appropriate management of risk factors that may predispose the client to further injury staff training about risks, referral and appropriate exercise programming for specific populations collaboration with medical or allied health professional, stakeholders and clients to develop, implement and monitor injury prevention and management strategies. The patient may fall into a cognitive trap where the interpretation is tantalizing and well connected with the emotional state, but where a consistent “error” in interpreting reality is made.7 This pattern of interpretation is like a lens that distorts one's view of the world and appears to function as a part of our response to stress.20 An example of such a thought process is pain catastrophizing, which can be defined as an exaggerated, negative orientation toward pain where a relatively neutral event is irrationally made into a catastrophe.21 In essence, the person imagines the worst possible result that could happen, but accepts it as the given result. An incidence of 0.11% was found in a study that did not exclude these patients. We acknowledge that there is currently a lack of clear information as to how psychological factors should be utilized by physical therapists and other clinicians. . Catastrophic thoughts usually are stated as assumptions (eg, “If the pain does not get better, I will end up in a wheelchair” or “The pain will never stop, it will only get worse and worse”). Ten Guiding Principles Relating Psychological Factors to the Management of Paina. Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors? Monitor vital signs: changes in blood pressure, compare BP readings in both arms. 2. Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain, Behavioral dimensions of adjustment in persons with chronic pain: pain-related anxiety and acceptance, Worry and chronic pain: a misdirected problem solving model, Worrying about chronic pain: an examination of worry and problem solving in adults who identify as chronic pain sufferers, Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain, Impact of the interaction between self-efficacy, symptoms and catastrophising on disability, quality of life and health with chronic pain patients, Self-efficacy in management of osteoarthritis, Long-term outcomes of an arthritis self-management study: effects of reinforcement efforts, Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain, Self-management education programmes by lay leaders for people with chronic conditions, Determinants of occupational disability following a low back injury: a critical review of the literature, Concepts of treatment and prevention in musculoskeletal disorders, Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability and Work Loss, Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee, © 2011 American Physical Therapy Association. Once the noxious stimulus has been attended to, cognitive processes are used to interpret what they mean. Adapted from: Eccleston C, Crombez G. Worry and chronic pain: a misdirected problem solving model. Return-to-work planning should include attention to aspects of organizational support, job stress, and workplace communication. Explain how factors may influence a client’s ability to recover from injury c. Give examples of how subjective information may influence treatment planning d. Identify reasons for treatment deferral and referral 5. In fact, females account for only about 20% of traumatic spinal cord injuries in the United States. A retrospective review of general surgical patients excluding those who had a neuraxial or peripheral nerve block quotes an incidence of 0.14%. Cognitive interpretation featuring catastrophizing. Psychological interventions range from simple techniques involving communication skills to advanced methods requiring considerable training and practice under supervision. Start studying a&p nervous system case studies. An obvious prerequisite for pain perception is that our attention is directed toward the noxious stimulus. Accordingly, we will highlight how psychological factors affect the development of persistent disability and illustrate the processes by describing pertinent theoretical models. This article reviews the role of psychological factors in the development of persistent pain and disability, with a focus on how basic psychological processes have been incorporated into theoretical models that have implications for physical therapy. -Muscular balance can affect predisposition to injury in specific areas. In his theoretical model, external risk factors act on the predisposed athlete from outside and are classified as enabling factors in that they facilitate the manifestation of injury. Table 2 provides a summary of the models and examples of the basic components, the processes involved, and some implications for treatment. Recent Evidence Suggests That The Cause of An Injury Can Affect Healing time. . For the acute dysfunction, motion restoration is usually all that is needed, for both the stuck neck example and those runners I’ve treated with stiff hips. The practical implication of this model is that repeated efforts to manage LBP through pharmacological, physical, and surgical (and even psychological) treatments that are focused on pain relief may inadvertently reinforce this misdirected problem-solving strategy. Your comment will be reviewed and published at the journal's discretion. Furthermore, such expectations or health perceptions are a good predictor of outcome in a host of medical conditions.16,17 One significant determinant of our experience of pain is whether our expectations are fulfilled. . Although some situations offer the opportunity to ponder which strategy might be best, such as a relapse or flare-up, the choice of coping strategy may occur quickly without conscious thinking in acute situations, such as an acute injury (eg, cut yourself with a knife, smashed finger with a hammer). As shown in Figure 3, this model suggests that emotional processes in the form of worries about pain and cognitive