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 extent should 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 interview and physical examination. During the consultation the osteopath may explore psychosocial aspects of the patients life based on the concept 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 Medicine Pub Med Clinical Queries search function, and the Cochrane Database of Systematic Reviews. The most recent systematic reviews on psychosocial risk factors for pain are summarised. Also, the most recent systematic reviews regarding the management of psychosocial 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 insufficient evidence 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 outcomes in 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 formal measurement of psychosocial factors using questionnaires is unnecessary in many patients. Also, specific psychological management or multidisciplinary treatment is not required in order to achieve meaningful outcomes for most patients. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Psychosocial aspects; Musculoskeletal system; Pain; Osteopathic medicine

1. Introduction Pain is a multifactorial experience that consists of more than the sensation of pain itself.1 Pain is the most common reason for patients to seek osteopathic treatment,2 with lumbar spinal pain constituting between 31 and 68% of

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complaints.2,3 Pain can be temporally categorised as being acute, sub-acute and chronic in nature.4 Acute pain is defined as the pain experienced by the patient in the first 0e12 weeks. Sub-acute pain is typically defined as a pain experience that persists for between 6 and 12 weeks; and chronic pain is defined as a pain experience that persists for longer than 12 weeks (3 months). However, temporality of pain as the criterion for determining chronicity has been questioned.4,5 Loeser

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and Melzack5 suggest that it may be the individual’s inability to restore homeostatic mechanisms that signals the transition to chronic pain and this may be only partially time dependent. The neurobiologic mechanisms operant in those with chronic pain have been elucidated to a great extent in the last decade.6e8 An extensive literature also informs the role that psychological, behavioural, social and environmental variables play in the pain experience of the patient.9 However, patients who endure chronic pain remain difficult to treat, and it remains difficult to identify those in the acute phase or sub-acute phase who are destined to develop chronicity. Indeed, in a multivariate model of factors implicated in chronic pain, only 30% of the variance in pain is attributable to psychosocial factors, while the remaining 70% are a mystery and is not explained by biomedical factors.10 The effectiveness of generic manual therapy in the management of chronic pain remains undetermined; however, it is reasonable to conclude from the literature that any therapeutic effects in those with chronic pain are minor and difficult to differentiate from non-specific effects of hands-on care.11e16 This conclusion requires careful interpretation from an osteopathic perspective, as osteopaths typically use more than one manual therapy technique in any given consultation and rarely only treat the region of pain. It is reasonable to consider the possibility that conclusions drawn from research investigating generic manipulative approaches, such as used in the recently reported UK Back Pain Exercise and Manipulation Trial (UK BEAM Trial),17 are not generalisable to an osteopathic approach to treatment. Specific judgements about osteopathic treatment should be based on research that specifically investigates an osteopathic approach. In a recent randomised controlled trial investigating the effectiveness of an osteopathic approach to chronic low back pain, Licciardone et al.18 report that there was no difference in outcome between the osteopathic manipulation group and the sham manipulation group; however, both groups demonstrated improvements in pain, better physical functioning and mental health at 1 month, and fewer co-treatments at 6 months when compared to the no treatment group. This result is consistent with the findings of systematic reviews of manipulation (cited above) and fails to demonstrate that a specific osteopathic approach offers benefits over other manipulative approaches, or sham manipulation. Given the limited benefit that manipulation alone appears to have on those with chronic low back pain, other approaches to the management of patients in pain, especially chronic pain, need to be considered. The osteopathic profession has a rich history of considering the patient as an integrated whole, with rejection of the concept of mindebody dualism.19 Osteopaths are well placed to recognise and understand current concepts in

