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Osteopathy and pain: Does psychology matter?
International Journal of Osteopathic Medicine 9 (2006) 47e48 www.elsevier.com/locate/ijosm
Editorial
Osteopathy and pain: Does psychology matter?
If you’re human, psychology matters to everything. You’re processing these sentences with your brain, identifying patterns, and evoking emotions, thoughts, even physiological responses. But that’s axiomatic. If you’re a practicing osteopath, you’re dealing with human beings (almost always). They will process what you say and do with their mind-sets, identifying patterns, evoking emotions, thoughts and even physiological responses. I’m claiming that their psychology and yours, and the interaction between the two, will affect not only how they behave (e.g. adherence to treatment and return to work etc) but how they feel emotionally and physically, and even their clinical response. This really shouldn’t be news to you, because you (of course) treat the person, not the problem and have a holistic approach, and remember the original Gate-Control theory of pain and the models that have followed. Despite some criticisms of detail, no one really refutes the basic principles of the original 1965 model, in which Melzack and Wall proposed that descending messages from the brain (such as expectations, fear, excitement and other psychological paraphernalia) act to open or shut neural pathways that relay pain to the brain.
1. Do psychological factors contribute to back pain? ‘‘All that is completely irrelevant’’, some may argue. ‘‘Treat the pain and you’ll affect the emotion, the behaviour, and the outcome. You don’t need to be a psychologist to have a decent plinth-side manner. Patients don’t come to osteopaths to be analysed, they want pain relief.’’ There are two assumptions with that view: (1) that pain is the most important contributor to outcome; and (2) that the osteopathic consultation is about pain relief. I disagree with both of these assumptions.1 The evidence from prospective cohorts that have followed patients from early stages of back pain to sometime later (usually 12 months) suggest that on top of, and perhaps beyond any clinical symptom (such as 1746-0689/$ - see front matter Ó 2006 Published by Elsevier Ltd. doi:10.1016/j.ijosm.2006.02.002
pain intensity), depression or distress is a robust predictor of outcome (reviewed by Linton2; Pincus et al.3 and Dionne4). ‘‘No worries,’’ some may argue, ‘‘if you remove the pain, the depression vanishes too’’. Actually, no. For some people it does. In other groups, depression appears to be present before the pain.5 In others, reduction of pain is all but impossible to bring about without addressing the psychological problems. Partly, this is because these psychological states and characteristics are closely linked to behaviour that maintains pain. Psychological factors contribute to pain at the time it first occurs and to its prognosis. In fact, psychological factors impact on pain before it even occurs. I can hear Schro¨dinger’s cat creeping up on me in the wake of that last sentence, so I’ll skip ahead into the next section. 2. Should osteopaths be trained to identify psychological factors? Well, no and yes. No, because, depression aside, we don’t actually know which psychological factors matter and which don’t. Partly this is because of poor measurement and poor conceptualisation. For example, can anyone really explain the term ‘fear-avoidance’ and how it differs and relates to: fear of pain; fear of movement; and fear of exercise respectively? In the current climate, vast sums of research funding are being squandered away on randomised controlled trials aiming to change factors such as fear-avoidance, for which there is no research evidence as a risk factor.3,6 Not surprisingly, these interventions show no difference in outcome.7,8 So, No, there is no point wasting resources and time training osteopaths to identify psychological factors until: (a) There is robust evidence that a psychological factor affects outcome. (b) There are valid, reliable and practical measurements available to osteopaths to identify this factor (not excluding clinical interviews).
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Editorial / International Journal of Osteopathic Medicine 9 (2006) 47e48
(c) There is good reason to believe that interventions can impact to change this factor. However, in the case of distress or depression, I believe the evidence is good for all three criteria. Osteopaths would benefit from better training in identifying the various aspects of negative emotions experienced by patients with pain.
3. Should osteopaths be trained to intervene, or refer? I’m going to focus only on distress or depression here, in line with my argument above. Not all negative emotions in pain are inappropriate, or even unhealthy. It is perfectly normal to feel overwhelmed and down as pain strips away whole elements of peoples’ lives. Coming to terms with change is tough. Good clinicians’ can help, with empathy and plenty of problem solving and reassurance. Quite different from this is distress coupled with anger, when patients’ catastrophizing thoughts get in the way of effective change. In these cases further training in cognitive-behavioural approaches is probably useful. Finally, in some individuals, pain is coupled with a sense of loss, self-loathing and guilt, which is much more akin to clinical depression. These patients are best referred on to psychological experts.
