A Long or short game? Psychosocial predictors of chronic low back pain 

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Summary: Psychosocial factors are known to be important in the development of low back pain. This 2020 study analysed the predictive value of specific types of psychosocial stress and self efficacy in development of chronic low back pain. It is relevant for Osteopaths to understand the possible influence of particular types of psychosocial stress such as work or social stress, and self-efficacy on “chronification” of low back pain since they may need to be addressed differentially in the treatment plan.

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Keywords: Psychosocial stress; Low back pain; Chronic pain; Self Efficacy

The link between stress and chronic low back pain is indisputable. In this 2020 study, from Journal of Pain  Research, psychosocial stressors and self-efficacy were assessed as predictors for the development of chronic low back pain over 2 years.

Particular types of stress (eg social or lack-of-control factors), repeated stressful events or long-lasting stressful  situations can lead to an over-activated stress response.  Not only does this result in depleted energy, poor repair and general wear and tear of body resources (“allostatic load”) but ultimately may result in dysfunctional reactions to acute stressors: depression, fatigue, increased pain. These are all familiar in a chronic pain patient presentation. 

Self efficacy is a “person’s belief to be able to deal with upcoming challenges”. It is associated with putting more effort into achieving goals and feeling more capable, all relevant for those in pain. It is regarded as one of the most important psychological protective factors for prevention of chronic pain, or reduced disability in those with chronic pain.

The study method was a prospective observational study over 2 years of 1071 subjects with low back pain at baseline. Psychosocial stress factors (perceived stress, work stress experiences, social stress experiences, vital exhaustion/stress fatigue, life event stress) and self efficacy were assessed using 5 questionnaires and regression analysis was used to identify specific predictors of pain intensity and pain-related disability at 1 year and 2 years.

A tendency to worry and social isolation predicted both back pain and disability 1 and 2 years later. Prior stressful life events, vital exhaustion and work discontent also predicted pain and/or disability 1 year later, and social conflicts, lack of recognition at work, work discontent and perceived stress predicted pain and/or disability 2 years later. Self efficacy showed a predictive effect for having back pain that was stronger for 2 years later than 1 year later.   

The study admits moderate prediction errors so the factors above provide some predictive value but do not reflect the whole story.  This is no surprise, back pain is very complex with multiple interactions so encapsulating some sort of linear predictive model or finding a predominant predictor is unrealistic.  The role of other factors such as depression, pain related beliefs and other yellow flags must also be considered. However, it is useful for Osteopaths to recognise different psychosocial stressors and promote self efficacy in order to moderate potential drivers and protectors for chronic low back pain.  This is relevant both for treating patients with chronic low back pain, and preventing low back pain from becoming chronic. Notably, stressors tendency to worry, social isolation and others are particularly  relevant in the current pandemic, for which undoubtedly patients  in osteopathic clinic will be experiencing additional psychosocial stress load. Osteopaths should be vigilant to this and address them appropriately in the treatment plan. 

References:

Puschmann A-K, Drießlein D, Beck H, Arampatzis A, Catala AM, Schiltenwolf M, Mayer F, Wippert P-M. Stress and Self-Efficacy as Long0Term Predictors for Chronic low Back Pain: A Prospective Longitudinal Study. Journal  of Pain Research 2020:13 613-621

https://pubmed.ncbi.nlm.nih.gov/32280264/

 

Hazel Mansfield

June 2021

Hazel is an Osteopath of 15 years’ experience with a background in neuropsychology, and a renowned lecturer of osteopaths and other manual therapists at both undergraduate and post-graduate levels. 

Hazel studied Natural Sciences at Cambridge University, specialising in neuropsychology before training as an osteopath at the British College of Osteopathy in London.

She consults in private practice in Stockholm, with a special interest in back pain, stress, and using the best available knowledge to elevate standards of patient care.

 

European wide Neck and Low Back Pain Treatment Recommendations 2020

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Brief Summary

In clinic, osteopathic treatment together with reassurance, exercises and specific advice for physical activity are the keys to helping your patients with low back pain and neck pain. 

However, electrotherapy, shortwave, laser and more than a couple of days bed rest are not recommended.

Summary of European-wide, evidence-based National and professional Guidelines 2020.

Key words

Low back pain, neck pain, evidence based, European Guidelines.

Background

Back pain causes the highest rate of years lived with disability globally out of 354 conditions, with neck pain ranked in the top 15 (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018).