regard to the role that psychosocial factors play in patients with pain, and the strategies that might be used to modify these factors. It is suggested that osteopaths consider the evidence regarding which psychosocial factors constitute risk for developing pain or maintaining pain; and which of those factors are remediable. The aims of this commentary are to: 1. orientate readers to the field of psychosocial research in pain populations; 2. explore the evidence for psychosocial risk factors for pain using information from systematic reviews; 3. explore the evidence for psychosocial interventions in patients with pain from systematic reviews; 4. develop an evidence-based answer to the question ‘‘to what extent should osteopaths assess psychosocial factors in patients presenting with pain?’’ In order to achieve these aims, background information regarding psychosocial factors in chronic pain and the psychogenic theory of pain will be introduced. Evidence in the form of systematic reviews will be used to discuss those factors which increase the risk of developing chronic pain and those factors that are potentially remediable with psychosocial interventions. Systematic reviews were retrieved using the National Library of Medicine Pub Med Clinical Queries function (for risk factors the search terms used were: psychological, psychosocial, risk, chronic, pain; for treatment the search terms used were: psychological, psychosocial, multidisciplinary, behavioural, treatment, pain, chronic, sub-acute, acute, musculoskeletal). When articles were identified, the ‘Related Articles’ function was used to search for any other relevant literature. The Cochrane Database of Systematic Reviews was also searched using the same search terms and by browsing all systematic reviews in the Back Group, Pain, Palliative Care and Supportive Care Group, Musculoskeletal Group and Musculoskeletal Injuries Group.

2. Psychosocial factors in chronic pain The assessment of psychosocial factors in patients presenting with a pain problem is based on the concept, and evidence, that psychological, behavioural, social and environmental variables contribute to the pain experience.20e25 There remains, however, controversy regarding the exact nature and extent of this contribution; and this controversy is not helped by the lack of a convincing and substantial body of evidence regarding exactly which psychosocial factors warrant assessment and are modifiable such that the risk of chronicity they pose is reduced.10 Certain psychosocial factors which have been considered to be risk factors for chronic pain have been labelled as ‘yellow flags’, and it has been

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advised that patients should be screened for the existence of these proposed psychosocial risk factors.26 However, 7 years have passed since the publication of the first guide to assessing psychosocial yellow flags, and one might reasonably ask, on the basis of evidence published since that time, ‘‘Which psychosocial factors should be evaluated in patients presenting with pain?’’ In other words, while the assessment of psychosocial factors may have concept validity, it is important to determine which of these have both discriminative validity and predictive validity. The answer to this question can be sought by looking at two types of evidence. Initially, evidence should be sought for those factors that have been demonstrated in good quality prospective cohort studies to increase the risk of pain and disability (discriminative validity). If such factors can be reliably identified, it seems plausible that the elimination or reduction of such factors might benefit the patient. Secondly, therefore, evidence should be sought for management strategies that have been demonstrated in randomised controlled trials to actually benefit the patient (predictive validity). In other words, the answer to the question comes in two parts: (1) which factors increase the risk of chronicity and/or maintain the chronic state, and; (2) which of these factors are remediable such that the patient experiences reduced pain and improved function. A review of the literature reveals many complex issues to consider in regard to the decision to include psychosocial assessments as part of a standard consultation in all patients presenting with pain, and how to interpret the information generated. Indeed, there are countless psychosocial ‘factors’, which do leave the term open to interpretation and makes the term too generic. Some psychosocial variables, such as psychosocial factors at work, have been demonstrated to have no appreciable relationship to chronic pain and disability,27 whilst others, such as distress and coping style, have been found to be associated with an increased risk of developing chronic pain.28 The situation is further complicated by the fact that many of the questionnaires used to measure a persons psychological state may be valid for use in patients with psychological and/or psychiatric disorders, but are considered biased for use in patients in whom the presenting complaint is, or has been, pain.28 For instance, the Minnesota Multiphasic Personality Inventory (MMPI) is primarily a personality test, and not a test which identifies psychosocial risk factors in patients presenting with pain. Additionally, numerous questionnaires contain both functional items and psychometric items which interact and may produce falsely elevated scores, called criterion contamination. Pincus et al.28 discuss these issues and describe the use and initial validation of an outcome measure (the

