Psychosocial issues in the prevention of chronic low back pain—a literature review

7 Psychosocial issues in the prevention of chronic low back pain a literature review S. WEISER C. C E D R A S C H I

Studies of chronic low back pain have given ample consideration to psychosocial factors (for a review see Joukamaa, 1987). Deleterious social and emotional aspects of chronic pain have been eloquently described by many experts in the field (Sternbach, 1978; Waddell, 1987a; Fordyce, 1988). Numerous studies confirm the clinical impression that chronic pain patients suffer from psychological distress and social isolation. Nonetheless, the role of these factors as predictors, correlates or outcomes of illness remains unclear. The importance of these relationships becomes particularly cogent when the objective is to prevent chronicity and disability through the identification of those at risk. Psychological and social factors play a greater role in the maintenance of illness as pain moves from the acute to the chronic stages. Acute pain is determined mainly by nociception and to a lesser extent, the psychosocial constitution of the individual. In chronic pain, the order is reversed. Nociception becomes less of a determinant of functional status then psychological and social attributes (Spengler et al, 1980; Waddell, 1987b). Theoretical models that describe the psychosocial processes by which pain becomes chronic have been formulated and well received (Sternbach, 1978; Waddell, 1987b; Fordyce, 1988; Waddell, Chapter 1). However, few studies have tested these theories. This chapter reviews studies of psychosocial factors associated with the development and prevention of chronic pain. It is organized into three sections. The first section discusses studies that identify psychological and social attributes of healthy or recent low back pain sufferers that may predict outcome. Some of the problems inherent in this type of research are discussed. The next section reviews low back pain prevention programmes that are based fully or partially on psychosocial strategies. The success of these interventions is assessed. Finally, issues of concern in the assessment and treatment of acute patients are presented and discussed. It is our hope that this information will be useful to researchers and clinicians who champion the cause of preventing chronic low back pain. Bailli~re' s Clinical Rheumatology--

Vol. 6, No. 3, October1992 ISBN0-7020-1637-3

657 Copyright9 1992,byBailli~reTindall All rightsofreproductionin anyformreserved

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PSYCHOSOCIAL FACTORS ASSOCIATED WITH ACUTE LOW BACK PAIN

Among the broad category of variables that have been associated with chronic low back pain are personality, cognition and affect, pain behaviour and the social environment including family, friends, co-workers and health care workers. Increased psychopathology and social problems have been found in patients who suffer from back pain that persists for more than 6 months. Although it is clear that chronic pain plays a causal role in the development of psychosocial dysfunction, the contribution of psychosocial factors to the development and maintenance of chronicity is less well understood. Chronic illness is a dynamic process that results from an ongoing interplay between physical and psychological characteristics. The identification of a factor as predictive at a certain stage does not preclude the possibility that this factor is also a consequence of the pain experience. From a multicausal perspective (Melzack and Wall, 1982; Wall, 1989), psychological factors can be predictors and consequences of pain simultaneously (Gamsa and VikisFreibergs, 1991). Therefore, for heuristic purposes, a distinction is made between primary, secondary and tertiary risk factors or predictors. Primary risk factors place those in the healthy population at risk for first-time back impairment. Secondary risk factors identify individuals with acute pain who are at risk of becoming chronic patients. Spitzer et al (1987) has defined acute pain as being of less than 7 weeks duration. However, few studies have investigated patients at this point in time. This review includes studies of patients with back pain for less than 6 months in secondary risk factor discussions. Tertiary risk factors allow us to predict which chronic pain sufferers will not be successfully rehabilitated. Most studies of low back pain use a multicausal model. A number of psychological, social, demographic and physical traits are considered simultaneously. Such a model acknowledges the multifaceted nature of illness as well as the considerable overlap that exists between variables such as coping and depression. This section is divided into categories that are to some extent artificial but that allow the reader to consider more easily the relative contribution of each factor. They are personality and psychological distress, illness cognitions, illness behaviours, stressful life events and social factors. , Personality and psychological distress

The ardent search for a personality that predisposes an otherwise healthy individual to become a chronic pain patient has been all but abandoned recently. Recurrent clusters of personality traits found in chronic pain patients have been interpreted to be the result of illness and not the cause. Instead, investigators have concentrated on the role of psychological distress in the aetiology of chronic low back pain. One problem with this approach is that the same instrument is often used to measure personality and psychological distress. The most widely used instrument, Minnesota Multiphasic Personality InventorY (MMPI), is used indiscriminately as a

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measure of personality in some studies and as a measure of reactive distress in other studies. This may explain the considerable conflict in results. The most commonly elevated scales of the MMPI in chronic back patients--hypochondriasis, hysteria and depression--showed no relationship to return to work in two studies of recently injured workers (Lacroix et al, 1990; Cats-Baril and Frymoyer, 1991). Other studies refute these lack of findings. In a prospective study of healthy workers, four MMPI scales (hysteria, psychopathic deviance, schizophrenia and low back pain) were found to distinguish new injury reporters from non-reporters. These scales were second only to work satisfaction in predicting the report of back injury (Bigos et al, 1991). Tertiary risk factor studies have found the MMPI to be useful. Barnes et al (1988) showed a relationship between hypochondriasis and poor outcome following a functional restoration programme. In a multifactorial study of 150 chronic patients, Gallagher et al (1989) found that the hysteria scale of the MMPI was negatively related to return to work at 6 months. Deyo and Diehl (1988) prospectively studied 179 mostly acute low back pain patients and found that those who reported 'always feeling sick' had a poorer outcome at 3 months on several psychosocial and functional measures. They associate the endorsement of 'always feel sick' with those who would have elevated MMPI hypochondriasis and hysteria scales on the MMPI. This hypothesis requires testing. Problems with the MMPI have been noted that make its appropriateness for chronic pain populations questionable. The MMPI is empirically derived and normed for use on a psychiatric population. Watson (1982) points out that MMPI elevations may be misinterpreted as psychopathology when they actually reflect an endorsement of items relevant to the patient's pain problem. Moore et al (1988) similarly notes that elevations on the schizophrenia scale may reflect somatic symptoms and depression associated with tow back pain. Several authors have proposed that the utility of the MMPI lies in its ability to identify subgroups of patients who exhibit similar behaviours rather than psychopathology (Keefe et al, 1991; Bigos et al, 1991). From the cumulative evidence, one may speculate that acute patients who are preoccupied with their symptoms and are depressed and anxious fare more poorly than others. One study that used the Hopkins Symptom Checklist (HSC) in addition to the MMPI refutes this hypothesis. The HSC (also known in another form as the Symptoms Checklist-90) is a scale developed for use in patient populations. Hysteria, depression, hypochondriasis and somatization were unrelated to return to work in 250 recently injured workers (Cats-Baril and Frymoyer, 1991). More studies of this nature with acute patients are necessary before conclusions can be drawn. Other measures of psychological status such as high levels of pain, depression, high scores on the premorbid pessimism scale of the Millon Behavioral Health Inventory (MBHI), and locus of control have been prospectively associated with poor outcome in tertiary prevention programmes (Barnes et al, 1988; Gallagher et al, 1989; Polatin et al, 1989). Barnes et al (1988) also found the cooperative scale of the MBHI to predict

