Psychosocial factors relevant to pain care. What psychosocial “yellow flags” relating to pain are commonly seen in your clinic, and how might they be addressed? Health care for people living with persistent pain has changed in recent years, and for good reason. With an estimated 100 million people suffering from chronic pain, it seems evident that an exclusively biomedical approach is not enough. (1) The unfortunate clinical reality is that total pain relief is not always possible. Thus, a shift in approach from pain relief to pain management is often what is needed.

The Pain Paradigm Shift

Research points to several factors that influence an individual’s pain level and persistence, raising doubt about pain care that focuses exclusively on identifying anatomical asymmetry, imbalances, or both through palpation or movement testing. (2, 3) The consequence of these findings has been a shift in approach to pain care that claims it is not only possible, but desirable, for people living with persistent pain to continue their normal daily activities. (4)

Modern pain care emphasizes the resumption of daily activities despite—not dependent on the absence of—pain. This shift in clinical perspective requires an understanding of the psychological impact of chronic pain, as well its integration into clinical practice. Learn more about the psychology of pain here.

The psychological impact of chronic pain is largely unaddressed in the biomedical sphere, yet it is of key interest to modern pain practitioners who intend to help their patients to lead meaningful and fulfilling lives. Studies suggest that these therapists require a new skill set; one that recognizes psychological obstacles to recovery and incorporates strategies that address these concerns into their treatment plan.

Three Skills of Psychologically Informed Care

1. Recognition of Yellow Flags

Yellow flags include psychological and social factors (fear, beliefs, mood states, perception of pain levels) known to predispose patients to maladaptive coping strategies and ongoing pain. (5) Once yellow flags are identified, a more comprehensive assessment can be undertaken to further explore barriers to recovery. Honing this skill is not only useful for avoiding the onset of pain chronicity; it also prevents clinicians from wasting time inquiring about psychosocial attributes among patients who don’t appear to have psychological barriers.  

2. Familiarity With Pain Psychology Approaches

Unlike the biomedical approach that aspires to diagnose the cause of pain, a pain psychology approach, such as cognitive-behavioral therapy, analyzes the interaction between a patient’s internal and external environments. The therapist then formulates a theory about what might be contributing to the patient’s ongoing pain. The fear-avoidance model is a good example, whereby unhelpful beliefs are uncovered and then “debunked” through structured activities and pacing.  The benefit of questionnaires, such as the Patient-Centered Outcome Questionnaire, is that they can be completed prior to assessment, thereby providing leads for further discussion. (6)

REFERENCES:  

1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press; 2011.
2. Levangie PK. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther 1999;79:1043-57.
3. Riddle DL, Freburger JK. Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study. Phys Ther 2002;82:772-81.
4. Nicholas MK, George SZ. Psychologically informed interventions for low back pain: an update for physical therapists. Phys Ther 2011;91(5):765-76.
5. Samanta A. Chronic low back pain. BMJ 2003;326:535.
6. Zeppieri G Jr, George SZ. Patient-defined desired outcome, success criteria, and expectation in outpatient physical therapy: a longitudinal assessment. Health and Quality of Life Outcomes 2017;15:29.