2. … learning objectives
On completion this online class, you will be able to:
1. Explaining the potential contributing factors related to pain to
the patient
2. Addressing the psychosocial issues related to the patient’s
profile in the management of pain
3. Develop treatment strategies to improve the outcome through
the biopsychosocial lens (the person-centered care)
6. The “new” epidemic: Iatrogenic disorders?
Your bones are out
of place!
Look at the damage
in your scan!
It’s dangerous to lift.
Don’t do that!
You should be
careful!
7. What predicts persistent disabling pain?
Foster et al. 2010; Lee et al. 2015, Chen et al. 2018.
Our emotion:
- Pain related-fear
- Emotional distress
- Worry/low mood
Our responses:
- Rest
- Over-protect
- Avoidance
- Poor sleep
Our thoughts:
- Identity
- Cause
- Consequences
- Timeline
- Curability
Influenced by:
1. Socio-econo
mic factors
2. Early life
stress
3. Pain severity
4. Social stress
5. Mental health
8. Psychological factors in the experience of pain
Attention
Linton & Shaw, 2011; Caneiro et al. 2021..
Cognition Emotion Overt Behavior
Vigilance may
increase pain
intensity
Poor beliefs & low
expectations
shape pain &
disability
Fear, anxiety, anger
& depression may
increase pain
disability
Avoidance &
over-protective
behavior may lead
pain persistence
9. Common-sense model of self-regulation
Leventhal 1980; Hagger & Orbell 2003
Low back pain
It’s wear & tear
Avoid
activities
The pain
stays/worsen
Perception Coping Appraisal
10. Pain related-fear & avoidance
Boersma et al 2006; Zale et al 2013; Meulders 2019
Failed attempts to gain
control over the pain
experience and its
impact can reinforce
fear learning and result
in increased disability
in the long term
11. The way we think about our body, attributes to
the way we behave
Adopted from de Raaij. 2021.
Grow
Recover
Change
Adapt
Repair
Replace
Wear & Tear
Get Stuck
13. Case study: Mr. A
With patient permission
41 years old men, having low
back pain radiating to the
buttock over 3 months. No
history of trauma/fall.
He has been told to avoid
movement/activity that hurts
by specialist. Spending time to
rest and hoping to recover but
pain get worst.
Autonomic arousal
(muscles tense-up,
inability to relax, linked
to anxiety)
Pain protective
behavior (slow
movement, breath
holding, bracing)
14. Pain management program for Mr. A
With patient permission
• Making sense of pain
• Reduce threat of
movement
• Change negative
beliefs
• Graded exposure &
symptom modification
• Facilitate learning &
reinforce new
behavior
• Self-coping/self-man
agement skills
Less vigilance,
enhance new learning
behavior, relax
movement
15. Case study: Mr. B
With patient permission
39 years old men, having radicular pain (right) with
lateral lumbal shift (to the left). Previous history of
back pain a year ago but recover quickly after
physiotherapy. However, currently, he has belief that
“his back is vulnerable and get trapped nerve”. He
avoid activity that provokes pain and feeling distress
because of absenteeism in the work.
Clinical exams:
- Increased neuromechanosensitivity (SLR +,
Contralateral SLR +, Slump test +)
- Reduced sensory (level L4-L5)
- No red flags
16. Pain management program for Mr. B
With patient permission
• Making sense of pain
• Educate the prognosis
of the condition
• Engage in active self
care (exercise):
Specific (lateral shift
correction &
neurodynamic
mobilisation) &
general (strength
conditioning program)
• Facilitate learning &
reinforce new
behavior
Lateral shift correction –
decrease pain symptom,
centralization phenomenon)
17. What lessons have we learned?
1. How a person makes sense of their pain will influence how they
respond to it from both a behavioral and emotional perspective.
2. Over-protective responses can be pro-nociceptive, leading to
abnormal stress on sensitized the nervous system and in turn,
increased pain intensity and pain persistence
3. Pain-related fear is modifiable and targeting protective (eg, slow
and guarded task performance) and avoidance (eg, not performing
a task) behavior may be an opportunity to reduce disability and
the burden of chronic musculoskeletal pain.
Boersma & Linton, 2006; Bunzli et al, 2015;
Wiech, 2016; van Dieen et al 2017
19. Central sensitization
Woolf, 2011; Nijs et al, 2014.
Central sensitization is defined as:
● An amplification of neural signaling within central nervous system that elicits
pain hypersensitivity
The accelerator activated by:
● Cognitive-emotional factors
● Pain catastrophizing
● Stress
● Hypervigilance
● Lack of acceptance
● Depressive thoughts
● Maladaptive illness
perception
20. Barriers to recovery
Foster et al, 2010; Caneiro et al. 2019
Our thinking
Loss of hope
No time for self-care
Lack of access/funding
Social stress
Comorbid health
'Quick fixes’
Low confidence
21. Screening psychological risk factor & disability
Linton et al. SPINE. 2011.
Total score >50
indicating higher
estimated risk for
future work
disability
22. Develop treatment strategies
Complexity
Low risk
High risk
Advice, education & self-management.
Avoid over-treatment and investigation.
Psychologically informed physiotherapy
with enhanced skills & more time.
Evidence-based physiotherapy.
24. The GAME Approach
Graded Activity, Movement with Exposure
Purwanto, PhysioKita. 2019.
Core concept – The behavioral experiment
● Pavlonian conditioning model
○ A conditioned learning that occurs because of the
individual's natural response to a stimulus.
○ Repeated stimulus affect individual behavior (a cognitive
challenge)
● Operant conditioning model
○ A conditioned learning by 'strengthening' individual behavior
(activities) gradually
26. The principles of reconceptualizing pain through
movement behavioral experimentation
Understand what
the patient
understand
Why do you think
you have pain?
Challenge unhelpful
beliefs
Is it safe for you to
exercise? Why?
Enhance
self-efficacy
Are you confident to
complete this
exercise?
Provide
safety
cues
Advice on movement
modification & suitable
level of pain
Pain is not a sign of
tissue damage
It’s important to
adjust the exercise
dependent on your
symptom
Smith et al. 2018; Caneiro et al. 2021.
28. Clinical tips
1. Identify modifiable factors and develop a formulation of
relationship between the biopsychosocial domains
2. Identify specific goals and break down into specific subgoals
3. Inform decision and develop a plan for dealing likely obstacles
(eg. at home and at work) to progress and setbacks.
4. Provide skills training as needed (self-management and
self-coping strategies)
5. Monitor and reinforce the performance of planned tasks
30. There is always a space for
improvement, no matter
how long you’ve been in the
recovery process
With patient permission
… another story
31. Take home messages
1. Biopsychosocial factors predict the transition from acute to
chronic/persistent disabling pain
2. Psychological approach (cognitive & emotional) can play an
important role to interrupt progression from acute to
chronic/persistent disabling pain & boost the recovery process
3. It’s time for action to
a. Make pain matter
b. Make pain understood
c. Make pain better
32. Deal with the person(s), is to deal with
their psychology & their behavior.