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good outcome. This last finding suggests the importance of assessing positive as well as negative attributes, since their relative contribution to chronicity may be equally important. This literature suffers from lack of methodological clarity and a consensual framework but it is possible to correct these problems. Though many would abandon the search for pre-existing personality traits, conducted properly this endeavour may yield interesting findings. After all, states of distress are in part determined by personality. Studies that use personality measures developed from a non-medical population may be useful before the onset of injury. Inclusion of positive personality measures such as optimism or hardiness may be more informative. After injury, such measures may require modification and should be used cautiously. At this point, the way the individual reacts to the pain may be easier to measure and more relevant to outcome. In addition, it is easier to modify a reactionary state than a personality trait. Measures of reactive distress should also be developed for a population with low back pain to ensure items that do not reflect physical symptomatology. Finally, investigators must be clear about the theoretical distinctions between personality and reactive emotional states. Personality is defined as a set of relatively stable and enduring traits. Certainly, personality can change over the course of a long illness but rapid or extreme changes may more likely be the result of fluctuations in distress. The indiscriminate interchange of these constructs has strong implications for the patient's self-perception and treatment and should be taken most seriously.

Cognitive factors Cognitive factors include coping and illness beliefs. Beliefs about illness and cognitive coping exist before pain begins but they are developed at the onset of back pain and are important determinants of affect and behaviour. Therefore, the identification of these cognitive factors in acute illness may provide a basis for the prevention of chronicity. Coping, in this context, refers to cognitive attempts to render pain more tolerable. Studies of chronic patients indicate that pain coping strategies predict pain perception and functional capacity (Rosenstiel and Keefe, 1983; Turner and Clancy, 1986; Turner et al, 1987). Attempts to overcome pain are associated with good outcome. Catastrophizing (imagining the worst) and diverting attention from low back pain-scales have been associated with depression and pain (Rosenstiel and Keefe, 1983; Turner and Clancy, 1986; Keefe et al, 1990). However, it has been argued that catastrophizing may be no more than a cognitive manifestation of depression and not a pain mediator (Sullivan and D'Eon, 1990). In one study of acute patients, coping did not predict return to work (Frymoyer and Cats-Baril, 1987; Cats-Baril and Frymoyer, 1991). This study is difficult to evaluate because the authors give no indication as to how coping was measured. Spinhoven and Linssen (1991) examined the relationship between three coping strategies--perceived control, active coping and helplessness--to outcome at 6 months in 53 chronic Dutch patients. Patients

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whose scores on perceived control increased over time reported less pain at 6 months than those whose score did not increase. The other two strategies were unrelated to outcome. The lack of methodological consistency between studies of acute and chronic patients is troubling. The use of the same measure in each population may help us understand the dynamics of coping. Different strategies may be more adaptive at different junctures. There is literature regarding other illnesses to support this contention (Taylor and Brown, 1988). Prospective studies should take this into consideration. Illness beliefs and the accuracy of these beliefs have been related to functional status in chronic pain patients (for a review see Keefe et al, 1991). Beliefs about illness have also been studied as potential predictors of chronicity. In one investigation, Sandstrom and Esbjornsson (1986) found that the patients' own projection of whether or not they could return to work correlated with work status 4 years after rehabilitation. Self-efficacy, the belief in one's ability to produce an outcome, has been related to health and illness behaviour in studies of other medical populations as well (O'Leary, 1985). The measurement of their belief is appealing because of its simplicity and the underlying assumption that the patient is the expert on his or her own situation. Lacroix et al (1990) showed that back pain patients who understood their illness had a better outcome than those who did not know what was wrong with them. They reason that understanding facilitates compliance and, therefore, a better result. However, the most talented clinicians do not know the origin of unspecified back pain and it is therefore difficult to provide the patient with an explanation. The resolution of this uncertainty may be hard to achieve. Pain behaviours

Pain behaviours refer to any physical or verbal attempt on the part of the patient to communicate suffering and disability. A number of behaviours have been identified. They include grimacing, bracing, guarding, groaning, limping, over-reacting and duration of inactivity (Keefe and Block, 1982; Waddell, 1987a). Though similar pain behaviours have been found to exist in acute and chronic low back pain patients, the meaning of these behaviours may be quite different (Zarkowska and Phillips, 1986). Pain behaviour in the acute stage is appropriate and adaptive in order to avoid further injury. In the chronic stage, pain behaviours have no therapeutic value. Instead, they perpetuate the patient's adoption of the sick role and are therefore maladaptive. It is for this reason that pain behaviours are often targeted as intervention outcomes in chronic pain patients. The predictive strength of pain behaviours in the acute pain population is unknown. Jensen et al (1989) adapted a method for assessing pain behaviour in the acute population from Keefe and Block (1982). However, further work is needed to determine whether variations in pain behaviours in the early stages of illness predict future chronicity.

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Social factors

The study of social factors that affect the course of low back pain include variables that originate outside the individual. Since the measure of these variables usually relies on patient reports, they are coloured by subjective perception. The patient's psychological make-up has been shown to influence the report of psychological traits as well as social events (Watson and Clark, 1984). Therefore, the distinction between psychological and social variables is blurred. Attempts have been made to identify aspects of the patient's social environment which may affect low back pain. Stressful life events have been studied in relation to back pain but not without considerable difficulty. The predictive value of a life event can only be determined when the exact point of the onset of pain is known (Creed, 1985). Back pain is often insidious and cyclical, making its origin ambiguous. Retrospective studies that rely on memory can yield spurious results. Furthermore, the measurement of life events is often confounded with the effects of illness, contaminating the relationship between such events and illness outcomes. Crauford et al (1990) attempted to control for these problems in a study of low back pain patients with recent and datable onset. Using the Life Events and Differences Scale, they investigated only life events that could be considered independent of pain such as the illness of a relative, or unemployment to rule out the possibility that these events may be the result of back pain. Life events were directly related to the onset of pain in patients with non-specific causes of pain. Patients with a specific diagnosis had a higher rate of life events after onset but before seeking treatment than other patients. This finding led the authors to conclude that the tendency to seek treatment in this group was the result of stressful life events. Long-term prospective studies are needed to determine the strength of the predictive value of life events over time. Several studies that sought to measure stress through stress-related symptoms have shown a relationship between these measures and pain (Feuerstein et al, 1987; Ackerman and Stevens, 1989; Svensson and Andersson, 1989). The causal direction between these variables was not determined. In a longitudinal 10-year study of 902 patients, Leino (1989) sought to determine the causal direction between 18 stress symptoms and general musculoskeletalcomplaints. Participants with greater stress symptoms had higher future aches and pains, more clinical findings and more chronic musculoskeletal diseases than others. These complaints also predicted stress symptoms, however. This underscores the cyclical nature of stress and pain. Job characteristics such as work satisfaction and social support at work have recently received attention in the study of low back pain. Methods of assessment have varied and are rarely thoroughly described. However, preliminary results indicate that these factors may be important in predicting the occurrence of low back pain. Several correlational studies attest to the relationship between work satisfaction or work stress and low back complaints (Bergenudd and Nilsson, 1988; Svensson and Andersson, 1989; Smith et al, 1990). A

