The Biopsychosocial Approach to the Assessment and Intervention for People with Musculoskeletal Disorders

Clinical issues

• Has the pain persisted for 3 months or longer despite appropriate interventions and in the absence of progressive disease?

• Does the patient report nonanatomical changes in sensation (e.g., glove anesthesia)?

• Does the patient seem to have unrealistic expectations of the healthcare provider or treatment offered?

• Does the patient complain vociferously about treatments received from previous healthcare providers?

• Does the patient have a history of previous painful or disabling medical problems?

• Does the patient have a history of substance abuse?

• Does the patient display many pain behaviors (e.g., grimacing and moving in a rigid and guarded fashion)?

Legal and occupational issues

• Is litigation pending?

• Is the patient receiving disability compensation?

• Was the patient employed prior to pain onset?

• Was the patient injured on the job?

• Does the patient have a job to which he or she can return?

• Does the patient have a history of frequent changing of jobs?

Psychological issues

• Does the patient report any major stressful life events just prior to the onset or exacerbation of pain?

• Does the patient demonstrate inappropriate or excessive depressed or elevated mood?

• Has the patient given up many activities (social recreational, sexual, occupational, physical) because of pain?

• Is there a high level of marital or family conflict?

• Do the patient’s significant others provide positive attention to pain behaviors (e.g., take over their chores and rub their back)?

• Is there anyone in the patient’s family who has chronic pain?

Does the patient have no plans for increased or renewed activities if their pain is reduced?

In addition to interviews, a number of assessment instruments designed to evaluate patients’ attitudes, beliefs, and expectancies about themselves, their symptoms, and the healthcare system have been developed. Standardized assessment instruments have advantages over semi-structured and unstructured interviews. They are easy to administer, require less time, and, most importantly, they can be submitted to analyses that permit determination of their reliability and validity. These standardized instruments should not be viewed as alternatives to interviews, but rather that they may suggest issues to be addressed in more depth during an interview. Several assessment instruments are described below (for comprehensive reviews, see Turk & Melzack, 2011).

Assessment of Functional Activities

The impact of chronic pain on function can be subdivided into patients’ physical capacities, the ability of patients to perform activities of daily living, and their ability to function in adult roles like work. Focus groups indicate that people with persistent pain report that their overall physical functioning was degraded due to their pain, supporting the recommendation that assessment of functioning should accompany pain assessment (Turk et al., 2003, 2008). The ability (or inability) to perform necessary and desired functions, in turn, can significantly impact quality of life. Physical and laboratory diagnostic measures are useful primarily to the degree that they are correlated with symptoms and functional ability. However, the traditional measures of function performed as part of the physical examination are not direct measures of symptoms or function, but are only approximations that may be influenced by patient motivation and desire to convey the extent of their pain, distress, and suffering to the physician. As noted, commonly used physical examination maneuvers, such as muscular strength and ranges of motion, are only weakly correlated with actual functional capacity. It is important to keep in mind that most functional tests depend on patients’ voluntary effort and are based on proxies for objective capabilities (Turk, Okifuji, Sinclair, & Starz, 1996). Similarly, radiographic indicators have been shown to have little predictive value for the long-term physical capacity of a patient, including the ability to return-to-work or usual routine activities.

Poor reliability and questionable validity of physical examination measures have led to the development of self-report, functional-status measures to quantify symptoms, function, and behavior directly, as well as the severity of pain when performing specific activities (e.g., ability to walk up stairs or lift specific weights, to sit for specific periods of time) associated with different types of painful conditions (e.g., osteoarthritis, low back pain). Research has demonstrated the importance of assessing overall health-related quality of life (HRQOL) in chronic pain patients in addition to function (Gladman et al., 2007; Salaffi, Sarzi-Puttini, Ciapetti, & Atzeni, 2009). Some of the common functional used assessment scales include the Roland-Morris Disability Scale (1983), the Sickness Impact Profile (Bergner, Bobbitt, Carter, & Gilson, 1981), and the Oswestry Disability Index (Fairbank, Couper, Davies, & O’Brien, 1980). These scales ask patients to report on their ability to engage in specific activities, such as sitting, standing, and walking. The items tend to be quite specific. For example, one item from the Oswestry Disability Index asks patients to indicate whether their pain prevents them from sitting at all, from sitting more than 10 minutes, sitting more than 1/2 hour, or sitting more than hour, or whether they are able to sit for as long as they like. A number of disease-specific functional activity scales have also been developed (e.g., the Fibromyalgia Impact Questionnaire, Bennett, 2005; Neck Disability Index, Vernon & Mior, 1991) and may be appropriate to use when assessing patients with a specific diagnosis.