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Depression, Anxiety and Positive Outlook Scale e DAPOS) that has been specifically designed to assess three mood states in patients with chronic musculoskeletal pain; those being depression, anxiety and positive outlook. Of particular interest is that the DAPOS was tested for validity on patients consulting a sample of osteopaths. Anagnostis et al.29 also discuss the issue of criterion contamination and describe a new psychometrically sound measure for chronic musculoskeletal disorders (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 psychogenic theory of pain: that persistent, unexplained pain may be caused by psychic disequilibrium; and that such pain would be resistant to biomedical treatments. The main feature of the psychogenic theory of pain is that emotional disturbance finds expression in pain. In a further critical appraisal of research methodology, Gamsa21 highlights that much of the original research that was used to support the psychogenic theory of pain was methodologically unsound. Also, subsequent research, that has used refined methodology to minimise bias and control for extraneous variables, has failed to find consistent evidence in support of the psychogenic theory of pain. Although dated, Gamsa’s reviews provide a challenge to the concept of psychogenic pain. At the very least, this view invites readers to consider that medically unexplainable pain does not provide evidence of a psychogenic cause. As an example of more contemporary literature on this issue, Raphael et al.30 report that although childhood sexual and physical abuse are often viewed as important factors in the development and persistence of chronic pain, the evidence for this causal association is lacking. Only in very large cross-sectional studies are a mild association found; however, cross-sectional studies cannot, by definition, demonstrate causality. Prospective cohort studies are the appropriate research design to investigate this issue and those prospective studies reviewed by Raphael et al.30 do not support the relationship. The lack of evidence to support the psychogenic theory of pain is important as it removes the temptation to label patients as having pain that is ‘all in their head’. In terms of deciding the extent to which psychosocial factors should be assessed in patients with pain, there does not appear to be evidence to support the notion that osteopaths should look for psychosocial causes of the original onset of pain. However, as discussed above, there is ample evidence to suggest that osteopaths should consider psychosocial variables that may increase patients’ risk of developing chronic pain, and may

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explain up to 30% of the variance in existing chronic pain conditions. Pain can be a feature of psychiatric disorders, however, strict criteria apply when making a psychiatric diagnosis, as outlined in the diagnostic and statistical manual of mental disorders (DSM-IV-TR).31 In order to ensure reliable, objective diagnosis and avoid subjective diagnoses based on personal judgement, osteopaths are encouraged to rely on the DSM criteria. In regard to the DSM-IV-TR diagnostic categories that include pain, it is clear for the majority that pain must be neither the primary concern of the patient nor the primary reason for disability. Furthermore, labels such as somatisation disorder stipulate that a patient has pain in at least four locations, as well as two gastrointestinal symptoms, a sexual symptom and a pseudo-neurological symptom, and is clearly an inappropriate label for those with chronic pain limited to one or two regions, e.g. neck and/or low back pain. In the DSM-IV-TR Pain Disorder category, there are two labels provided for patients in whom psychosocial factors are considered important: 1. Pain disorder associated with psychological factors; and 2. Pain disorder associated with psychological factors and a general medical condition. However, determining which psychological factors are associated with pain in a particular patient remains largely conceptual, and is based on personal opinion rather than evidence. For example, if one was to assume that a work-related psychosocial factor had been demonstrated to increase the risk of developing chronic pain in a population-based study, how could one look back retrospectively with an individual patient and determine if this factor played a role in the development of that patient’s pain? Also, some patients in pain experience distress, anxiety and depression as a result of being in pain, in which case the psychological factors are subsequent to the pain disorder. Furthermore, to say that a pain disorder is associated with psychological factors does not imply that psychological factors caused the pain disorder. Clearly, it is difficult to make an informed and valid decision that a patient’s pain is associated with a psychological disorder, and it has been suggested that most patients with chronic pain should be labelled as having pain associated with a general medial condition (i.e. non-psychological cause), even if this medical condition is to be assumed.32 The existence of emotional and psychological responses to pain does not warrant the label ‘pain disorder that is associated with a psychological factor’, because everyone who experiences pain has, by definition, an emotional experience of that pain. If the label ‘pain

disorder associated with psychological factors’ was to be applied to everyone experiencing pain, then it would cease to have any discriminative validity and would become a useless label.