evaluations (eg, pain catastrophizing) are the product of a human predisposition (and probably an evolutionary advantage) to solve problems (a behavioral process) by verbally ruminating on possible negative outcomes and plotting methods of avoidance or escape.49 Thus, worrying about pain and its implications is part of a natural-born problem-solving strategy, but one that, at least in the case of chronic pain, can have negative long-term consequences. A tenet of this model is that active coping promotes a sense of confidence, or “self-efficacy,” for dealing with pain that is associated with improved function and well-being.52,53. Body Composition. When these behaviors result in less pain, this outcome may reinforce the action and make the behavior more likely with future pain episodes, as illustrated in Figure 1. In fact, one function of pain is to demand attention.8 Viewed as a warning signal, pain is helpful because this attention should lead to appropriate responses in dealing with the injury. Thank you for submitting a comment on this article. . Adapted from Vlaeyen and Linton.39, One practical implication of this model is that patients expressing catastrophic thoughts about pain (eg, “I can't stand it anymore”) are at greater risk of delayed recovery.21 These individuals may require a higher level of support and encouragement, as well as a very gradual exposure to increasing levels of physical activity. These beliefs include the idea that “hurt is harm” (ie, if it hurts, something serious must be broken), that “pain is a signal to stop what you are doing” (ie, if an activity results in pain, you should stop before you injure yourself), and that “rest is the best medicine” (ie, pain is a signal you should rest to recuperate your body). -Bone mineral density is a key factor in preventing skeletal injuries, e.g. Therefore, in this article, we focus on the most important psychological factors that have been incorporated into theoretical models of pain that may explain pain perception and treatment benefits. Genes and behaviour: nature, nurture or … This may compromise the tendon and predispose it to rupture under physiologic loads. Lack of resources may prevent you from affording health insurance to access medical care and purchasing healthier food choices for you and your family. In the next section, we examine pertinent theoretical models of pain that have applied psychological processes to explain how pain problems develop over time and how these models might guide clinical interventions. Indeed, emotions are powerful drivers of behavior and shape our experience of the pain via direct neural connections. Nevertheless, it still may be difficult to appreciate how these processes work in reality and how we might utilize them in specific ways in the clinic. Nicholas MK, Molloy A, Tonkin L, Beeston L. Foster G, Taylor SJ, Eldridge SE, et al. This mechanism also underscores the close link between emotional and cognitive processes and attention.7,10 Attentional factors are quite pertinent in the clinic because there are techniques that address them. How we think about our pain may influence it. At the heart of this model is a cognitive interpretation process, namely the concept of psychological inflexibility, or the inability to persist in or change behavior patterns that might service long-term goals or values.44 The implication of this model for chronic pain is that individuals should reduce futile attempts to avoid or control pain and focus instead on living life to the fullest, participating in valued activities, and pursuing personally relevant goals.45 Recent studies of patients with chronic pain have suggested that pain-related acceptance leads to less emotional distress and higher physical functioning.46–48 The clinical implication is that once LBP has persisted beyond several weeks, provider advice and treatment should communicate realistic expectations and focus more on functional adaptation and daily coping than on experimenting with new curative or palliative measures. If part of the suffering and disability are related to learned changes, it is possible to make further changes toward a more preferable goal by utilizing the principles of learning. Pain. One relatively new model for understanding psychological factors in chronic pain is that of acceptance and commitment. Although this model is probably the least formally construed, there is considerable evidence that individuals with a psychiatric history, with depressed mood, with major life adversity, or reporting high levels of stress are at greater risk of transitioning to chronic and disabling LBP.24,32,59,60 Although the burden of persistent LBP obviously can contribute to emotional distress, it also is possible that pre-existing emotional distress (or perhaps the immediate emotional response to pain onset) might predispose some individuals to cope poorly with an episode of acute LBP. A number of theoretical models have been proposed to explain more-specific ways in which psychological factors might have a bearing on pain and disability over time. Three of these models (fear-avoidance, acceptance and commitment, and misdirected problem solving) are specific to the experience of chronic pain, and 2 of these models (stress-diathesis and self-efficacy) represent broader theories of health behavior that can be applied to pain. The learning experiences help to fine-tune these strategies by providing feedback as to whether they work or not. Leeuw M, Goossens ME, Linton SJ, et al. Assessment and treatment planning should take into account individual differences in pain beliefs and attitudes. Effective strategies for coping with persistent, recurrent, or chronic pain are very different from those for managing acute pain, and pain that persists beyond a few weeks can lead to emotional and behavioral consequences that are deleterious to pain recovery and functional rehabilitation. Depression is defined as a psychological problem characterized by negative mood, hopelessness, and despair, and an average