.
Psychological Mediators and Disability
“First things first,” said Rashbaum. “Every patient needs a reasonable investigation for the etiology of their back or neck pain. That being said, primary care providers will likely have patients that have real pain due to internal stress without a structural cause.” 3
The meta-analysis in PAIN suggests that certain stressors are more likely to increase the risk of disability. But the authors admit that the quality of the studies was weak, and it was not possible to draw definitive conclusions about the strength of any specific mediator.
The meta-analysis found the pain catastrophizing was not a strong mediating factor, although many pain psychologists believe it is.1
“It was remarkable that pain catastrophizing was not more of a factor. All cognitive behavioral approaches to chronic pain target it. It is also difficult to define disability. It is not just a single thing. The ability to keep going despite pain is a very case-by-case thing. White collar disability is different than blue collar disability,” noted Rostafinski. 4
There is no substitute for a good clinical interview, but primary caregivers who deal with back and neck pain may benefit from screening questionnaires designed to tease out psychological mediators. These include the Pain Catastrophizing Scale, the Coping Strategies Questionnaire, the Fear-Avoidance Beliefs Questionnaire, and several other screening tools.2,3,4
“Questionnaires may be helpful, but most primary caregivers will usually have a hunch if they ask questions about fear and stress. Referral to a mental health professional familiar with the mind-body pain syndrome is appropriate,” said Rashbaum.
“The first referral for these patients should be to physical medicine, not to surgery. These specialists are likely to work with experienced pain psychologists and to use conservative treatments that include behavioral interventions,” said Rostafinski.
Self-Efficacy and Psychological Stress
Self-efficacy refers to a person’s ability to cope and move forward despite back or neck pain.
“People with chronic back and neck pain may have a catastrophic loss of self-efficacy. They may find that they used to be able to handle everything but now can’t handle anything. Perhaps they are dealing with circumstances that might overwhelm anyone. Perhaps they have never before had to deal with a curve ball like this one,” said Rostafinski.
Management of loss of self-efficacy or significant psychological stress may include cognitive behavioral therapy given by a mental health professional specializing in pain management. Significant depression or anxiety may require psychiatric treatment. 2
“I try to rebuild self-efficacy by reminding people of the positive things they can do – maybe they are going to work despite the pain. The goal is to return to as close to normal life as possible,” says Rostafinski.
Fear of Pain and Fear of the Future
Fear is a major risk factor noted in the PAIN study and recognized by both Rashbaum and Rostafinski as a key mediator. 1
“Fear runs hand in hand with pain. Once you have determined that the patient is neurologically intact, the best advice is be not afraid,” says Rashbaum.
“Patients may fear that they are doomed to a future of pain and suffering. They may worry that this is the way it’s going to be. They need to counter this fear by maintaining physical, mental, and social activity,” says Rostafinski.
Another type of fear is fear of damage. Many patients falsely believe that because they have pain, activity will make the pain worse. Education is the best way to counter this type of fear. 2
“Acute pain is an evolutionary warning sign. It is telling you to stop, protect, and guard. That is not the proper response for chronic pain. I tell most of my pain patients that hurt does not mean harm,” says Rostafinski.
Studies show that the average amount of pain reduction achieved by all methods in all patients with chronic pain is only about 30 percent. The goal of pain management is to move away from pain treatment to pain management. Helping patients return to a more active lifestyle in spite of pain may be the best way to prevent disability and reduce pain. 2
“For many patients with back and neck pain and no structural or neurological cause, the best treatment is physical activity and psychological therapy. Reducing fear may be the best analgesic of all,” says Rashbaum.
Medically reviewed by: Pat F. Bass III, MD, MS, MPH
1. Lee H, et al. Pain. 2015; DOI: 10.1097/j.pain.0000000000000146