Despite the obvious limitations of self-report instruments of physical function, they have several advantages. They are economic, efficient, and enable the assessment of a wide range of behaviors that are relevant to the patient, some of which may be private (sexual relations). Although the validity of such self-reports or the ability to perform functional activities is often questioned, studies have revealed fairly high correspondence among self-reports, disease characteristics, physicians or physical therapists’ ratings of functional abilities, and objective functional performance (Deyo, 1988).

Ideally, a biopsychosocial evaluation of musculoskeletal disorders that involves injured workers should include having a vocational rehabilitation counselor perform a comprehensive evaluation of the work status of pain patients and their potential for vocational rehabilitation. In many situations, though, the job of assessing vocational disability falls on the physician or psychologist on the multidisciplinary team. There are no standardized instruments to assess the vocational status of people with chronic pain. In the absence of a standard instrument, the clinicians assessing these patients should address the following issues: (1) Is the patient currently working? (2) If the patient is not working, is this related to his or her health? (3) How long has the patient been out of the work force? (4) Is he or she receiving any kind of work disability benefits? Which ones?

Assessment of Emotional Distress

The results of numerous studies suggest that chronic pain is often associated with emotional distress, particularly depression, anxiety, anger, and irritability (Gallagher & Verma, 2004; McBeth, Macfarlane, Benjamin, & Silman, 2001). The presence of emotional distress in people with chronic pain presents a challenge when assessing symptoms such as fatigue, reduced activity level, decreased libido, appetite change, sleep disturbance, weight gain or loss, and memory and concentration deficits, as these symptoms can be the result of pain, emotional distress, or treatment medications prescribed to control pain. Instruments have been developed specifically for pain patients to assess psychosocial distress, the impact of pain on patients’ lives, feeling of control, coping behaviors, and attitudes about disease, pain, and healthcare providers (Turk & Melzack, 2011).

Both the Beck Depression Inventory (BDI) and BDI-2 (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Beck, Steer, Ball, & Ranieri, 1996) and the Profile of Mood States (POMS, McNair & Lorr, 1971) have well-established reliability and validity in the assessment of symptoms of depression and emotional distress, and they have been used in numerous clinical trials in psychiatry and an increasing number of studies of patients with chronic pain. In research in psychiatry and chronic pain, the BDI provides a well-accepted criterion of the level of psychosocial distress in a sample and its response to treatment. The POMS (McNair & Lorr, 1971) assesses six mood states—tension–anxiety, depression–dejection, anger–hostility, vigor–activity, fatigue–inertia, and confusion–bewilderment—and also provides a summary measure of total mood disturbance. Although the discriminant validity of the POMS scales in patients with chronic pain has not been adequately documented, it has scales for the three most important dimensions of emotional functioning in chronic pain patients (depression, anxiety, anger), and it also assesses three other dimensions that are very relevant to chronic pain and its treatment, including a positive mood scale of vigor-activity. The scores must be interpreted with caution, and the criteria for levels of emotional distress may need to be modified to prevent false positives (e.g., Turk & Okifuji, 1994).

Assessment of Fear of Activity and Activity Avoidance

A number of studies have implicated the role of the patient’s idiosyncratic appraisals of his or her symptoms, expectations regarding the cause of the symptoms, and the meaning of the symptoms, in addition to organic factors, as essential in understanding the individual’s report of pain and subsequent disability (Carragee, Alamin, Miller, & Carragee, 2005; Jarvik et al., 2005; M.P. Jensen, Romano, Turner, Good, & Wald, 1999; M.P. Jensen, Turner, & Romano, 1994; M.P. Jensen, Turner, Romano, & Lawler, 1994). Fear of activity that might either amplify pain or cause further damage has been shown to play an important role in musculoskeletal disorders, particularly back pain (Vlaeyen & Linton, 2012). Many patients with chronic pain, especially those who attribute their symptoms to traumas, are fearful of engaging in activities that they believe may either contribute to further injury or exacerbate their symptoms. Avoidance of activities may, in the short term, lead to symptom reduction; but, over time, restriction of activities is likely to lead to decreased functional capacities as a result of deconditioning. Also, avoidance of activity has the unfortunate consequence of preventing corrective feedback.