In this evidence based and European wide systematic review thirteen databases were searched for National and Professional Guidelines for the clinical management of low back pain and neck pain. The guidelines were issued between 2013-2020. Inclusion criteria: the guidelines were evidence-based, European and issued by professional bodies and organisations; the guidelines were for an adult population over 18; Treatment needed to be deliverable within primary care; treatments were included that aimed to reduce pain, improve function, and support return to work. 

National and Professional Guidelines from Belgium, Denmark, France, Germany, Italy, The Netherlands, Poland and UK were included.

Seventeen guidelines were systematically identified, synthesised and graded using the AGREE II reporting checklist. Of these seven were identified to be of high quality, two guidelines for neck pain and five for low back pain. 3,941 unique citations were identified and analysed. The degree of evidence for or against a treatment was ranked as strong, moderate, weak, inconsistent/consistent or inconclusive.

The Results of the study found that:

Back Pain -there is evidence (both strong and weak) for: 

reassurance, advice, education with specific advice for physical activity, manual therapy combined with exercise, exercise programme and work, group exercise programmes, work-based rehabilitation, and return to work programmes. 

Back pain -there is evidence (strong) against: 

electrotherapy, shortwave, laser, more than a couple of days bed rest, use of paracetamol, anti-depressants, anticonvulsants, muscle relaxants, spinal injections for non-specific low back pain, traction, and orthoses.

Referral for imaging is only recommended for those with red flags -Risk of fracture, infection, metastatic cancer, neurological emergencies including cauda equina, aortic aneurysm or systemic inflammatory arthritis, or deterioration of symptoms.

Psychological therapies are mainly recommended for subgroups of patients with psychosocial risk, complex mood problems or persistent back pain. Surgery is only recommended where there is a specific pathology.

There is inconsistent or inconclusive evidence for: manual therapy without additional active treatment, traction, NSAID’s, opioids, steroid injections, acupuncture, postural therapies. The guidelines recommend entirely non-pharmacological treatments for low back pain. 

Neck Pain -there is evidence (moderate or weak) for: reassurance, advice, education, manual therapy combined with exercise, exercise programme, oral analgesics, topical medications, and psychological therapies. Multidisciplinary treatment for those with psychosocial risk or persistent neck pain or disability. 

Neck Pain– there is inconsistent or inconclusive evidence for manual therapy without additional active treatment, traction, electrotherapies, thermotherapies, cervical orthoses, acupuncture/dry needling and referral for imaging.

This paper gives an up-to-date European wide analysis of National and Professional Guidelines for the treatment of neck and low back pain. It provides highly relevant informative evidence-based recommendations which osteopaths should apply in clinic.

References:

Corp N. et.al. 2020 Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. European Journal of Pain Vol 25 (2) 275-295

https://pubmed.ncbi.nlm.nih.gov/33064878/

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018 Nov 10;392(10159):1789-1858. doi: 10.1016/S0140-6736(18)32279-7. Epub 2018 Nov 8. Erratum in: Lancet. 2019 Jun 22;393(10190):e44. PMID: 30496104; PMCID: PMC6227754.

https://pubmed.ncbi.nlm.nih.gov/30496104/

 

Caroline Frost

Juni 2021

Caroline är utbildad som D.O. på British College of Osteopathic Medicine, London, 1989-1993 och blev legitimerad Osteopat i UK 1999. Osteopatiutbildningen bestod av fyra års heltidsstudier. Hon har genomfört en masters i osteopati (MSc) genom Osteopathie Schule Deutschland/ Dresden International University.

Hon är också KBT-terapeut (kognitiv beteendeterapeut) efter att ha genomfört Steg 1 (grundutbldning) i KBT-kognitiv beteendeterapi år 2012. KBT-utbildningen är godkänd av Socialstyrelsen och motsvarar den av ”Svenska föreningen för kognitiva och beteendeinriktade terapier” fastställda normen för grundutbildningen. Jag har även en fil.kand. i biologi.

I England jobbade Caroline på ett hälsocenter i Bethnal Green, London, tillsammans med andra osteopater. Hon samarbetade också med den lokala vårdcentralen där hon erbjöd osteopatiska behandlingar via motsvarigheten till landstinget i Storbritannien. Hon arbetade också som volontär på OCC (osteopathic centre for children) under en tid. År 2004 flyttade Caroline till Sverige från Storbritannien och hennes osteopati- och kbt-mottagning är baserad i centrala Stockholm.