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prospective study by Bigos et al (1991) showed a significant negative relationship between work satisfaction and the report of back injury. Physical, psychosocial, workplace and demographic variables were assessed in 3020 aircraft employees. After back pain history, work perceptions were the strongest predictors of back injury reports at the 4-year follow-up. Cats-Baril and Frymoyer (1991) found job characteristics such as work history, occupation and satisfaction to be the strongest secondary risk factors for low back pain disability in a multifactorial prediction model. Among a variety of physical, demographic and psychological variables, Hurri (1989) found global work satisfaction to be the strongest tertiary risk factor for back school outcome in chronic patients: the higher the satisfaction the better the outcome. Finally, Leino and Lyyra (1990) found work stress and lack of social support to predict musculoskeletal complaints after 10 years in Finnish blue-collar workers but not in white-collar workers. To the contrary, a prospective study by Viikari-Juntura et al (1991) found no relationship between job satisfaction and the report of low back symptoms. These discrepant results are likely due to differences in outcome variables, methods of assessment and population demographics in each study. More work needs to be done in this area to support these findings. Compensation status has often been implicated in the development of chronic low back pain. Patients with pending compensation claims have been shown to have lower success rates in rehabilitative programmes than patients who do not expect financial remuneration (Fordyce, 1976; CatsBaril and Frymoyer, 1991). Cats-Baril and Frymoyer (1991) also found that placement of blame for the injury and lawyer involvement were additional predictors of disability. In a retrospective study, Sander and Meyers (1986) found that patients who were injured on duty and therefore received compensation were out of work significantly longer than those injured off duty. The nature of the injury for these two groups differed, which limits the interpretation of the results. The results of one study by Barnes et al (1988) diverge from the others. They found that chronic patients who were working one year after rehabilitation were receiving higher levels of monetary compensation at the time of treatment than those who did not return. The authors explain that higher compensation in this group reflected higher paying jobs. It may be that patients with lucrative jobs also held jobs that were more satisfying and had more incentive to return. This study introduces a new perspective on compensation that should be considered in future studies. Much research has been done in the area of chronic pain and families (see Payne and Norfleet, 1986; Turk et al, 1987 for a review). Although differences in research design and assessment render comparisons among studies difficult, some general trends have emerged. Spouses have been shown to play a significant role in the acquisition and maintenance of pain behaviour. Patients who have supportive spouses (spouses who are sympathetic and accept the patient's disability status) have more pain and exhibit greater pain behaviours than patients whose spouses were not supportive (Block et al, 1980; Anderson and Rehm, 1984; Flor et al, 1987a). Flor et al (1987b) found that patients with supportive spouses reported greater marital satisfaction

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despite the fact that they were more disabled than their counterparts. These findings suggest that emotional support may not always be in the best interest of the chronic pain patient. According to systems theory, an acute problem may be maintained because it provides a dysfunctional unit with a way to stabilize the family system (Payne and Norfleet, 1986). The chronic pain sufferer is the identified patient but in actuality the entire family is ill. For this reason, the involvement of the family may be a crucial component in the treatment of the patient. The role of the family in the onset of low back pain and its progression to chronicity is as yet unstudied. The manner in which family interactions exacerbate existing problems or increase susceptibility remains to be seen (Turk et al, 1987). An institution as powerful as the family affects the way we perceive and respond to illness. This is fertile ground for future prospective studies. It has been proposed that the doctor-patient relationship plays an essential role in the patient's recovery (Cherkin et al, 1991a,b). No study has been done to measure the effect of the medical establishment on the course of chronic low back pain. In his treatise on low back pain, Waddell (1987b; see also Chapter 1) gives particular attention to the role of medical paradigms and clinical practice in stimulating or preventing recovery. Likely iatrogenic factors leading to disability include the overemphasis on pain to guide treatment, inadequate diagnosis, and the over-prescription of rest. Waddell cautions health care professionals to distinguish between psychological distress and physical disease and to aim for functional restoration and pain relief simultaneously. The health care professional's attitude toward the patient's illness and recovery is implicitly or explicitly conveyed to the patient and is bound to affect treatment (Shapiro, 1971). S u m m a r y o f psychosocial factors

Studies that assess psychosocial traits in acute populations are few. The chronic low back pain literature has suggested which variables may be of importance in predicting chronicity. Several factors have emerged. The results of the predictive studies are summarized in Table 1. Personality must play a role in how an individual responds to back pain. Table 1. Significantpsychosocialpredictors of low back pain: summary of current research. Study

Population

Barnes et al (1988)

Recurrent

-

Bigos et al (1991)

Healthy

+ + + + + + -

Predictionvariables

Outcome

Painlevel Depression Premorbid pessimism Cooperation scale Hypochondriasisscale Levelsof compensation Hysteria Psychopathy Schizophrenia LBPscales Work perceptions

Return to work

Report of back injury

PSYCHOSOCIAL ISSUES IN PREVENTION OF LOW BACK PAIN Study

Population

Prediction variables

Outcome

Cats-Baril and Frymoyer (1991) Crauford et al (1990)

Acute

+

Work status

+

Job characteristics (including compensation) Life events

Acute

Deyo and Diehl (1988)

Acute

+

'Always feel sick'

-

'Always feel sick'

+

Work satisfaction

Hurri (1989)

Recurrent

Gallagher et al (1989)

Recurrent

Lacroix et al (1990)

Acute

+

Leino (1989)

Healthy

+

-

+

+ Leino and Lyyra (1990)

Healthy

Polatin et al (1989)

Chronic

Rosenstiel and Keefe (1983)

Chronic

+ -

+ + -

+

Sandstrom and Esbjornsson (1986) Spinhoven and Linssen (1991) Turner et al (1987) Waddell et al (1984)

Recurrent

+

Chronic Chronic

+ +

Chronic

+ +

Hysteria scale Internal Health Locus of Control Hysteria Hypochondriasis scale Patient's understanding of his back condition Stress symptoms Musculoskeletal complaints Work stress Social support Pain intensity Depression Premorbid pessimism Job characteristics Cognitive coping and suppression Helplessness Diverting attention or praying Beliefs about return to work

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Onset of pain in patients 'with a certain cause of pain'. Related to seeking treatment in patients with 'specific diagnosis' Pain level Compensation seeking Number of visits to a physician Physical + psychological improvement Return to work Spontaneous recovery Return to work Return to work

Musculoskeletal complaints Stress symptoms Musculoskeletal complaints in blue-collar workers Response to treatment

Functional impairment Adjustment to pain Report of pain

Return to work

Perceived control as a coping strategy

Pain level

Pain levels Primary stress or coping responses Psychological distress Inappropriate symptoms and signs

Pain level Functional capacity Disability

+, significant positive relationship; - , significant negative relationship.