Healthcare providers may inadvertently contribute to avoidance of activity by providing patients with cervical collars that restrict neck movements and advising them to avoid activities that hurt (i.e., hurt = harm). They may contribute to the patient’s anxiety that something is seriously wrong with their bodies by continuing to order sophisticated diagnostic tests in search of occult physical pathology.

Two self-report measures have been shown to be particularly useful in assessing fear of activity: the Tampa Scale for Kinesiophobia (Kori, Miller, & Todd, 1990) and the Fear of Activity and Behavior Questionnaire (Waddell, Newton, Henderson, Somerville, & Main, 1993). Responses to these measures have been shown to predict disability and response to treatment (Vlaeyen & Linton, 2012).

Assessment of Coping and Psychosocial Adaptation to Pain

Historically, “traditional” psychosocial measures that are designed to evaluate psychopathological tendencies have been used to identify specific individual differences associated with reports of pain, even though these measures were usually not developed for, or standardized on, samples of medical patients. Thus, it is possible that responses by medical patients may be distorted as a function of the disease or the medications that they take. For example, as noted, common measures of depression ask patients about their appetites, sleep patterns, and fatigue. Similarly, the commonly used MMPI includes items related to physical symptoms, such as the presence of pain in the back of the neck, the ability to work, feelings of weakness, and beliefs regarding health status in comparison with friends. Because disease status and medication can affect responses to such items, patients’ scores may be elevated, distorting the meaning of the responses. More recently, a number of assessment instruments have been developed for use specifically with pain patients. Instruments have been developed to assess psychosocial distress, the impact of pain on patients’ lives, feelings of control, coping behaviors, and attitudes about disease, pain, and healthcare providers and the patient’s plight (for a detailed review and critique, see DeGood & Cook, 2011).

A sample of an instrument developed to assess both psychosocial and behavioral factors associated with chronic pain is the West Haven-Yale Multidimensional Pain Inventory (MPI, Kerns et al., 1985). This 60-item questionnaire is divided into three sections, with the first assessing the patient’s perception of pain severity, the impact of pain on their life, affective distress, feelings of control, and support from significant people in their lives. The second section assesses the patient’s perceptions of the responses of significant people to their complaints of pain. The third section examines the change in patients’ performance of common activities such as household chores and socializing (see DeGood & Cook, 2011).

Assessment of Overt Expressions of Pain

Patients display a broad range of responses that communicate to others that they are experiencing pain, distress, and suffering (what are called pain behaviors). Pain behaviors include verbal reports, paralinguistic vocalizations (e.g., sighs, moans), motor activity, facial expressions, body postures and gesturing (e.g., limping, rubbing a painful body part, grimacing), functional limitations (reclining for extensive periods of time), and behaviors designed to reduce pain (e.g., taking medication, use of the healthcare system). Although there is no one-to-one relationship between these pain behaviors and self-report of pain, they are at least modestly correlated.

A number of different observational procedures have been developed to quantify pain behaviors (Keefe, Somers, Williams, & Smith, 2011). Several investigators using the Pain Behavior Checklist (Turk, Wack, & Kerns, 1985) have found a significant association between these self-reports and behavioral observations. Behavioral observation scales can be used by patients’ significant others as well. Healthcare providers can use observational methods to systematically quantify various pain behaviors and note the factors that increase or decrease them. For example, observing the patient in the waiting room, while being interviewed, or during a structured series of physical tasks.

As previously described, pain is a complex, subjective phenomenon comprising a range of factors and is uniquely experienced by each person. Wide variability in pain severity, quality, and impact may be noted in reports of patients attempting to describe what appear to be objectively identical phenomena. In addition, patients have a different frame of reference from that of the caregiver. These unique views may complicate communication between patient and caregiver and may prevent direct comparisons among patients from different backgrounds and with different experiences. Patient’s descriptions of pain are also colored by cultural and sociological influences. It is the unique experiences of each patient that make assessment of pain so difficult. Because of the subjectivity inherent in pain, suffering, and disability are difficult to prove, disprove, or quantify in a completely satisfactory fashion. As discussed previously, response to the simple question, How much does it hurt? is, indeed, far from simple. The experience and report of pain are influenced by multiple factors, such as cultural conditioning, expectancies, current social contingencies, mood state, and perceptions of control. Physical pathology and the resulting nociception are important, albeit, not the sole contributors to the experience of pain. It is important to acknowledge the central importance of patients’ self-reports, along with their behavior in pain assessment. It is highly unlikely that we will ever be able to evaluate pain without reliance on the person’s perceptions. The central point to keep in mind is that it is the patient who reports pain and not the pain itself that is being evaluated.