of 52% of patients with pain fulfill the criteria for depression.27 Even more people have a depressed mood but do not fulfill the diagnostic criteria for major depression.28 The presence of depression in a pain condition is associated with higher levels of pain intensity and is a potent risk factor for disability.27,29 Furthermore, people who have musculoskeletal pain and are depressed have been found to have twice the sick leave duration as those who have pain but are not depressed.30,31 Future risk of long-term disability also is affected negatively, as is treatment outcome.22,27,32 Studies have shown that high levels of pretreatment depression are associated with poor rehabilitation outcomes.33–35. Although many acute low back pain (LBP) problems resolve, a minority of people (∼10%) directly develop a persistent problem that disables them for a long period of time.4,5 The transition from acute to chronic pain problems is known to be catalyzed by psychological processes (see article by Nicholas et al6 in this issue). associated with these traditional risk factors may in part explain why they predispose to atherosclerosis. Negative affect is a key reason we associate pain with suffering. Being between the ages of 16 and 30. 2.1 Explain factors which may predispose clients to injury and dysfunction 2.2 Explain how factors may influence a client’s ability to recover from injury 2.3 Give examples of how subjective information may influence treatment planning 2.4 Identify reasons for treatment deferral and referral 3. Inhibiting the vascular endothelial growth factor ... dysfunction and albuminuria has been appreciated for >20 years, 29 the mechanisms by which a primary endothelial injury may predispose to ... are regulated by eNOS in an Akt-dependent manner. Thus, these psychological processes have tremendous value for survival.1 Yet, psychological factors are not completely understood, and the translation of their use to the clinic remains a challenge. Graded exposure to physical activity has been considered a critical aspect of treatment in order to overcome a fear of pain.40,42. Incontinence can be caused by injury to the ring-like sphincter muscles at the end of the rectum. Note that these processes also form the basis of the models presented in the next section. A retrospective review considering a broad surgical population quotes an incidence of PPNI of 0.03% (112 patients out of 380 680).3 The incidence of ulnar neuropathy has been quoted as 0.… People with what’s known as an apolipoprotein E genotype can experience more severe brain injury effects from trauma and have a more difficult time recovering from the impact of a brain injury. Raine et al. Thus, pain is more likely to result in functional difficulties and emotional distress. Hypertension or postural hypotension may have been a precipitating factor. Individuals hold very different attitudes and beliefs about the origins of pain, the seriousness of pain, and how to react to pain. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. McCracken LM, Spertus IL, Janeck AS, et al. Impairment of soft tissue is mainly caused by two factors which are dysfunction and injury. . Learn vocabulary, terms, and more with flashcards, games, and other study tools. Although pain is a complex experience that is difficult to understand, it basically is no more so than other psychological problems such as depression or generalized anxiety that also are conceptualized in this way. amygdala dysfunction may also lead to poor fear conditioning which may predispose an individual to crime. You will also develop detailed knowledge of the bony and soft structures of the major joints of the body, factors that may predispose clients to injury, factors that may influence clients ability to recover from injury, postural deviations, ageing and the pathophysiology of common muscle and Yet, these psychological factors are not routinely assessed in physical therapy clinics, nor are they sufficiently utilized to enhance treatment. This model was borrowed from a more general psychotherapeutic approach (acceptance and commitment therapy43) that has been offered as a complement to cognitive-behavioral therapy. Furthermore, internal events such as thoughts and emotions also are considered to be forms of behavior. Thus, pain activates negative emotions that vary from tolerable to miserable.23 It is interesting, therefore, that clinicians often focus more on the sensory aspects of pain (eg, intensity) than on the emotional aspects. Thus, although we encourage application, we also believe that professional competency is warranted. A specific emotion regulation factor in the model is fear. Any impairment of the soft tissues, including muscles, tendons, ligaments and cartilage, will directly affect the quality and efficiency of movement. Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial, The role of illness perceptions in patients with medical conditions, The prognosis of low back pain in general practice, On the course of low back pain in general practice: a one year follow up study, Anxiety and its Disorders: The Nature and Treatment of Anxiety and Panic, The pain catastrophizing scale: development and validation. The ideas or perceptions we have about our pain also are mirrored in our expectations and may have considerable impact on our experience of the pain.14 Normally, we have ideas about the cause of the pain, its management, and how long it should take for recovery.16,17 These expectations appear to drive coping behavior, even in the seeming absence of actual feedback. Sullivan MJ, Adams H, Thibault P, et al. The sphincter muscles normally stay tightly closed and keep stool in the rectum. Psychological concepts of learning can be useful to provide empathy and support without reinforcing pain behavior. The belief that a person is capable of coping with pain is directly related to self-management; low self-efficacy, with feelings that the pain is uncontrollable cause physical and psychological dysfunction. 