Somatic Dysfunction: past its sell by date!

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Brief summary

Somatic dysfunction (SD) is considered a key idea within the theory and practice of osteopathy.  However, a closer inspection of this concept reveals it is outdated, and bears little relevance to the paradigms of person-centred care and evidence-informed practice.  It is time to re-evaluate such key terms and concepts within osteopathic discourse, and make them compatible with 

modern day healthcare.

Key words

Somatic dysfunction, diagnosis, facilitated-segment

Somatic dysfunction: an osteopathic conundrum (Fryer, 2016)

Gary Fryer has been engaged in osteopathic education and research since 1997. He has published extensively, and has a  particular interest in advocating an evidenced informed approach to the teaching and practice of osteopathy.  

 

This master-class paper suggests that the central concept of somatic dysfunction (SD) within osteopathy is no longer relevant.  The conceptual framework of  SD is critiqued in relation to “its unclear pathophysiology and poor reliability of detection.”  Palpation as a diagnostic tool is critiqued and found to be wanting.  Fryer provides a brief historical summary including Korr’s facilitated segment theory which attempted to explain the neurological basis for SD.  However, a thorough review of Korr’s research has revealed serious flaws, and that it cannot validate the notion of SD.  A more compelling explanation for palpatory findings and patient experience of pain in the osteopathic setting is the one of central sensitisation, in which all pain is perceived in the higher centres, not the local tissues.  Fryer urges us as a profession to widen our perspectives and integrate the ever increasing knowledge from current pain and chronic pain research. He suggests a more plausible explanation for the palpable findings, we as osteopaths experience on a daily basis, could be attributable to “nociceptive-driven functional changes.”  These produce changes in tissue quality, texture and alter pain sensitivity.

It is suggested that SD now lacks relevance within modern day health studies. As a theory it is too unspecific, lacks reliability and validity, and dramatically undermines the claim that it is a useful concept in health and disease. Fryer deepens his critique by suggesting that the term dysfunction is also unhelpful, potentially producing a negative picture of the body for the patient (see also Darlow, 2016).  He particularly points to Fryette’s biomechanical model which perpetuates the “bone out of place” concept, which may leave the patient believing they have a serious structural problem.  Fryer states quite clearly “positional terminology is anachronistic and potentially harmful.

The use of this type of negative language is also heavily critiqued in the placebo research literature (Benedetti and Amanzio, 2011) and may induce a nocebo response.  The words and concepts we use with are patients are highly loaded with meanings both positive and negative.  It is therefore important that our language should be considered with care.

The article also provides an alternative model for understanding the palpatory findings without referring to SD, which he suggests we as a profession need to rethink in the light of current research findings on the nature of pain.  The paper ends with a clear message that as a profession we need to examine our theoretical concepts in the light of the best available evidence.

References

Benedetti, F. and Amanzio, M., 2011. The placebo response: How words and rituals change the patient’s brain. Patient Education and Counseling, 84(3), pp.413-419. 

https://pubmed.ncbi.nlm.nih.gov/21621366/

Fryer, G., 2016. Somatic dysfunction: An osteopathic conundrum. International Journal of Osteopathic Medicine, 22, pp.52-63. 

https://www.journalofosteopathicmedicine.com/article/S1746-0689(16)30002-5/pdf

Darlow, B., 2016. Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine, 20, pp.53-61. 

https://www.sciencedirect.com/science/article/abs/pii/S1746068916000067

 

Robert Shaw PhD

June 2021

Robert has worked as an osteopath for over 30 years and a psychotherapist for over 25 years. He obtained his PhD in 2000 exploring the concept of embodiment within the therapeutic encounter. He has written many journal articles, a book, and lectured throughout Europe on the subject.

He has a specialised training in dealing with the physical and psychological aspects of post traumatic stress disorder. He moved to Sweden in 2010 and currently has a private practice as an osteopath, integrative psychotherapist, and supervisor, and is the program leader for the Skandinaviska Osteopathögskolan.

He is on the international editorial board for The International Journal of Osteopathic Medicine, and a member of the European School of Osteopathy International faculty. He is an Honorary Research Fellow at University of Technology Sidney (ATS), Australia, which has organised the first International Osteopathy Research Leadership and Capacity Building Program for osteopathy.