4. Factors that increase the risk of developing chronic pain It is important to note that the majority of prospective cohort studies examining the relationship between pain and psychosocial factors has been designed to examine the relationship between a specific location of pain (such as lumbar spinal pain) and specific psychosocial factors.22,23,25,27 The question arises as to whether the results found in such specific studies are then generalisable to all pain syndromes and all psychosocial variables? For instance, the findings from research investigating psychosocial issues in patients with lumbar spinal pain25,33,34 should not be extrapolated to those patients with cervical spinal pain, in whom a different profile of psychosocial risk factors exists.35,36 Furthermore, studies examining psychosocial issues in patients with acute pain should not necessarily be extrapolated to those with sub-acute pain, or those with chronic pain. Whilst theories in regard to a given pain syndrome may be extrapolated to other syndromes (along with the limitations of theory transference), data from research studies should not be extrapolated. In 2000, Hoogendoorn et al.23 published a systematic review of psychosocial factors at work and in patients private lives, as risk factors for back pain. These authors concluded that evidence was found for a risk associated with work-related psychosocial factors, but the evidence for specific work factors was lacking. The strength of this finding was affected by the quality ratings given to each of the articles, which determined their eligibility for inclusion in the systematic review, and changes in the way articles were rated affected the conclusions that could be drawn. For example, the authors state that ‘‘None of the publications on any of the studies clearly demonstrated, with reference to repeatability data, that standardised methods of acceptable quality were used for the assessment of psychosocial factors at work’’. It was also reported that there was insufficient evidence to determine the role of private life psychosocial factors in back pain. Four years later, in 2004, Hartvigsen et al.27 published a systematic review of prospective cohort studies designed to investigate the relationship between psychosocial factors at work and low back pain, and the consequences of low back pain. Hartvigsen et al.27 reported that many of the instruments used to collect data on work-related psychosocial factors remained to be validated, which threatened the internal validity of the original research using these instruments, and

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therefore the systematic reviews based upon this research (such as the Hoogendoorn et al.23 review). Antinomy in this regard is evident in the findings of Hartvigsen et al.27 who, in contrast to Hoogendoorn et al.23, found evidence for no association between psychosocial factors at work; specifically, no association for low back pain and perception of work, organisational aspects of work, and social support at work. In 2000, Linton22 reported the findings of a systematic review evaluating the psychological risk factors in patients with back and neck pain. Linton22 reports that psychological variables are clearly linked with neck and back pain; citing stress, distress, and anxiety as well as mood, emotions, cognitive function and pain behaviour as significant factors. Linton22 also makes the suggestion that these factors may be linked to the aetiology of acute pain, especially in relation to the transition from acute to chronic pain. However, Linton22 highlights that these conclusions should be interpreted with caution given the low methodological quality of the studies included in the systematic review. In 2002, Pincus et al.25 reported the findings of their systematic review of psychological factors as predictors of chronic pain and disability in patients with low back pain. They report that distress (a composite of psychological distress, depressive symptoms and depressive mood), somatisation, and cognitive factors (such as praying/hoping and catastrophising) were implicated in the transition to chronicity in patients with low back pain. However, these findings were reported with the caveat that further research was needed for substantiation. Of interest in the Pincus et al.25 review was their analysis of feareanxiety, in which they found the evidence to be ‘‘surprisingly scarce’’. They report the findings of Burton et al.37 who found that removal of feareanxiety from a multivariate model, which included other psychological parameters, did not weaken the predictive power the model. This review provides some contrasts to the conclusions of Linton,22 who stated that anxiety 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 literature reviewed to date that psychosocial factors do not play an aetiological or causative role in the onset of pain.20,21,30 However, it does appear that work-related psychosocial issues may play a role in chronic back pain,23 and that distress, anxiety, depression,22,25 somatisation,27 and certain cognitive factors25 play a role in the transition from acute back pain to chronic back pain and disability. However, these systematic reviews pertain predominantly to lumbar spinal pain and not necessarily to other spinal pain syndromes, or