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Premorbid personality should be measured before or as soon after injury as possible. Measures designed to assess enduring traits should be used. Positive as well as negative traits may have strong implications for prognosis. The work done on reactive distress such as somatic perception and depression is quite promising. While a link may exist between the emotional response to pain and the development of chronic pain syndrome, the mechanism by which this occurs is unknown. Psychological distress may obviate effective coping strategies or provoke sympathetic reactions in others which reinforce pain behaviours. These mechanisms need further clarification. Cognitive factors such as coping and illness beliefs have been proven important to the recovery of chronic pain patients. No doubt they contribute to the development of the problem as well. This is an area quite amenable to modification and deserves further attention. The research on work satisfaction is promising. Studies suggest that workers who enjoy their work or have low work stress report less back pain than others. It should be noted that work stress or satisfaction is one of the most frequently studied variables. The impact of other social variables on the course of low back pain has yet to be determined but may prove to be of equal importance. The impact of psychosocial factors on the development and maintenance of chronic low back pain can only be determined in multicausal models. It is likely that many of these variables share predictive variance since they are measured subjectively. Interrelationships between these variables deserve further investigation, and whenever possible, objective outcome criteria should be used. THE APPLICATION OF PSYCHOSOCIAL TECHNIQUES TO THE PREVENTION OF CHRONIC BACK PAIN Psychosocial treatment modalities

Various psychosocial treatments have been used for patients with chronic low back pain. They are often administered in multidisciplinary settings along with traditional medical treatment, physical therapy, occupational therapy and sometimes ergonomic instruction. It is a common practice to use several psychological techniques in one programme. Behavioural strategies are oftenused in conjunction with pain or stress management techniques. Research into the effectiveness of these strategies with acute low back pain patients is just beginning. Before presenting these studies, a brief description of each technique is given.

Relaxa~on Walter Canon's celebrated treatise on the 'fight or flight' response in the early part of this century explained how a perceived threat, be it physical or psychological, results in many automatic physiological changes (Canon, 1914). These changes over prolonged periods may lead to various illnesses. Muscle tension is one such change that has been implicated in the develop-

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merit of chronic back pain problems. Ischaemia, caused by the lack of blood flow that occurs from tension has also been associated with pain problems. Since the early half of this century, researchers have studied our ability to control 'involuntary' bodily functions (Jacobson, 1938; Wolpe, 1958) such as our autonomic nervous system. Achieving what Herbert Benson calls 'the relaxation response' reduces the harmful effects of stress and has been used as a treatment for a variety of stress-related illnesses, including low back pain (Benson, 1976). Various techniques are used to achieve the relaxation reponse such as meditation, yoga, self-hypnosis, progressive muscle relaxation, autogenic training, or simple deep breathing exercises. All these techniques emphasize diaphragmatic breathing associated with natural resting states. This type of breathing is incompatible with the psychological perception of threat. When the brain receives this feedback from the body, fear is diminished (Borysenko, 1988). Relaxation techniques may also be effective because they provide a sense of control that is lacking in many pain patients. They also put the patient in a relaxed frame of mind that is more conducive to problem solving than anxiety. Moreover, they make the patient more receptive to other psychosocial approaches because they demonstrate the stress-pain relationship. For these reasons, relaxation training has become an integral part of many psychologically oriented chronic pain programmes. Biofeedback allows for the monitoring of EMG responses in the muscles through visual and auditory output. In chronic pain therapy it is used in conjunction with relaxation techniques to allow the patient and therapist to monitor progress (DeGood, 1991). Feedback of reduced muscle tension can serve as a reinforcement to the patient and encourage the practice of relaxation techniques.

Cognitive techniques Cognitive approaches to the management of chronic low back pain are based on the assumption that maladaptive or erroneous beliefs contribute to the patient's distress (see Turner and Romano, 1990a). Patients who are in pain often think that the pain will last forever and that they are helpless to change it (Williams and Thorn, 1989). These thoughts result in depression and anxiety that can heighten the experience of pain and diminish the patient's motivation to recover. Waddell (1987b) has pointed out that cognitions and emotions determine 'suffering' that is distinct from actual physical pain. Cognitive restructuring.is a technique used to modify negative thoughts. The patient is taught to identify maladaptive beliefs, to accept that beliefs are amenable to change, to develop alternative adaptive beliefs, and actively to replace their old beliefs with new ones. Positive affirmations are a form of cognitive restructuring where individuals identify negative self-statements (beliefs about themselves) and create positive ones in their place. Patients may also practise taking new and more positive perspectives on their problem (i.e. finding the good in a bad situation). The aim of thesestrategies is to make adaptive thinking habitual over time (Borysenko, 1988).

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Creative imagery is another cognitive technique often used in conjunction with relaxation. The patient, once relaxed, is asked to imagine a peaceful place or a healing force entering the body. These images can serve to further relax the patient or can help them to develop coping strategies using distraction when the pain is severe. Imagery may also be used to help the patient visualize themselves as healthy and active (Borysenko, 1988). In this case, imagery augments the effects of cognitive restructuring. Because all psychosocial techniques used in the management of chronic pain are to some extent cognitive (they rely on the active will and understanding of the patient), these techniques carry over to many other approaches.

Contingency management Wilbert Fordyce is credited with pioneering the behavioural approach of operant conditioning to treat low back pain (Fordyce et al, 1973; Fordyce et al, 1986; Fordyce, 1988). Pain behaviours such as grimaces, bracing, downtime and moaning are the target of intervention. Because these behaviours are subject to the same contingency management as any other behaviours, they will increase when followed by a reward and decrease when followed by punishment or the withdrawal of a reward. Fordyce advances the concept of incompatible responses to shape the behaviour of the patient. Rewarding behaviour incompatible with pain behaviours is more successful than merely punishing a pain behaviour because it emphasizes an alternative way to approach pain. In this paradigm, cognitions are important insofar as they determine the anticipation of rewards or punishments. These expectations can be changed through educating the patient about the differences between hurt (pain) and harm (damage), and through enforcing contingency management of pain behaviours. Many of the modern functional restoration clinics operate on this theory (Mayer et al, 1985; Hazard et al, 1989). The goals of treatment are preset regardless of the pain experienced by the patient. This helps to break the association between pain and harm in the patient's mind and rewards the patient for functioning regardless of pain level. Fordyce and other champions of this approach make an effort to train the spouse as part of the intervention since they are a significant source of reinforcement for the patient. In addition, efforts may be made to train medical personnel in the management of low back pain in order to avoid the unwitting reinforcement of pain behaviours and cognitions.

