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Chiropractic Journal of Australia : CJA September 2013
Chiropractic Journal of Australia Volume 43 Number 3 September 2013 95 language diffculties, and associated with poorer outcomes in a number of other diseases including arthritis.14 In addition, Soucy and colleagues, studying 248 workers with subacute LBP who were receiving workers' compensation, have reported that perceived stress, fears and beliefs about work correlated strongly with progression to chronicity.22 Taken together, these studies highlight the importance of physical as well as psychological demands associated with work on chronicity of LBP. PSYCHOLOGICAL FACTORS Psychological factors with an adverse bearing on prognosis have been identifed in most studies. Burton and colleagues have demonstrated that the patient’s psychological profle at presentation has a much stronger infuence on outcome than does conventional clinical information gathered at the time.23 Similarly, Shaw and co-workers have demonstrated, using 140 men in a cohort study, that a history of major depressive disorder increases the likelihood of chronicity in LBP by a factor of five. They further demonstrated signifcant correlations with LBP chronicity of a range of other pre-existing psychiatric/psychological conditions including: generalised anxiety; post-traumatic stress disorder; and nicotine addiction.24 Klenerman and co-workers found evidence of psychological morbidity, particularly fear avoidance behavior, at the onset of the presenting attack in susceptible subjects.8 In a large prospective study, Van der Windt and colleagues also identifed fear of movement was a factor in progression to chronicity in LBP cases.25 A prospective study in 2007 in Australia has reported that evidence-based management of acute LBP, in which patient reassurance and communication was emphasised, was more effective than usual care by a general practitioner and reduced the recurrence rate from 27% to 6%.26 It is generally believed that at the earliest stage of LBP fear should be identifed, and where it is severe, should be addressed as part of the treatment, to prevent progression to chronicity.27-29 However, controversy continues to surround this issue, as it is diffcult to differentiate primary from secondary psychological disturbances. That is, whether the psychological problems were a cause of the chronicity, or a consequence. PSYCHOSOCIAL FACTORS In a number of studies, psychosocial risk factors have been reported to be associated with the development of chronic LBP, and have been defned as ‘yellow fags’. The World Health Organisation defnes psychosocial factors as any factor determining the way people "deal with the demands and challenges of everyday life, maintain a state of wellbeing while interacting with others, their cultures and the environment" in.30 Gatchel and co-workers,1 identifed the presence of a 'robust psychosocial disability factor' associated with those injured workers who are likely to develop chronic LBP. In another publication, the same authors evaluated the predictive power of a comprehensive assessment of psychosocial and personality factors in identifying acute LBP patients who subsequently developed chronic LBP.10 The data from that study revealed the importance of three psychosocial measures: self-reported pain and disability; scores on scale three of the Minnesota Multiphasic Personality Inventory (MMPI); and workers compensation and personal injury insurance status. Barnes and co-workers31 examined a variety of psychological, socioeconomic and demographic factors and identifed several instruments that had predictive power in progression to chronicity. These included: MMPI and Million Behavioural Health Inventory (MBHI) scale scores; prior surgical history; the level of workers compensation; and pain intensity ratings. These data are consistent with the importance of psycho-socioeconomic factors in chronicity of LBP. However, an interesting cross-cultural study of Dutch and Greek nursing staff has found that while Greek nurses were more likely to seek specialist care for their LBP, they were not more likely to progress to chronicity.32 There is evidence that early identifcation of psychosocial problems is important in understanding, and possibly preventing, the progression to chronicity.23 A recent study by Melloh and co- workers, found that depression and maladaptive cognitions (depression, somatisation, a resigned attitude towards the job, fear-avoidance, rumination, helplessness, catastrophising of pain, and negative expectations on return to work) were risk factors for the development of persistent LBP, 6 month following the onset of acute LBP in the primary care setting.33 A recent systematic review of psychosocial risk factors for chronic LBP in primary care has found that the judgments of patients and care providers about the likely evolution of an episode of LBP had the most powerful and independent predictive power.30 PRACTITIONERS' BELIEFS AND PERCEPTIONS The great costs and the poor outcomes in chronic LBP patients have given impetus to clinical and research efforts to better understand the transition of acute to chronic pain and to devise more effective management strategies for chronic LBP. Chiropractors, medical practitioners, health and clinical psychologists are part of the group of practitioners involved in the assessment and management of LBP. Each of these professions has with its own knowledge base and beliefs about the causes and treatment of chronic LBP that are based on training, group perceptions, clinical experience, and memory. However memory can be selective and inaccurate, and be infuenced by factors other than factual experience in both patients and practitioners. For instance, a large prospective study has shown that over time the accuracy of recall of pain relief by LBP patients is increasingly dependent on their current levels of pain than the actual pain relief they had initially reported.34 In addition, each profession's perception of current literature is partly related to the avenues that are used to gather the information. For example, the way in which a chiropractor and a psychologist approach the assessment and diagnosis of a case of chronic LBP would in all likelihood differ. The chiropractor would be likely to manage a presenting LBP problem from a neuromusculoskeletal perspective, whereas the psychologist would be equally likely to view behavioural/personality factors as being more important in the transition from acute to chronic LBP. These differences would also be refected in the manner in which each profession would choose to treat the presenting complaint. The chiropractor would use a physical or manipulative technique; while the psychologist would use a cognitive or behavioural technique to address the same problem. Each intervention however, would be deemed entirely acceptable in the context of each profession's training and practice. It would be plausible therefore to infer that beliefs and perceptions could have a direct bearing on LOW BACK PAIN: BIOPSYCHOSOCIAL PERSPECTIVE DoNNolI • aZaRI
CJA June 2013
CJA December 2013