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chronic pain and disability in general. The evaluation of psychosocial factors in patients presenting with pain is therefore a conceptual, pragmatic practice based more on common sense rather than a cohesive body of evidence. In summarising these systematic reviews, it is apparent that there is a lack of good quality studies from which to draw firm conclusions, and this explains, to some extent, the antinomy evident in this field. It is also important to point out that as soon as a systematic review is conducted, it readily becomes out of date, as new additions to the primary literature might challenge the conclusions of a previously reported systematic review. A good quality prospective cohort study should be given more consideration than a systematic review based on poor quality studies, even though systematic reviews are ranked more highly than prospective studies in the hierarchy of evidence. Lastly, while the topic of this commentary is concerned with pain in general, the majority of systematic reviews focus on a specific pain syndrome, which reflects the focus of the primary literature. For these reasons it is suggested that the conclusions of the systematic reviews be interpreted with caution rather than accepted as being conclusive.

6. Management of relevant risk factors The reliable and valid identification of clinically relevant psychosocial factors that, when present, increase the risk of chronicity, leads one to consider which of these factors are remediable. If, by addressing a psychosocial factor, patient outcomes improve, then this increases the predictive validity of evaluating psychosocial factors. If, on the other hand, a given psychosocial factor has no effective management strategy that results in improved outcomes, then the routine measurement of this factor lacks clinical utility. Nevertheless, the assessment of such factors may still help the osteopath understand the patient in the context in which they experience their pain. There are various approaches to the management of psychosocial issues, and these include pharmacotherapy and cognitive-behavioural therapies (CBT) nested within a biopsychosocial approach to pain management. The evidence for the efficacy and/or effectiveness of behavioural therapy, CBT and multidisciplinary management of certain pain conditions is discussed below. A detailed discussion of the evidence for the effectiveness of pharmacological management of psychological factors will not be presented in this article. However, it may be of interest to readers that the authors of a recent systematic review of antidepressants in the treatment of chronic low back pain conclude that selective serotonin reuptake inhibitors do not appear to be beneficial for patients with chronic low back pain, whereas tricyclic and tetracyclic antidepressants appear to produce

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moderate symptom reductions for patients with chronic low back pain. However, what is interesting is that this benefit appears to be independent of the patient’s depression status. The authors also conclude that there is conflicting evidence whether antidepressants improve functional status of patients with chronic low back pain.38

7. Psychosocial factors that are potentially remediable and may help prevent chronicity and disability The main reason for evaluating psychosocial factors is in the hope that by addressing these factors, patients might be prevented from developing chronic pain and have a greater chance of recovery. While it is logical to target risk factors in prevention, we must recognise that if the variance explained by the risk factor is small, then the changes achieved by modifying those risk factors will also be small. In the case of psychosocial factors, the variance in pain attributable to these factors is estimated to lie between 15 and 30%10; so, by addressing these factors one might hope to vary the pain by 30% at the best. The chance of a 30% improvement is obviously a worthwhile aim; however, ones’ expectations of the effectiveness of psychosocial intervention should be placed within the realm of what is likely to be possible. Further, while it is interesting to consider theoretical possibilities, it is far more useful to consider the actual extent to which psychosocial intervention is successful as reported in the systematic reviews discussed below. The evidence for the effectiveness of managing psychosocial factors with psychosocial interventions is discussed under the headings of acute pain, sub-acute pain, and chronic pain. 7.1. Acute pain In regard to the management of relevant psychosocial issues in those with acute pain, there is no specific evidence from which to form an opinion at this stage. More specifically, we do not yet know if addressing psychosocial issues in those with acute pain actually decreases the risk of chronicity and disability. The development of research investigating psychosocial interventions in acute pain will be interesting to follow as it is only in the acute phase that prevention of chronicity is likely to be viable, simply because the detection of psychosocial risk factors in patients already in the chronic phase is obviously too late to prevent chronicity. In one study that compared standard medical treatment with evidence-based treatment for acute low back pain, the authors report that patients in the evidence-based treatment group had statistically significant reductions in pain and the amount of ongoing