Modifying environmental stressors Since the role of stress in the development of pain becomes more apparent with time, one approach to the prevention of back pain is the reduction or elimination of stressors. This may include training the patient to be more assertive, to set goals or to manage time more effectively. Individuals who are important to the patient may be included in treatment and be helped to understand their role in the problem. The 'high-risk' workplace may be particularly amenable to modification. Programmes aimed at reducing back injury and chronicity at work have

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sought to make ergonomic changes (for a review see Nordin et al, 1991). It is only a matter of time before the impact of psychosocial work stress on back problems is realized by management and worker alike. Worker dissatisfaction may originate from a variety of factors such as poor management or lack of feedback. At least one documented effort has been made to reduce injury through organizational change (Steffy et al, 1986). Modification of organizational stressors is inevitable in our effort to reduce back pain.

Psychotherapy The use of psychotherapy in the treatment of back pain may arise from different but not mutually exclusive perspectives, on chronic low back pain. One is that pain poses certain pressures and requires readjustment on the part of the patient that may be modified by therapy. The other is that psychosocial problems contribute to the development of the pain problem and must be addressed before the pain will subside. The latter approach concerns us because it is relevant to the acute pain sufferer with the potential to become chronic. Psychodynamic theories of pain exist (Sarno, 1976; Dejours, 1989). According to this school, physical pain is the manifestation of an underlying psychological conflict which the patient's defence mechanisms will not allow him/her to recognize. In this case, physical pain is more acceptable to the patient than the underlying psychic pain. Somatization is the result of profound psychological trauma with which the patient is unable to cope (Marty, 1968, 1984, 1990; Kreisler, 1976). If the social and or medical structure accommodates this expression of pain, the illness persists and 'secondary gains' are obtained. This theory is largely the basis for the interpretation of measures of psychopathology, such as the MMPI. It has been hypothesized that individuals who develop chronic pain are unable to acknowledge depression and focus on physical symptomatology instead. The aim of psychotherapy is to allow the patient to experience the psychic pain in a safe context. Long-term psychotherapy may allow the patient to come to terms with unconscious inner conflicts and to express themselves without the pain (Marty, 1990). Review of current research

Programmes aimed at preventing chronic back pain may take three forms: primary, secondary and tertiary. Primary prevention refers to efforts to reduce the incidence of initial back pain episodes. Secondary prevention programmes seek to reduce the severity and recurrence of acute or subacute back problems (less than 6 months). Tertiary prevention involves the abatement of further deterioration in chronic back pain sufferers. This category refers to patients who have suffered intractable pain for more than 6 months. Psychosocial techniques may be incorporated at each level.

Primary prevention Programmes developed for the primary prevention of back pain in the

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general population are rare. Although a number of physical and psychological risk factors have been identified, we are unable to predict accurately who will actually develop back pain. Therefore, a general prevention programme may be difficult to justify to a funding agency and to the population at large. At certain workplaces, however, the cost of back injuries has escalated to a degree that warrants primary prevention efforts. Studies that support the use of primary prevention programmes have not included psychological variables as yet (Matmiller, 1980; Nordin et al, 1981). Several studies report the success of general stress management programmes in reducing a variety of somatic complaints including muscle tension. Murphy (1984) compared biofeedback and progressive muscle relaxation in highway maintenance workers. At 3 months, trained subjects showed lower E M G levels than the control group, although the differences were slight. Both groups improved in somatic complaints, anxiety, sleep behaviour, work satisfaction and alcohol use. Stress at work has been prospectively linked to accidents and back pain (Bureau of National Affairs, 1984; Smith et al, 1990; Bigos et al, 1991). Steffy et al (1986) describe three case studies in which corporate stress management programmes substantially reduced the number of accidents and related costs at three high-risk work sites, two hospitals and a trucking company. At each site, work stress and symptoms were assessed. The results were used to guide management in modifying work conditions. High-risk groups were identified and treatment in the form of Employee Assistance Programs and health education (including stress management) was provided. The effectiveness of the interventions was assessed using a quasiexperimental design. The authors report a monthly reduction of overall costs at the two hospitals combined of $21 622 one year after the intervention. At the trucking company costs went from $26 592 to $4510 in 9 months. The success of the programme was attributed to the reduction in psychophysiological arousal levels that caused accident-prone states such as anxiety and fatigue, and to the organizational changes that modified the existing stressors. This theory, however, is untested. The programme detailed by Steffy et al (1986) contains several important components that define successful stress management interventions (Pelletier and Lutz, 1989). First, a comprehensive approach to stress reduction, including organizational change as well as employee education was used. Programmes attempting to provide stress management skills to workers without the support of management are unlikely to succeed. The diversity of the stress management approaches that were offered increased the likelihood that all participants will benefit from the programme. High-risk sites and groups were identified for intervention. This approach maximizes costeffectiveness by providing assistance only to those who need it. Finally, these programmes were designed to be ongoing. Short-term stress management programmes have proved less successful. Steffy's findings argue for the inclusion of psychological and behavioural techniques in any low back pain prevention programme in an occupational setting. Obviously, additional prospective studies of this nature are needed.

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Secondary prevention Secondary prevention programmes for low back pain have flourished in response to the prevalence of disability and suffering in society. Back school is one of the most popular approaches to this problem. Back schools have been described in detail elsewhere (see Nordin et al, Chapter 8). They represent a recognition of the importance of psychobehavioural principles in the management of acute back pain. Back schools attempt to motivate the patient to care for the back through exercise, proper posture and body mechanics and a healthy lifestyle. The patient's active participation is critical to the success of the back school. A group format is used that allows for mutual support among back pain sufferers. This may also have a therapeutic effect. Moreover, many back schools teach the students about psychophysiological arousal and muscle tension. Relaxation techniques are often taught. The effectiveness of such back schools has been a topic of great controversy recently (Bergquist-Ullman and Larsson, 1977; Linton and Kamwendo, 1987). We will not address the merits and flaws of back school in this chapter. The importance of back school, from a psychological perspective, is the introduction of the patient to psychobehavioural approaches to back care. We have seen that many back school patients become interested in the stress-pain relationship and stress reduction techniques following this type of programme. Fordyce's behavioural approach to pain has been applied to acute patients. In 1986, Fordyce and his colleagues conducted a study that compared behavioural management of low back pain to traditional management at 6 weeks, and 9 to 12 months after treatment (Fordyce et al, 1986). Subjects with back pain for less than 10 days were randomly assigned to the treatment or control group. Subjects in the treatment group received timecontingent care: analgesics were given at fixed intervals, activity and exercise levels were preset, treatment had a specified time limit, and return visits were set at 2 weeks. By contrast, the control group received typical care: they were permitted to take medication as needed, engage in activities and exercise until pain was experienced, continued treatment until pain subsided, and returned to the clinic as needed. A 'sick/well' score and two activity dimensions were computed as outcome variables. At 6 weeks there were no differences between the two groups. However, at follow-up, the treatment group was significantly less 'sick' than the control group and had returned to pre-pain levels of impairment. The authors conclude that 'the physician who would rely on patient definitions of pain or illness is at peril to promote chronicity' (Fordyce et al, 1986). Clearly this message has been taken to heart by clinicians who have developed functional restoration approaches to back problems (Mayer et al, 1985; Hazard et al, 1989). These programmes are distinguished by their aggressive approach to rehabilitation and their emphasis on returning the patient to work by incorporating work-related tasks in the treatment regimen. A behavioural approach is emphasized in that activity level is

