Last week, we discussed some of the psychological components of pain, and the potent effect emotion and attitude can have on the day-to-day management of your pain.  Many patients coping with chronic pain experience kinesiophobia, an irrational fear of reinjuring oneself or exacerbating pain by participating in physical activity.

One study of patients with foot and ankle pain found that out of movement-related fear, pain intensity, and range of motion deficit, fear was by far the greatest predictor of disability status (http://1.usa.gov/1fXzxN5).  Clearly, fear of movement plays an important role in the quality of life of patients living with pain.

Managing pain more successfully as reflected in continuing to work and be involved in life  is associated with less fear than those with lower levels of functioning when all other metrics are also considered.  A review of seven studies which examined patients with chronic musculoskeletal pain who chose to continue working found that these patients were significantly more likely to have low scores for both emotional distress and perceived disability (http://1.usa.gov/H4v9gc).

Treatments that address both the physical and emotional aspects of pain can produce better outcomes.  A study of 130 patients who had undergone a spinal fusion found that patients who participated in a rehabilitation program that included cognitive-behavioral therapy to address  kinesiophobia and catastrophizing as well therapeutic exercise faired significantly better than those who participated in a program consisting only of therapeutic exercise.  The psychological intervention was found to reduce dysfunctional thoughts and enhance quality of life for up to one year after treatment ended (http://1.usa.gov/17M2T91).

It is apparent that attitude – especially beliefs about movement – impacts the quality of life for patients in pain.  Those who maintain a positive outlook and a healthy perspective on movement, though not necessarily reporting reduced levels of pain, do show an increase in function.

Several different variables have been studied: Catastrophizing, depression, kinesiophobia, and self-efficacy.

Catastrophizing is a type of dysfunctional thought in which the patient exaggerates the severity of a situation. Examples of catastrophizing are thoughts like “I can’t take it!” “What did I do to deserve this?” “What’s the use?”  “I might as well be dead!” One study of patients entering a multidisciplinary pain treatment center found that the extent to which a patient catastrophized was a better predictor of disability status than pain intensity (http://bit.ly/1aVCGa6).  A separate study of fibromyalgia patients found that pain catastrophizing was correlated with an increase in brain activity in areas related to attention to pain, anticipation of pain, and motor control (http://bit.ly/17y4Up8).  This suggests that catastrophizing affects the intensity with which patients perceive pain.

Depression and chronic pain often coexist.  Both conditions can markedly affect a patient’s health, motivation, and overall quality of life.  Patients with depression often experience feelings of helplessness, fatigue, and hopelessness – all feelings which can impair treatment outcome.  Depression and pain are also linked biologically through 2 common pathways:  the serotonergic and noradrenergic systems (http://bit.ly/1gqi29f).  The neurotransmitters serotonin and norepinephrine modulate pain transmission and also play key roles in the development of depression.  Therefore, treatments that target these neurotransmitters, such as tricyclic antidepressants, and SNRIs (serotonin/norepinephrine reuptake inhibitors) can be helpful for both conditions (http://bit.ly/1fID6GQ).

Kinesiophobia is fear of movement based on the belief that activity will result in re-injury or exacerbation of pain. Hi kinesiophobia scales result in less activity and interfere in effective rehabilitation (http://bit.ly/19RClca).  Depression often co-exists with kinesiophobia.

Self-efficacy in the context of chronic pain refers to confidence in one’s ability to cope and function despite persistent pain.   A study of patients with an acute whiplash injury found that patients with less belief in their ability to manage their life in the face of pain were significantly more likely to have their injury develop into a chronic condition (http://bit.ly/1bylac/).  A separate study of 45 low back pain patients found that higher self-efficacy predicted better overall functioning and decreased levels of pain at 6 month follow-up (http://bit.ly/19RClca).

Psychological factors play an important role in evaluating and treating pain.  When usual treatment is not progressing well, assessment and treatment of emotional factors may help the patient succeed in finding pain relief.