treatment, and a greater proportion were fully recovered at 12 months.39 What is important about this study is that included in the evidence-based treatment group, was an emphasis of dealing with patients’ fears and misconceptions, providing confident explanations, and empowering the patient to resume normal activities. This study, therefore, primarily supports the use of the evidence-based guidelines for the management of acute low back pain,39 and secondarily lends support to the concept that addressing certain psychosocial issues, such as catastrophising and fear-avoidance behaviour, might benefit the patient. However, this argument does not provide specific support for the contention that psychosocial issues warrant formal investigation and, if detected, warrant specialised psychosocial interventions. Rather, it supports the argument that the management of all patients with acute low back pain should include reassurance, education, and advice to stay active, irrespective of whether psychosocial factors are measured or not.39 7.2. Sub-acute pain In a systematic review in 2001, Karjalainen et al.40 report that biopsychosocial multidisciplinary rehabilitation helps patients return to work faster, decreases sick leave and alleviates disability. However, this review was based 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 advice in those with sub-acute low back pain; however, this evidence is based on low methodological research and should be viewed with caution. In 2003, Karjalainen et al.42 updated their 2001 systematic review and after screening 1808 abstracts, and the references of 65 reviews still found only two low quality RCTs that satisfied their criteria on sub-acute low back pain. They conclude that ‘‘that there is moderate evidence of positive effectiveness of multidisciplinary rehabilitation for sub-acute low back pain and that a workplace visit increases the effectiveness. However, because this evidence is based on trials that had methodological shortcomings, and several expensive multidisciplinary rehabilitation programmes are commonly used for uncomplicated/non-specific subacute low back problems, there is an obvious need for high quality trials in this field.’’ 7.3. Chronic pain In 1999, Morley et al.43 report that when compared with the waiting list control conditions, cognitivebehavioural treatments were associated with significant effect sizes on all domains of measurement. Comparison with alternative active treatments revealed that cognitivebehavioural treatments produced significantly greater

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changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophisation), and social role functioning. Morley et al.43 conclude that active psychological treatments based on the principle of cognitive-behavioural therapy are effective. In 2000, van Tulder44 reported that there is strong evidence that behavioural treatment has a moderate positive effect on pain intensity and function in those with chronic low back pain. However, this effect was not found when behavioural treatment was added to a usual treatment program, casting doubt as to whether behavioural treatment is any more effective than other non-behavioural treatments (such as exercise therapy). In 2002, Guzman et al.45 report in their systematic review that only an intensive multidisciplinary approach to chronic low back pain with a functional restoration approach (unavailable to most osteopaths in private practice) resulted in clinically useful outcomes, and that less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. In 2005, Ostelo et al.46 report in their systematic review that ‘‘combined respondent-cognitive therapy and progressive relaxation therapy are more effective than waiting list controls on short-term pain relief. However, it is unknown whether these results sustain in the long term. No significant differences could be detected between behavioural treatment and exercise therapy. Whether clinicians should refer patients with chronic low back pain to behavioural treatment programmes or to active conservative treatment cannot be concluded from this review.’’ In 2003 Karjalainen et al.47 published their updated systematic review on multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults and conclude that there appears to be little scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation compared with other rehabilitation facilities for neck and shoulder pain. In 2003 Eccleston et al.48 report the findings of their systematic review evaluating psychological therapies for the management of chronic and recurrent pain in children and adolescents. The main findings of this review pertain to chronic headache, as this represented the majority of the primary literature in children and adolescents, in contrast to those studies on adults which tend to focus on low back pain. Eccleston et al.48 report that there is evidence that psychological treatments, principally relaxation and cognitive-behavioural therapy, are effective in reducing the severity and frequency of chronic headache in children and adolescents. However,