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determined by the instructor and the completion of tasks is rewarded. These programmes have begun to address the needs of the acute patient as well. Ramos et al (1981) report the results of an early intervention programme for railroad workers. A random matched sample design revealed that patients who were treated early returned to work sooner than the control group. The authors report a 70% reduction in time lost due to early intervention. Other psychosocial approaches to the management of acute low back pain have surfaced in the workplace itself. Back schools have been given on-site in a number of occupational settings (MeKechnie, 1985). More recently, Linton et al (1989) investigated the effects of a behaviourally based treatment programme to prevent chronicity in nurses and nursing aides at risk for long-term disability. Subjects were randomly assigned to the treatment or control (waiting list) group. The intervention consisted of physical therapy and behavioural techniques that included relaxation and pain control coping strategies. Subjects were given reinforcement in the form of periodic group meetings with a psychologist during the 6 months after treatment. Before treatment and at 6 months after treatment a comprehensive group of variables were assessed. Significant differences in favour of the treatment group were found in regard to pain intensity, fatigue, anxiety, sleep quality, depression, helplessness, marital satisfaction, satisfaction with daily activities, recorded pain behaviours, and sick listing. Differences in medication intake and overall absenteeism were not significant. Nonetheless, these findings illustrate the pervasive impact of pain on the patient's life and the salutary effects of psychobehavioural interventions. Kamwendo and Linton (1986) and Linton and Kamwendo (1987) discuss the effectiveness of relaxation breaks during the day as a secondary prevention method for neck and shoulder pain in workers. Subjects were instructed to take 60 s pauses consisting of stretching and rapid relaxation every half hour. This was found to decrease the development of pain over the course of the day. Although adherence was a problem, the utility of this approach is demonstrated. The benefits of this technique may apply to acute back pain sufferers. Cherkin et al (1991a) have noted that physicians hold negative views of low back pain patients and are often frustrated by their overdependence on medical care. These feelings may adversely affect the quality of care the patient receives. They implemented a back pain evaluation education programme for physicians. The programme was successful in improving the confidence of physicians but it did not change negative attitudes. In a follow-up study on acute and chronic patients, Cherkin et al (1991b) found no effect of the physician education intervention on the patient's subsequent physical and psychological status. They attribute this to the deleterious effects of unfavourable attitudes towards the patient. This they contend is more important than the physician's confidence in his or her ability in treating the patient. A discussion of psychosocial prevention techniques would be incomplete without mention of organizational modifications in the workplace. The

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importance of involving management in a workplace stress management programme has been emphasized (Steffy et al, 1986; Pelletier and Lutz, 1989). Snook and White (1984) have argued for the training of management in the early care and detection of back disorders. The same philosophy should apply to organizational stressors that put a worker at risk of developing back problems. Management and worksite medical departments alike should be educated in identifying and ameliorating organizational stress. This approach is the only long-term answer to an ongoing problem.

Tertiary prevention The application of psychosocial techniques for the treatment of low back pain originated with the chronic pain population. It is not surprising then that a robust literature exists attesting to the success of these strategies. Interventions that provide temporary relief of symptoms may not be considered preventive. Therefore, to remain consistent with the present topic, this section will include only those studies which report follow-up data of at least 6 months. In such cases, interventions may be said to prevent future deterioration or recurrence. Kabat-Zinn et al (1985) report the benefits of 'mindfulness meditation' for 90 patients with a variety of chronic pain problems. Mindfulness meditation requires the patient, once trained in the art of meditation, to focus on the perception of pain and its changes as a detached observer. Through this process, the patient gains new insights into the pain and learns to perceive it in a more adaptive way. Subjects were trained for 2 hours once a week for 10 weeks and were instructed to practise daily. Follow-up data on pain and psychosocial status were collected at various points up to 15 months after treatment. A non-random comparison group of 21 patients receiving standard medical care was used. Results were similar for back pain patients and other pain groups. Mediators showed significant improvements in pain, body image, activity level, medical symptoms, mood and affect, and psychological symptomatology after treatment. The study group also differed significantly from the control group in the expected direction. These effects were maintained at follow-up with the exception of pain level. Furthermore, almost two-thirds of the respondants were still practising meditation. The authors theorize that, taken together, these findings may reflect the patient's ability to cope better with an invariable intensity of pain. This type of pattern was noted in. particular with back pain patients as opposed to patients with other pain syndromes. Although a randomized control group was not used, these results encourage the use of mindfulness meditation as a tertiary prevention technique for individuals with chronic back pain. Studies have shown relaxation and cognitive-behavioural treatments to be an effective means of pain control. Turner (1982) compared progressive relaxation training with cognitive-behavioural therapy for 36 chronic low back pain sufferers. A waiting-list control group was used. Progressive relaxation consisted of training individuals to tense and relax different

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muscle groups in order to relieve muscle tension and anxiety. The cognitivebehavioural group received instructions in the use of imagery, behavioural goal-setting, and cognitive strategies. A group format was used for both conditions. Patients were followed for 1/2 to 2 years after treatment. Both treatment groups improved significantly in impact of illness, depression and pain severity. In contrast, the control group showed no change and worsened in pain reports. At follow-up, both treatment groups maintained decreases in pain ratings and health care use. The cognitivebehavioural group also increased the number of hours worked per week. Cognitive-behavioural patients reported a higher pain tolerance and greater progress towards their goals than the relaxation group. Both groups were significantly more improved than the control group. Turner and Clancy (1988) subsequently compared operant behavioural and cognitive behavioural treatment for chronic low back pain. Seventyfour patients were randomly assigned to and completed one of the two treatment groups. The operant behavioural condition was based upon Fordyce's principle of reinforcing 'well behaviours' instead of 'pain behaviours'. Spouses participated. Behavioural goals for exercise and activities were preset. Patients in the cognitive-behavioural group used progressive muscle relaxation in conjunction with imagery. They were also taught cognitive restructuring. After treatment, the operant behavioural group showed marked improvements on sickness impact, pain behaviour and cognitive errors, superior to the cognitive-behavioural and waiting-list control groups. The last groups did not differ. However, at a 12-month follow-up, the gains obtained by the operant behavioural group were sustained and were equalled by the cognitive behavioural group. These findings indicated that the two treatments may differ in the nature of their impact. The patients in the cognitive-behavioural group, however, were more satisfied with their treatment than the operant group. This may be because the cognitive approach provides more emotional involvement than the operant approach. A recent study investigated the effects of behaviour therapy for chronic low back pain (Turner et al, 1990). Ninety-six subjects were randomly assigned to one of four conditions: behavioural treatment, exercise, behavioural treatment combined with exercise, and waiting-list control. Outcome variables included pain rating, related physical and psychosocial dysfunction, pain behaviours, depression, physical fitness and patient satisfaction with treatment. Follow-up was conducted at 6 and 12 months after treatment. Following treatment the behavioural/exercise combination treatment group showed more significantly improved psychosocial outcomes than the exercise and the control group, but not the behavioural treatment only group. The authors speculate that behavioural treatment and exercise ther~tpy may make different contributions to rehabilitation. All groups improved their fitness level over time. At both follow-ups, all treatment groups improved significantly from pretreatment. However, there were no significant differences between treatment groups, although trends in favour of the combined group were