Treatment based on a biopsychosocial perspective should address any identified pathology as a first step. However, for the majority of chronic musculoskeletal pain problems, there is no cure. There are, of course, some exceptions. For example, the patient with severe knee joint deterioration due to osteoarthritis may be “cured” following knee replacement, as may some patients who are surgically treated for severe spinal canal claudication. Those who do not benefit from such disease-modifying interventions, or for whom there are no comparable interventions, will continue to experience at least some levels of pain. For these patients, consideration needs to be given to how to help them to function as effectively as possible and to maintain a reasonable level of health-related quality of life despite persistent pain. For this large majority, a comprehensive intervention based on the biopsychosocial model that may include medication, symptomatic interventions (e.g., epidural steroids), nonpharmacological somatic modalities (e.g., physical therapy), and psychosocial interventions (e.g., relaxation, problem solving, pacing of activities, goal versus symptom directed, stress management) as an integrated package may be most appropriate. It is useful to view such comprehensive treatment from a cognitive-behavioral perspective because this perspective is applicable to any combination of modalities, individualized to meet patients’ needs and unique characteristics (Flor & Turk, 2011).

Cognitive-Behavioral Perspective on the Treatment of Chronic Musculoskeletal Pain

The cognitive-behavioral (CB) perspective has become the most commonly accepted psychological treatment choice for use with chronic pain patients (e.g., Eccleston, Williams, & Morley, 2009; Gatchel & Okifuji, 2006; Hoffman, Papas, Chatkoff, & Kerns, 2007). The CB perspective suggests that behaviors and emotions are influenced by interpretations of events, rather than solely by the objective characteristics of an event itself. Rather than focusing on the contribution of cognitive and emotional factors to the perception of a set of symptoms in a static fashion, emphasis is placed on the reciprocal relationships among physical, cognitive, affective, and behavioral factors. According to the CB perspective, it is peoples’ idiosyncratic attitudes, beliefs, and unique representations that filter and interact reciprocally with emotional factors, social influences, behavioral responses, and sensory phenomena. Moreover, peoples’ behaviors elicit responses from significant others that can reinforce both adaptive and maladaptive modes of thinking, feeling, and behaving. Thus, a reciprocal and synergistic model is proposed.

Assumptions of the Cognitive-Behavioral Perspective

There are five central assumptions that characterize the CB perspective:

The first assumption is that all people are active processors of information, rather than passive reactors to environmental contingencies. People attempt to make sense of the stimuli from the external environment by filtering information through organizing attitudes derived from their prior learning histories and by general strategies that guide the processing of information. People’s responses (overt as well as covert) are based on these appraisals and subsequent expectations, and they are not totally dependent on the actual consequences of their behaviors (i.e., positive and negative reinforcements and punishments). From this perspective, anticipated consequences are as important in guiding behavior as are the actual consequences.
A second assumption of the CB perspective is that one’s thoughts (e.g., appraisals, attributions, and expectations) can elicit or modulate affect and physiological arousal, both of which may serve as impetuses for behavior. Conversely, affect, physiology, and behavior can instigate or influence thinking processes. Thus, the causal priority depends on where in the cycle the person chooses to begin. Causal priority may be less of a concern than the view of an interactive process that extends over time, with the interaction of thoughts, feelings, physiological activity, and behavior.
CB perspectives are unique in that they emphasize the reciprocal effects of the person on the environment and the influence of environment on the person and his or her behavior. The third assumption of the CB perspective, therefore, is that behavior is reciprocally determined by both the environment and the person. People not only passively respond to their environment but also elicit environmental responses by their behavior. In a very real sense, people create their environments.
A fourth assumption is that if people have learned maladaptive ways of thinking, feeling, and responding, then successful interventions designed to alter behavior should focus on these maladaptive thoughts, feelings, and physiology, as well as behaviors and not on one to the exclusion of the others. There is no expectancy that changing only thoughts, or feelings, or behaviors will necessarily result in changes in the other two areas.
The final assumption is that, in the same way as people are instrumental in the development and maintenance of maladaptive thoughts, feelings, and behaviors, they can, are, and should be considered active agents of change of their maladaptive modes of responding. People with chronic pain, no matter how severe, despite common beliefs to the contrary, are not helpless pawns of fate. They can and should become instrumental in learning and carrying out more effective modes of responding to their environment and their plight.