4. Summary The real question about psychological factors in people with pain is not ‘‘do they matter’’, but rather, which ones do, and which don’t. The psycho-social bandwagon is breaking down from the weight of the unsubstantiated myths, hunches and personal favourites heaped on it. However, given that some psychological factors seem to matter a great deal, let’s turn the question on its head: ‘‘Psychology and pain e does
osteopathy matter?’’ I believe osteopaths are uniquely placed to help pain patients with the majority of difficulties they encounter, including social and psychological barriers to recovery. To do this effectively might involve further training, but it would place osteopaths in a very attractive position from the perspective of policy makers and care funders.
References 1. Foster NE, Pincus T, Underwood MR, Vogel S, Breen A, Harding G. Understanding the process of care for musculoskeletal conditions e why a biomedical approach is inadequate. Rheumatology (Oxford) 2003 Mar;42:401–4. 2. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000 May 1;25:1148–56. 3. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109–20. 4. Dionne CE. Psychological distress confirmed as predictor of longterm back-related functional limitations in primary care settings. J Clin Epidemiol 2005 Jul;58:714–8. 5. Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. Br Med J 1999;318:1662–7. 6. Sieben JM, Vlaeyen JW, Portegijs PJ, Verbunt JA, van RietRutgers S, Kester AD, et al. A longitudinal study on the predictive validity of the fear-avoidance model in low back pain. Pain 2005 Sep;117:162–70. 7. Jellema P, van der Windt DA, van der Horst HE, Twisk JW, Stalman WA, Bouter LM. Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice. Br Med J 2005 Jul 9;331:84. Epub 2005 Jun 20. 8. Pincus T, Breen A, Burton K, Underwood M. Psychological risk factors for chronicity are not well known. Br Med J 2005 July 13. Rapid Response.
Tamar Pincus Department of Psychology, Royal Holloway University of London, London, UK E-mail address: [email protected]
Editorial
Osteopathy and pain: Does psychology matter?
If you’re human, psychology matters to everything. You’re processing these sentences with your brain, identifying patterns, and evoking emotions, thoughts, even physiological responses. But that’s axiomatic. If you’re a practicing osteopath, you’re dealing with human beings (almost always). They will process what you say and do with their mind-sets, identifying patterns, evoking emotions, thoughts and even physiological responses. I’m claiming that their psychology and yours, and the interaction between the two, will affect not only how they behave (e.g. adherence to treatment and return to work etc) but how they feel emotionally and physically, and even their clinical response. This really shouldn’t be news to you, because you (of course) treat the person, not the problem and have a holistic approach, and remember the original Gate-Control theory of pain and the models that have followed. Despite some criticisms of detail, no one really refutes the basic principles of the original 1965 model, in which Melzack and Wall proposed that descending messages from the brain (such as expectations, fear, excitement and other psychological paraphernalia) act to open or shut neural pathways that relay pain to the brain.