2007;132:233–236. Reducing futile attempts to achieve unrealistic goals (acceptance) produces flexibility and engagement in pursuing important life goals (commitment). Once the strategy is activated, it is likely that this process will be reflected in actual behavioral attempts to cope with the pain. This model explains why persistent pain repeatedly interrupts attention, fuels worries about negative consequences, produces hypervigilance to pain, and produces repeated efforts to alleviate pain, even when there is no belief that a solution exists.8,50,51 If pain is framed as solely a biomedical problem, problem-solving efforts inevitably will be based on strategies to remove or reduce pain. Psychological factors that may affect pain outcomes are not routinely assessed by many treating clinicians. Please check for further notifications by email. For example, Fordyce36 suggested that although resting or taking analgesics may be a good coping strategy in the acute phase, these behaviors might actually facilitate the development of long-term problems. van den Hoogen HJ, Koes BW, Devillé W, et al. A majority of physical therapists are aware of the importance of psychological factors and attempt to utilize this awareness in their practice.2,3 The application of psychological knowledge in physical therapy might range from providing reassurance to setting goals or inquiring about the functional consequences of pain. Catastrophic thinking about pain is an important marker for the development of long-term pain problems as well as for poor treatment outcome. The dilemma is that we sometimes pay attention to pain when there is little we can do to alleviate it (eg, having chronic musculoskeletal pain), but do not attend to it when it may be a useful warning signal (eg, during an accident). (1997) identifies some specific physiological processes which may predispose some criminals to violent behaviour. A painful injury may result in catastrophizing and fear, which lead to avoidance of certain movements. The typical emotional reaction to pain includes anxiety, fear, anger, guilt, frustration, and depression. Emotions: fear, worry, and depression Consequently, treatment programs for people with chronic musculoskeletal pain problems have been built on gradually changing these behaviors, such as by decreasing analgesics and increasing activity levels. • Explain how poor movement patterns and dysfunctional movement strategies can result in injury or reinjury. Muscle Imbalance and Postural Dysfunction. There is a growing need to translate these ideas into useful clinical tools and interventions for widespread dissemination. Indeed, the paradox is that attempting to suppress thoughts about pain actually increases the pain experience.12 Cognitive processes are central in explaining why we sometimes may experience an insignificant stimulus, such as light pressure, as severe pain, or a serious injury as little or no pain. Hypervigilance to pain symptoms contributes to rumination and failed attempts to escape pain; vicious circle, Redirect problem-solving efforts toward achievement of functional goals. Thus, one learns to cope with pain by taking various actions or thinking in a certain way. . Your household income or employment status may affect your chances of developing type 2 diabetes. from subjective and objective client assessments. There are different ways in which we might group psychological factors. Self-efficacy has been defined as “the belief in one's capabilities to organize and execute the courses of action required to produce given attainments.”54(p3) It has been an important theoretical construct underlying research in arthritis and other sources of chronic pain.55,56 This way of thinking has contributed to the development of self-management interventions for chronic pain that focus on teaching pain coping skills, educating patients about pain, and providing social support.57,58 Low pain self-efficacy is characterized by a feeling that pain is uncontrollable and unmanageable, given the physical demands of daily life. In simple terms a muscle imbalance in when muscles (or groups of muscles) attached to either side of a joint (that usually work against one another to control the normal position and movement of the joint) do not have equal strength, length and/or activity. Both authors provided concept/idea/project design and writing. Additionally, each year there is evidence that there is a genetic component that increases the risk of suffering a traumatic brain injury. When a painful stimulus has been attended to and interpreted as being a threat, strategies for dealing with this threat are activated.7 As illustrated in Figure 1, these strategies first may be activated cognitively and involve a host of cognitive techniques (eg, ignoring, visualizing) and overt behavioral techniques (eg, relaxation, self-statements) believed to reduce the threat of the pain. Based on a review of the scientific evidence, a set of 10 principles that have likely implications for clinical practice is offered. We may expect, for instance, that we will fully recover from a bout of neck pain in 3 or 4 days. This model is supported by the evidence that high levels of pain-related fear are associated with distraction from normal cognitive functions, hypervigilance of pain-related sensations, and unwillingness to engage in physical activities.40 Essentially, the fear-avoidance model purports that fear of pain and of injury or reinjury sometimes is more disabling than the pain itself.41 Over time, fear of pain results in musculoskeletal deconditioning, reduced pain tolerance, and fewer attempts to overcome functional limitations. We consider them individually as a means of presentation. To facilitate understanding and application, various models have been put forward. One study reported that a failure to form an association between a loud noise and fear at the age of three years appeared to precede criminal activity in adulthood. Steven J. Linton, William S. 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