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observed on many outcome variables. One explanation offered by the authors for these results is the lack of sufficient statistical power resulting from a small sample size. An adequate sample size would allow the detection of small but significant differences. Patients in the combined group were, on average, more satisfied. These patients were, on the whole, mildly disabled. This may have obscured more dramatic differences that could have been detected between treatments in a more disabled group. Multidisciplinary clinics have been established throughout the world in response to the chronic pain problem. These clinics coordinate the medical, physical, psychological and social care of the patient to address the problem comprehensively. Many require inpatient treatment, especially if detoxification from prescription analgesics is included in the treatment. Patients are treated in groups and maintain a strict treatment schedule. This type of care may undermine the independence that these programmes aim to engender in the patients (Mayer et al, 1985). Pain clinics are often a last resort for long-term sufferers who have exhausted other forms of treatment for pain. Few long-term follow-up studies exist on the effectiveness of these clinics. Those that do, report varying success rates (for a review see Loeser, 1991). This may be due to variations in patient selection criteria, attrition rates, different treatment modalities and disparate outcome criteria. Additional problems are small sample sizes and lack of controlled studies (Loeser, 1991). However, it should be noted that this group of patients has historically been unresponsive to any treatment. Even slight improvements may be considered significant. Loeser (1991) points out that until a superior approach is developed, pain clinics remain the preferred mode of treatment for the patient who is unresponsive to other therapies. Functional restoration programmes represent a more aggressive approach to chronic low back pain than multidisciplinary pain clinics. Guided by the tenet that chronic pain syndrome is largely the result of disuse, physical conditioning supplemented by cognitive-behavioural treatment is emphasized. Goals are set for the patient despite pain. Objective physical measurements are used to guide therapy and provide reinforcement to the patients on an ongoing basis. Because a major objective of these programmes is returning the patient to gainful employment, work tasks are often simulated. Hence these programmes may be referred to as 'work hardening' clinics. In the United States, Mayer et al (1985) evaluated the effects of such a programme on 66 participants in comparison with 38 comparison subjects. At follow-up, the treatment group was significantly improved with regard to work and medical variables compared with the comparison group. Of the treatment group, 87% had returned to work. According to the authors, these effects were mediated by functional recovery. Hazard et al (1989) replicated this programme with 90 patients and found comparable results. It is interesting to note that similar approaches to low back pain and disability have proved less successful in returning patients to work in other cultures. In Norway, Oland and Tveiten (1990) recreated a similar programme but omitted the psychosocial component and obtained

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poor results. Estlander and her associates (1991) sought to replicate Mayer's protocol but did not emphasize return to work. Again, the findings were disappointing. These results suggest the importance of accurate replications and may also caution against cross-cultural comparisons.

Summary of prevention strategies It is difficult to assess the relative merits and drawbacks of psychosocial interventions for the prevention of low back pain and chronicity for several reasons. First, few studies exist that evaluate psychosocial treatments in the acute population. The recent willingness of the medical community to recognize the importance of psychosocial aspects of chronic low back pain and the success of psychosocial interventions in treating chronic patients makes it likely that more work will be done in this area in the future. In addition, it is impossible to disentangle the 'psychosocial' aspect of treatment from multidisciplinary approaches. A good example of this would be back schools that teach relaxation strategies. The use of many techniques at once, while beneficial to the patient, may camouflage the effect of any one treatment. Randomized, prospective clinical trials are always difficult for practical reasons. Nonetheless, more studies of this nature are required before conclusions regarding individual treatments can be drawn. Finally, it is important to observe that a uniform practice of most psychosocial techniques does not exist (Turner and Clancy, 1988). Relaxation and cognitive coping strategies are taught in a variety of ways by instructors with different levels of training. This makes comparisons between studies difficult. This is less problematic with behavioural interventions for which more stringent guidelines are available. Turner and Clancy (1988) were able to conduct a component analysis of this approach in order to determine why it was successful. More studies of this kind with other psychosocial strategies would be useful. These problems aside, it does appear that psychosocial and behaviour techniques hold substantial promise for the prevention of back injuries and chronicity. Programmes that incorporate these techniques in their protocol tend to have superior results to programmes that ignore them. The value of stress management techniques such as relaxation and cognitive coping are easily understood and may be taught with little expense. There exists a good rationale for including multiple techniques in any prevention programme. Once back pain has become chronic, psychosocial and behavioural interventions are necessary for successful rehabilitation. Functional restoration programmes offer a viable alternative to traditional approaches. Although more prospective research with control groups is needed, the functional restoration approach appears to be the preferred treatment for the prevention of further deterioration in chronic pain patients. Given the exorbitant costs associated with chronic pain, these programmes ($3000 to $7500) (Hazard et al, 1989) seem good value.

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ISSUES IN ASSESSMENT AND TREATMENT OF THE ACUTE PATIENT Research considerations

Perhaps the most important issues to be resolved in the literature reviewed here are methodological. Conceptual clarity is needed to differentiate between personality traits and reactive states. Researchers should also strive for some uniformity in measures of predictors and outcomes. While multifactorial studies are important, they too often lack a theoretical framework. Scientific rigour can only be the result of theoretically driven research. It is important to recognize that chronic illness is a dynamic process resulting from an interplay between physical and psychosocial characteristics. Psychological and social status may change over the course of the illness. In the acute phase of illness, anxiety and depression may predominate. Later these feelings may give way to helplessness and hopelessness, and culminate in the adoption of the sick role. The process by which this unfolds needs to be studied at progressive points in time. Research conducted on self-identified patients poses restrictions on the interpretation of results. Self-selection ensures an over-representation of subjects who cope poorly with illness. It would be instructive to study individuals who suffer chronic back pain and remain vital, if they exist. Lessons learned from their experiences could help others. These problems aside, the importance of psychological and social factors in the onset and progression of low back pain cannot be ignored. Deyo and Diehl (1988) have remarked that 'psychosocial, demographic and functional t r a i t s . . , may be more predictive than data from the examination' and 'may be more important determinants of outcome than the therapy prescribed'. The application of psychological and social paradigms to acute populations is sure to yield important results and deserves further effort. Clinical considerations: when to assess and treat