From the CB perspective, people with pain are viewed as having negative expectations about their own ability to control certain motor skills without pain. Moreover, pain patients tend to believe they have limited ability to exert any control over their pain. Such negative, maladaptive appraisals about the situation and personal efficacy may reinforce the experience of demoralization, inactivity, and overreaction to nociceptive stimulation. These cognitive appraisals and expectations are postulated as having an effect on behavior, leading to reduced efforts and activity, which may contribute to increased psychosocial distress (helplessness) and subsequent physical limitations.

If we accept that pain is a complex, subjective phenomenon that is uniquely experienced by each person, then knowledge about idiosyncratic beliefs, appraisals, and coping repertoires becomes critical for optimal treatment planning and for accurately evaluating treatment outcome. People with persistent pain have beliefs, appraisals, and expectations about pain, their ability to cope, social supports, their disorder, the medicolegal system, the healthcare system, and their employers, all of which are important because they may facilitate or disrupt the sufferer’s sense of control. These factors also influence patients’ investment in treatment, acceptance of responsibility, perceptions of disability, adherence to treatment recommendations, support from significant others, expectancies for treatment, and acceptance of treatment rationale.

Cognitive interpretations also affect how patients present symptoms to others, including healthcare providers. Overt communication of pain, suffering, and distress will enlist responses that may reinforce pain behaviors and impressions about the seriousness, severity, and uncontrollability of pain. That is, reports of pain may induce physicians to prescribe more potent medications, order additional diagnostic tests, and, in some cases, perform surgery (Turk & Okifuji, 1997). Family members may express sympathy, excuse the patient from responsibilities, and encourage passivity, thereby fostering further physical deconditioning. The CB perspective integrates the operant conditioning emphasis on external reinforcement and respondent view of conditioned avoidance within the framework of information processing. Indeed, people with persistent pain often have negative expectations about their own ability and responsibility to exert any control over their pain. Moreover, they often view themselves as helpless. Such negative, maladaptive appraisals about their condition, situation, and their personal efficacy in controlling their pain and problems associated with pain reinforce their experience of demoralization, inactivity, and over-reaction to nociceptive stimulation. These cognitive appraisals are posited as having a negative effect on behavior, leading to reduced effort, reduced perseverance in the face of difficulty, and reduced activity and increased psychosocial distress.

The CB perspective on pain management focuses on providing the patient with techniques to gain a sense of control over the effects of pain on his or her life, as well as actually modifying the affective, behavioral, cognitive, and sensory facets of the experience. Behavioral experiences help to show patients with that they are capable of more than they assumed, increasing their sense of personal competence. It is important to distinguish the CB perspective from cognitive and behavioral techniques (e.g., self-monitoring to identify relationship among thoughts, mood, and behavior; distraction using imagery; and problem solving). Although many treatment studies and clinics report that they use a cognitive-behavior therapy, “CBT,” the components can be quite varied, and there is no consensually agreed upon standard set of components that comprise CBT. From the CB perspective, the assumption is that long-term maintenance of behavioral changes will occur only if the person with chronic pain has learned to attribute success to his or her own efforts. There are suggestions that these treatments can result in changes of beliefs about pain, coping style, and reported pain severity, as well as direct behavior changes. Furthermore, treatment that results in increases in perceived control over pain and decreased catastrophizing also results in decreases in pain severity and functional disability. When successful rehabilitation occurs, there is a major cognitive shift from beliefs about helplessness and passivity to resourcefulness and ability to function regardless of pain, and from an illness conviction to a rehabilitation conviction (e.g., Tota-Faucette, Gil, Williams, & Goli, 1993; Turner et al., 2000).

The complexity of chronic pain that we have described suggests that no single healthcare professional or discipline is likely to prove effective for a large number of patients by itself. Over the past 30 years, this observation has resulted in the development of interdisciplinary pain rehabilitation programs (IPRP) designed to deal with the complexities. The perspective offers a way to think about patients and people in general, and it does not require training as a mental health professional or training in the use of specific techniques used to bring about change. Not all patients with persistent pain require a comprehensive rehabilitation program.

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