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due to a lack of primary literature, there is at present no evidence for the effectiveness of psychological therapies in attenuating pain in conditions other than headache. Lastly, in 2000 Karjalainen et al.49 report the findings of their systematic review concerning multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. The authors discuss that of the RCTs that were relevant, none were of high methodological quality. They conclude that there is little scientific evidence for the effectiveness of multidisciplinary rehabilitation for these musculoskeletal disorders.

8. Summary of recent systematic reviews e management Multidisciplinary biopsychosocial interventions, behavioural therapy, and cognitive-behavioural therapy have been evaluated for efficacy in those with sub-acute and chronic pain. While some positive benefits arise from the application of these approaches, the recent systematic reviews discussed above do not provide convincing evidence that these approaches offer better outcomes than those already existing biomedical and rehabilitative approaches. For example, while behavioural therapy for chronic low back pain is better than no therapy, and better than placebo, it is not better than exercise therapy.44,50 Similarly, while intensive multidisciplinary biopsychosocial rehabilitation (with functional restoration) improves function and reduces pain, less intensive outpatient multidisciplinary biopsychosocial rehabilitation did not show improvement in pain, function or vocational outcomes when compared with usual care.45,50 In support of this, Pincus et al.51 conclude in their report of cognitive-behavioural therapy and psychosocial factors in low back pain that ‘‘In the treatment of psychological factors, the role of clinicians in primary care remains unclear. Further evidence is needed to identify specific psychological risk factors, primary care tools for their identification need developing, and interventions at different stages of low back pain by different professionals need to be tested.’’

9. Discussion This overview of recent systematic reviews regarding the relationship between psychosocial factors and pain sets the background for the justification of the extent to which psychosocial factors should be routinely explored in osteopathic practice (Box 1). Psychosocial factors may primarily increase the risk of chronic pain and disability and may be potentially remediable with a view to reducing risk of chronic pain and disability and improving rehabilitation outcomes; however, this approach remains largely conceptual.10 Also, the decision to evaluate psychosocial factors in a patient will be

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Box 1. A suggested outline of the extent to which psychosocial factors should be assessed in patients presenting 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 psychosocial issues, but are still being developed and improved.

influenced by whether they have acute, sub-acute or chronic pain. In patients with acute pain, it is proposed that the osteopath should make initial enquires regarding relevant psychosocial factors, with a view to implementing further and more detailed enquiry if the patient’s symptoms do not improve before they enter the subacute phase. The main reason for this is to make an early identification of relevant psychosocial issues in those patients who are progressing toward sub-acute pain and chronicity. However, it should be noted that of those patients with acute low back pain, only 2e7% develop chronic pain,52 and so it is in these 2e7% of patients who develop sub-acute pain (6e12 weeks duration) that psychosocial factors become increasingly relevant. In patients with chronic pain, psychosocial issues should be more formally assessed, however, it may be considered that since chronicity has already occurred, assessment for psychosocial issues ceases to be for preventative purposes, and becomes important for the wholistic management of an existing condition in order to meet patients’ physical and emotional needs. It is important to consider the possibility that patients with chronic pain do not necessarily have psychosocial factors that either increased their risk of developing

chronic pain or are maintaining their present status. In fact, as discussed above, regression models of chronic pain and associated features show that psychosocial variables only account for between 15 and 30% of the variance.10 Those factors which explain the remaining 70% are a mystery in populations, and even more so in individual patients. It should be acknowledged that patients in chronic pain do not automatically have chronic pain because of psychosocial factors. The following four a priori possibilities highlight this fact: 1. An individual patient with chronic pain may have no psychosocial issues. 2. An individual patient with chronic pain may have psychosocial issues, but which are not important in their pain condition. 3. An individual patient with chronic pain may have psychosocial issues as a result of being in chronic pain, but which may, or may not, be maintaining the pain. 4. An individual with chronic pain may have developed chronic pain because of relevant psychosocial factors that were present during the acute phase, and which increased their risk of developing chronic pain.

