Effective Reassurance in Primary Care of Low Back Pain: What Messages From Clinicians are Most Beneficial at Early Stages of LBP?

OBJECTIVES:: Effective reassurance of patients suffering from complaints for which no clear aetiological origin is available, is one of the most important challenges in the early phases of non-specific back pain. However, there is a lack of empirical studies on the effects of reassurance and, effects shown, were small. Improvements are needed with respect to the process of physician-patient interaction and to the methods used by the physician.METHODS:: We provide a short narrative review of the literature with special reference to affective and cognitive communication, based on a systematic review of 16 studies. We further consider recent evidence in the prognosis of low back pain, the role of physical activity and sub-groups-based individual differences in pain coping, questioning the information basis of reassurance.RESULTS:: A two-process model of affective and cognitive reassurance, was supported. Recovery improved in a combination of communication of empathy with cognitive reassurance, giving concrete information and instructions. In terms of information, recent research indicate that a substantial rate of patients do not recover within the first year after onset of back pain. Further, very low and high levels of physical activity are associated with pain and disability, associated with cognitive/behavioural pain coping.DISCUSSION:: Reassurance of patients in early phases of persistent back pain might improve from affective and cognitive parts of communication and individually tailored information. Subgroup differences with respect to different prognosis, associated patterns of adaptive or maladaptive pain coping and levels of health-promoting versus harmful physical activity should be considered more carefully

Avoidance and endurance in chronic pain:A self- regulation perspective

This chapter focuses on two vexing aspects of coping with daily activities while experiencing pain-the tendency to avoid actions that are perceived as exacerbating the pain (avoidance), and the tendency to endure pain by persistent engagement in ongoing activities (endurance). Based on theoretical approaches such as the fear-avoidance and the avoidance-endurance models of pain, the chapter provides insights into the wide variety of cognitive, emotional, and behavioral pain responses that are related to an avoidant or endurance pain response style and aspects of dysfunctionality. Several specific response patterns are identified that mirror dysfunctional avoidance or endurance in addition to an adaptive pattern. The chapter provides preliminary evidence from both clinical and experimental research and is based on selected models of goal striving as conceptualized within a broad self-regulation perspective

Overactivity in chronic pain, the role of pain related endurance and neuromuscular activity - an interdisciplinary, narrative review

Objectives: Decades of research have convincingly shown, that fear of pain and pain-related avoidance behavior are important precursors of disability in daily life. Physical underuse as a consequence of avoidance, however, cannot not be blamed for chronic disability in all patients, a contrasting behavior, pain-related dysfunctional endurance in a task and overactivity, have to be considered. Currently there is a need to better understand psychological determinants of overactivity, dysfunctional endurance and neuro-biomechanical consequences. Methods: Narrative review. Results: The first part of this review elucidates research on self-reported overactivity, showing associations with higher levels of pain and disability, especially in spinal load positions, e.g. lifting, bending or spending too long in specific positions. In addition, measures of habitual endurance-related pain responses, based on the avoidance-endurance model, related to objective assessments of physical activity and again, especially in positions known to cause high spinal load (part two). The final part reveals findings from neuromuscular research on motor control indicating the possibility that in particular overactivity and dysfunctional endurance may result in a number of dysfunctional adaptations with repetitive strain injuries of muscles, ligaments and vertebral segments as precursors of pain. Discussion: This narrative review brings together different research lines on overactivity, pain-related endurance and supposed neuromuscular consequences. Clinicians should distinguish between patients who rest and escape from pain at low levels of pain -but high levels of fear of pain - and those who predominantly persist in activities despite severely increasing pain until a break will be enforced by intolerable pain levels

Pain-related avoidance and endurance behaviour in migraine: an observational study

Abstract Background The role of avoidance and endurance behaviour is well established in chronic musculoskeletal pain, but less is known about its significance in migraine. Methods The Avoidance-Endurance Questionnaire behavioural subscales, the Pain Disability Index (PDI), the Migraine Disability Assessment Scale (MIDAS) and the Hospital Anxiety and Depression Scale (HADS) were obtained from 128 migraine patients (90 episodic, 38 chronic). Sixty nine of them were re-evaluated after 3–6 months. Results At baseline, there were positive relations between avoidance (especially social avoidance behaviour) and pain-related disability as assessed by the PDI (Wald χ2 [1] = 32.301, p < 0.001) and the MIDAS (Wald χ2 [1] = 14.387, p < 0.001). A negative relation of endurance behaviour with PDI scores did not survive multiple regression analysis. In addition, there was a positive relation of social avoidance with the HADS depression score (Wald χ2 [1] = 3.938, p = 0.047) and a negative relation of endurance (especially the humour-distraction subscale) with the HADS anxiety score (Wald χ2 [1] = 6.163, p = 0.013). Neither avoidance nor endurance were related to headache intensity or frequency, or to a diagnosis of episodic vs. chronic migraine. 3–6 months after treatment at our headache centre, headache frequency, intensity and pain-related disability were significantly improved (all p < 0.01) while avoidance and endurance were unchanged. Conclusions This indicates that improvement in headache frequency and disability can be achieved in the absence of changes in avoidance or endurance behaviour. However, because of its significant link to headache-related disability, avoidance behaviour (especially social avoidance) should be investigated as a potential additional target of migraine therapy

Evaluation of the short-term effects of recovery tools in the rehabilitation of chronic back pain: a feasibility study

Background: Recovery represents an individualised, psychological construct serving as a buffer for health complaints and back pain. Recovery might also help in reducing chronic back pain (CBP) but has not been examined within CBP rehabilitation. Aim: Testing the acute effects of recovery tools to reduce CBP and stress and to improve recovery. Methods: A longitudinal, quasi-randomised pilot study with 55 individuals on sick leave caused by CBP was conducted. The acute effects of a multimodal out-patient rehabilitation programme were evaluated, while recovery tools were conveyed within the intervention group. The control group received regular treatment. Validated psychometric questionnaires to measure CBP, stress and recovery were used. Results: Repeated measures ANOVA indicated significant reductions for Pain Intensity (p

Gray matter alteration associated with pain catastrophizing in patients 6 months after lumbar disk surgery: a voxel-based morphometry study

Abstract. Introduction:. Pain catastrophizing (PC), the increased attention to harmful aspects of pain (magnification), and the belief of low controllability (helplessness) has been shown to be important in the maintenance of pain. A growing research on structural alterations in chronic pain revealed an association between PC and brain areas that are involved in affective and cognitive pain processing. However, little is known about a differential effect of the components magnification and helplessness. Objective:. The aim of this study was to identify brain regions associated with overall PC and with the single components of magnification and helplessness. Methods:. We investigated 29 patients 6 months after lumbar disk surgery using voxel-based morphometry. Magnification and helplessness were assessed with subscales of the Avoidance-Endurance Questionnaire (AEQ); overall PC was computed using the sum score. The structural brain imaging data were preprocessed and analyzed using SPM8 and VBM8. Multiple regression analyses were performed with PC scales as predictors and depression as covariate. Results:. Pain catastrophizing was significantly associated with cortical gray matter in brain areas involved in processing attentional, sensory, and affective aspects of pain, including the left posterior cingulate cortex, supplementary motor area, and medial frontal gyrus. In addition, we provide preliminary evidence for brain structure association related to magnification and helplessness. Conclusion:. This study provides evidence for PC-related structural alterations in patients with low back pain, which are consistent with findings from previous research in different chronic pain disorders. This study is the first to evaluate brain changes related to differential domains of PC