The psychological assessment and treatment of all individuals who develop back pain would not only be far too time-consuming but is completely unnecessary. Fortunately most people recover from back pain without any intervention whatsoever. However, if the patient exceeds the expected recovery period (approximately 7 weeks according to Spitzer et al, 1987), shows few signs of improvement, and medical treatment has been ruled out, a psychosocial assessment may be useful. This may also be true for the patient who suffers from severe recurrent back pain for which there is no known physical cause. Early identification and modification of maladaptive psychosocial characteristics may be challenging but research suggests that it is critical to patient care. At the very least, assessment may consist of the clinical impressions drawn from informal questions. Such an examination should include an explanation of the psychosocial and behavioural aspects of low back pain. At the very most, this may include a referral to a psychologist. Most patients do not encounter anyone with psychological expertise until they are well into the

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chronic phase of illness. This must change if chronicity is to be prevented. Figure 1 suggests optimal points at which to assess psychosocial characteristics. Many psychosocial and behavioural assessment tools are available for chronic low back pain patients (for a review see Turner and Romano, 1990b). These may be useful for the acute patient, although their validity has yet to be determined. Care should be taken to review instruments before administration to establish the appropriateness of the items for an acute population. Interpretation should also be undertaken with caution since items may have different meanings for acute and chronic populations. While the specific battery of psychosocial tests chosen may depend on the patient's specific situation, some standard measures may be helpful. There is enough evidence from the chronic pain literature that assessing variables such as depression, anxiety, somatization, pain beliefs, pain behaviours, work satisfaction, and social support may provide clues as to the barriers to a patient's recovery. We re-emphasize that until these instruments are validated for an acute population, they should not be used diagnostically, but merely as a guide to treatment. Clearly, any psychosocial intervention should be the choice of the patient. After living with a painful condition for an extended period, many patients begin to feel helpless. Allowing patients to choose and accept responsibility for treatment is the first step in helping them manage their condition. It is also important that the patient accept the link between psychological factors and pain for treatment to be successful. This may be most easily achieved through the concept of stress management. Stress is something that everyone understands; many patients intuitively link stress to their pain. Stress management can include relaxation, coping strategies, cognitivebehavioural treatments, group discussions, and psychotherapy. Presenting treatment in this way can enhance motivation and compliance. In the case of primary prevention, psychosocial paradigms may be added to any programme of ergonomic or biomechanical origin. This may be especially helpful in the workplace, where stress reduction strategies can enhance many aspects of work life. Moreover, stress at work has been linked to accidents, many of which result in back pain. Helping individuals to avoid chronic back pain is only one half of a successful intervention effort. The rest of the responsibility lies with us, as a society that produces and encourages chronic pain behaviour. Organizations must learn how to prevent and manage low back pain from a psychomedical paradigm. Health care professionals must be enlightened as to the multicausal nature of low back pain. Friends and families of back pain sufferers must be educated in adaptive ways to support their loved ones. Finally, society must make working more attractive than accepting worker's compensation. This will benefit us all in the end. SUMMARY

This chapter has reviewed research on psychological and social factors associated with the onset and progression of low back pain. From this review

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it can be concluded that psychosocial traits appear to be important contributors to the course of pain and disability though methodologically welldesigned longitudinal studies are rare. For this reason it is difficult to assess the relative importance of, for example, psychological distress compared with work stress. Furthermore, the mechanisms by which specific variables effect back pain remain unknown. The answer, no doubt, lies in longitudinal studies which employ multicausal models. It has been noted the psychosocial treatments which have proven effective for chronic pain populations are rarely assessed with acute pain patients. Some problems are the inaccessibility of acute back pain sufferers to psychologists, the difficulty of isolating the effect of one component of a multidisciplinary programme and the lack of uniform practice of psychosocial techniques. None the less, programmes which include psychosocial interventions appear to have superior results to those which do not. Since these techniques are often simple and inexpensive to include they should be incorporated into all treatment programmes where the potential for chronic pain syndrome exists. Gaps and flaws in current research methodologies have been identified and suggestions for future investigations have been proposed. In addition we have attempted to provide some practical guidelines for health care professionals to help them identify salient psychosocial issues which may effect the course of their patient's treatment. Recommendations for assessment and referral are also provided.

Acknowledgement This chapter was made possible through a grant from CDC/NIOSH No. U60/CCU206153-01 and grant 4026-27065 of the Swiss National Science Foundation.

APPENDIX: PSYCHOSOCIAL ASSESSMENT OF THE ACUTE BACK PAIN PATIENT Since no valid tests have been constructed to predict chronicity in patients with acute low back pain, we are unable to recommend standardized questionnaires. Drawing from current research and work derived from chronic low back pain patients we can suggest some indications for psychosocial intervention. At the first visit

During the routine examination the clinician may look for unusual signs of psychological distress. What is considered unusual may vary from one patient to another. The impact of back pain on the patient's life and how well the patient is coping with it must be determined by clinical ~mpresslon. This impression should be based on expressed attitudes or behaviours which would lead the clinician to believe that the patient's recovery may be affected by his or her attitudes or beliefs. Such clinical impressions should be noted in the patient's file. These observations may contribute to the understanding of the patient's back pain history and may help to guide treatment. From the onset, the patient should be encouraged to take part in his or her own recovery.

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At 7 weeks after onset

Once the expected period of recovery is reached, the clinician should open up a dialogue with the patient about psychosocial issues that may be delaying recovery (see this chapter for more information). The clinician should ascertain whether or not the patient acknowledges any relationship between stress and pain. This must be done cautiously. Some patients refuse to consider that their pain is anything but somatic. Suggesting that stress may play a role in their pain may indicate to them that the clinician does not believe they are really suffering or that their problem is serious. The stress-pain relationship should be explained with this in mind. The clinician should be aware of life events which precipitated or followed the onset of back pain and the social context in which the patient lives. This includes family, friends and work. The patient's beliefs about the cause of pain, its controllability, and future prognosis may be cause for concern. The best way to make sure that the patient understands medical information is to have him or her repeat it verbally. The clinician should try to modify false or irrational beliefs about back pain while maintaining respect for the patient's point of view. Beliefs and attitudes towards pain may lead to psychological distress. Anxiety, depression, helplessness and hopelessness are common emotions experienced by long-term back pain sufferers. The patient should be reassured that his or her reactions are not unusual. Stress management techniques may be suggested at this point. This dialogue may make the patient more receptive to psychosocial explanations for pain. If the clinician is not comfortable initiating such a conversation, another health care professional should be called in. If the patient is agreeable, he or she may be referred for a psychological assessment or to a multidisciplinary team for evaluation. Over 7 weeks after onset

The clinician should explain the limitations of prolonged medical treatment and emphasize the psychosoeial aspect of pain. Evaluation of the patient should include formal psychological testing. Treatment should be multidisciplinary with emphasis on behavioural intervention and stress management.

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