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For example, a patient may present with pain, but is actually expressing dissatisfaction with their marriage; and each of these constitute two separate problems (point 2 above), each of which is worthy of management. This is different from having pain that is either due to, or is being maintained by, psychosocial issues (point 4 above). Given these possibilities, it is clear that the symptom of chronic pain is not pathognomonic for the diagnosis of psychological or social problems and, at present, no tool or measure exists by which to reliably distinguish between these individual groups. It should be clearly understood that it is inappropriate to label patients as having psychosocial problems simply on the basis that the patient has chronic pain. Bogduk and McGuirk10 present the strategy of observing and listening for relevant psychosocial factors during the standard medical interview, and summarise the patient’s beliefs, and also their behaviours that pertain to (1) physical activity, (2) domestic responsibilities, (3) social interactions and (4) vocational matters, should be explored. It is suggested that practitioners look for26:  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. The administration of questionnaires in acute pain patients is perhaps too intrusive, whereas an exploration of patients’ fears, beliefs and work issues through informal conversation during the consultation is considered to be a satisfactory approach.10 In order to elicit this information it 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 back pain? 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 pain that it is most important to more formally assess for relevant psychosocial issues. This involves a re-assessment of those psychosocial factors listed above. Such reassessment can be conducted verbally, or a questionnaire can be administered. However, the problem with using questionnaires is deciding which one to use? Given that the literature does not provide an adequate answer to that question as yet, it becomes a personal choice. It has not been an aim of this commentary to discuss specific questionnaires, but to consider their usefulness in

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general for osteopaths in private practice. Information regarding questionnaires is widely available and a brief summary of commonly used questionnaires can be found in Bogduk and McGuirk’s text.10 Having conducted an assessment of psychosocial factors in an individual patient, and made the decision that certain psychosocial factors are present and relevant to the pain condition, the osteopath is left to consider the appropriate management of these factors.

10. Conclusions It is clear from the literature that a patient’s tendency to catastrophise may increase their risk of chronicity. Further, catastrophisation and distress resulting from being in pain interacts in some way with patients’ beliefs and behaviours, as well as their coping strategies, which also interacts with how they engage in their work and social lives. In those patients who do develop chronic pain, this complex mix of variables may have an association with the transition of pain from the acute stage to the chronic stage. Most patients do not go on to develop chronic pain and disability, so it could be argued that an in-depth assessment of psychosocial factors in all acute pain patients is not warranted. However, it is equally important to try and identify those patients in whom psychosocial factors represent a risk of developing chronic pain and disability, such that these factors can be modified with the intention of preventing chronicity and disability. In answer to the question, ‘‘to what extent should osteopaths assess psychosocial factors in patients presenting with pain?’’ a pragmatic and sensible approach is to informally, yet consistently, make an assessment of psychosocial factors during the medical interview and ensuing conversation and to include reassurance, education, and advice to stay active in acute pain patients.39 In those with sub-acute pain, it is important to focus on and make a re-assessment of those psychosocial factors that were considered during the acute stage. This can be achieved verbally during the course of conversation, or could be more formally assessed using a questionnaire (such as the DAPOS28). In patients who have already developed chronic pain, it is important to identify the presence of psychosocial factors that may have contributed to their current chronicity with a view to helping the patient manage their symptoms. The most effective management of psychosocial factors in sub-acute and chronic pain is difficult to determine from the evidence. Given the limitations of the current literature to inform practitioners about the specific roles that psychosocial assessment and psychosocial intervention have in various pain syndromes, it would be wise to stay attuned to developments in this area, as new, good quality research is likely to clarify current understanding.

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