1. Do psychological factors contribute to back pain? ‘‘All that is completely irrelevant’’, some may argue. ‘‘Treat the pain and you’ll affect the emotion, the behaviour, and the outcome. You don’t need to be a psychologist to have a decent plinth-side manner. Patients don’t come to osteopaths to be analysed, they want pain relief.’’ There are two assumptions with that view: (1) that pain is the most important contributor to outcome; and (2) that the osteopathic consultation is about pain relief. I disagree with both of these assumptions.1 The evidence from prospective cohorts that have followed patients from early stages of back pain to sometime later (usually 12 months) suggest that on top of, and perhaps beyond any clinical symptom (such as 1746-0689/$ - see front matter Ó 2006 Published by Elsevier Ltd. doi:10.1016/j.ijosm.2006.02.002
pain intensity), depression or distress is a robust predictor of outcome (reviewed by Linton2; Pincus et al.3 and Dionne4). ‘‘No worries,’’ some may argue, ‘‘if you remove the pain, the depression vanishes too’’. Actually, no. For some people it does. In other groups, depression appears to be present before the pain.5 In others, reduction of pain is all but impossible to bring about without addressing the psychological problems. Partly, this is because these psychological states and characteristics are closely linked to behaviour that maintains pain. Psychological factors contribute to pain at the time it first occurs and to its prognosis. In fact, psychological factors impact on pain before it even occurs. I can hear Schro¨dinger’s cat creeping up on me in the wake of that last sentence, so I’ll skip ahead into the next section. 2. Should osteopaths be trained to identify psychological factors? Well, no and yes. No, because, depression aside, we don’t actually know which psychological factors matter and which don’t. Partly this is because of poor measurement and poor conceptualisation. For example, can anyone really explain the term ‘fear-avoidance’ and how it differs and relates to: fear of pain; fear of movement; and fear of exercise respectively? In the current climate, vast sums of research funding are being squandered away on randomised controlled trials aiming to change factors such as fear-avoidance, for which there is no research evidence as a risk factor.3,6 Not surprisingly, these interventions show no difference in outcome.7,8 So, No, there is no point wasting resources and time training osteopaths to identify psychological factors until: (a) There is robust evidence that a psychological factor affects outcome. (b) There are valid, reliable and practical measurements available to osteopaths to identify this factor (not excluding clinical interviews).
48
Editorial / International Journal of Osteopathic Medicine 9 (2006) 47e48
(c) There is good reason to believe that interventions can impact to change this factor. However, in the case of distress or depression, I believe the evidence is good for all three criteria. Osteopaths would benefit from better training in identifying the various aspects of negative emotions experienced by patients with pain.
3. Should osteopaths be trained to intervene, or refer? I’m going to focus only on distress or depression here, in line with my argument above. Not all negative emotions in pain are inappropriate, or even unhealthy. It is perfectly normal to feel overwhelmed and down as pain strips away whole elements of peoples’ lives. Coming to terms with change is tough. Good clinicians’ can help, with empathy and plenty of problem solving and reassurance. Quite different from this is distress coupled with anger, when patients’ catastrophizing thoughts get in the way of effective change. In these cases further training in cognitive-behavioural approaches is probably useful. Finally, in some individuals, pain is coupled with a sense of loss, self-loathing and guilt, which is much more akin to clinical depression. These patients are best referred on to psychological experts.
4. Summary The real question about psychological factors in people with pain is not ‘‘do they matter’’, but rather, which ones do, and which don’t. The psycho-social bandwagon is breaking down from the weight of the unsubstantiated myths, hunches and personal favourites heaped on it. However, given that some psychological factors seem to matter a great deal, let’s turn the question on its head: ‘‘Psychology and pain e does
osteopathy matter?’’ I believe osteopaths are uniquely placed to help pain patients with the majority of difficulties they encounter, including social and psychological barriers to recovery. To do this effectively might involve further training, but it would place osteopaths in a very attractive position from the perspective of policy makers and care funders.
References 1. Foster NE, Pincus T, Underwood MR, Vogel S, Breen A, Harding G. Understanding the process of care for musculoskeletal conditions e why a biomedical approach is inadequate. Rheumatology (Oxford) 2003 Mar;42:401–4. 2. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000 May 1;25:1148–56. 3. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109–20. 4. Dionne CE. Psychological distress confirmed as predictor of longterm back-related functional limitations in primary care settings. J Clin Epidemiol 2005 Jul;58:714–8. 5. Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. Br Med J 1999;318:1662–7. 6. Sieben JM, Vlaeyen JW, Portegijs PJ, Verbunt JA, van RietRutgers S, Kester AD, et al. A longitudinal study on the predictive validity of the fear-avoidance model in low back pain. Pain 2005 Sep;117:162–70. 7. Jellema P, van der Windt DA, van der Horst HE, Twisk JW, Stalman WA, Bouter LM. Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice. Br Med J 2005 Jul 9;331:84. Epub 2005 Jun 20. 8. Pincus T, Breen A, Burton K, Underwood M. Psychological risk factors for chronicity are not well known. Br Med J 2005 July 13. Rapid Response.
Tamar Pincus Department of Psychology, Royal Holloway University of London, London, UK E-mail address: [email protected]