This in response to Dr Phil Snell's post on Facebook which is a very important conversation to have. Thanks Phil!
With a boom in the 'brain first' approaches, many patients with musculoskeletal pain and disabilities are being told that the cause of their problem is psychosocial and that is the first and most important part of treatment. Clearly, many people need this approach. Past studies have pointed to the (sorry to simplify this) 'think-well-behave-well-and-you'll heal-well' approaches in the evidence-based literature, which is now irrefutable - that psychosocial mechanisms often need treatment because they can definitely be an obstacle to recovery. However, the paper that Dr Snell posted raises the idea that pain may influence catastrophizing and that the latter is not a given or fixed.
A problem with research generally is that it's difficult to tease out which initiates and which responds, or in what way they may be integrated. Here's a study in point that challenges the psychosocial first approach.
UK Million Women Study - The Lancet
As part of the UK Million Women study, here is an investigation of 720,000 women in which the effects of health-on-happiness or happiness-on-health were studied. Many assume that the statement "Be happy and you'll be healthy" prevails and a lack of happiness produces health problems. However what did this study find?
The study pretty much found that, it was NOT the psychosocial that caused the health problems. It was actually health problems that caused the women to be unhappy.
Funny how we ignore the obvious. Being sick is horrible.
With a boom in the 'brain first' approaches, many patients with musculoskeletal pain and disabilities are being told that the cause of their problem is psychosocial and that is the first and most important part of treatment. Clearly, many people need this approach. Past studies have pointed to the (sorry to simplify this) 'think-well-behave-well-and-you'll heal-well' approaches in the evidence-based literature, which is now irrefutable - that psychosocial mechanisms often need treatment because they can definitely be an obstacle to recovery. However, the paper that Dr Snell posted raises the idea that pain may influence catastrophizing and that the latter is not a given or fixed.
A problem with research generally is that it's difficult to tease out which initiates and which responds, or in what way they may be integrated. Here's a study in point that challenges the psychosocial first approach.
UK Million Women Study - The Lancet
As part of the UK Million Women study, here is an investigation of 720,000 women in which the effects of health-on-happiness or happiness-on-health were studied. Many assume that the statement "Be happy and you'll be healthy" prevails and a lack of happiness produces health problems. However what did this study find?
The study pretty much found that, it was NOT the psychosocial that caused the health problems. It was actually health problems that caused the women to be unhappy.
Funny how we ignore the obvious. Being sick is horrible.
Neck Pain Study - Whiplash
See/download study
Another, and underquoted, study is the one by Gurumoorthy and Twomey (1996), for which Gurumoorthy was awarded a PhD at Curtin University, Western Australia, supervised by the eminent Professor Lance Twomey.
They randomly placed acute whiplash sufferers into 3 treatment groups for the first 4 weeks after whiplash and compared the clinical outcomes of pain; range movement; muscle strength; return to work and disability at 4, 6, 12, 24 and 52 weeks - basically a year's follow-up.
The groups were 1. mobilisation - activity, muscle strength and ROM exercises, 2. immobilisation - Philiadelphia brace (rigid) so they could not move their neck and 3. return to the Dr for medical management, medication, analgesics etc.
As time passed the best group was the IMMOBILSATION group. They got better and better and better in their pain, muscle strength and ROM than the other two groups. Again, this was tested at 4, 6, 12, 24 and 52 weeks so the benefits carried through to the chronic stage. The immobilisation group also showed better return to work and less disability than the other two groups at 1 year.
Surprise! The IMMOBILISATION group did better and, what's more, reduced activity and movement did NOT produce more disability or loss of function.
Pain messes up function.
These results support the basis for tissue (aka nociceptive) mechanisms in which, when they hurt, pathologies such as microfractures, haematomas, disc ruptures, arthropathies and radiculopathies (which have been shown to occur in whiplash) can sometimes be managed acutely as a means of preventing chronicity. Funny also how we do this with sports injuries but for spinal pain that we don't understand, we often dismiss tissue (nociceptive) approaches and instead apply psychosocial.
Professors Nikolai Bogduk and Charles Aprill have also shown that abnormal psychosocial scores in people with back pain can improve substantially when nociception and pain are relieved with local anaesthetics.
Pain can drive you crazy.
We often attribute pain and disability to psychosocial factors, which can definitely be an obstacle. But co-existence is not proof of a directional cause.
Clearly, a lot of very precise research is necessary to prove directional effects (either way) and co-existence is not always proof of a causal relationship. But the above is helpful in challenging the view that we should be routinely, or by default or philosophical position, be telling patients that their pain and disability are due to psychosocial problems.
All should be considered in balance and tested in each patient from an unbiased standpoint. As such, there is no substitute for being an open-minded, diligent and skilled clinician willing to treat the relevant aspects, including the tissues.
MICHAEL SHACKLOCK
DPT, MAppS, FACP
See/download study
Another, and underquoted, study is the one by Gurumoorthy and Twomey (1996), for which Gurumoorthy was awarded a PhD at Curtin University, Western Australia, supervised by the eminent Professor Lance Twomey.
They randomly placed acute whiplash sufferers into 3 treatment groups for the first 4 weeks after whiplash and compared the clinical outcomes of pain; range movement; muscle strength; return to work and disability at 4, 6, 12, 24 and 52 weeks - basically a year's follow-up.
The groups were 1. mobilisation - activity, muscle strength and ROM exercises, 2. immobilisation - Philiadelphia brace (rigid) so they could not move their neck and 3. return to the Dr for medical management, medication, analgesics etc.
As time passed the best group was the IMMOBILSATION group. They got better and better and better in their pain, muscle strength and ROM than the other two groups. Again, this was tested at 4, 6, 12, 24 and 52 weeks so the benefits carried through to the chronic stage. The immobilisation group also showed better return to work and less disability than the other two groups at 1 year.
Surprise! The IMMOBILISATION group did better and, what's more, reduced activity and movement did NOT produce more disability or loss of function.
Pain messes up function.
These results support the basis for tissue (aka nociceptive) mechanisms in which, when they hurt, pathologies such as microfractures, haematomas, disc ruptures, arthropathies and radiculopathies (which have been shown to occur in whiplash) can sometimes be managed acutely as a means of preventing chronicity. Funny also how we do this with sports injuries but for spinal pain that we don't understand, we often dismiss tissue (nociceptive) approaches and instead apply psychosocial.
Professors Nikolai Bogduk and Charles Aprill have also shown that abnormal psychosocial scores in people with back pain can improve substantially when nociception and pain are relieved with local anaesthetics.
Pain can drive you crazy.
We often attribute pain and disability to psychosocial factors, which can definitely be an obstacle. But co-existence is not proof of a directional cause.
Clearly, a lot of very precise research is necessary to prove directional effects (either way) and co-existence is not always proof of a causal relationship. But the above is helpful in challenging the view that we should be routinely, or by default or philosophical position, be telling patients that their pain and disability are due to psychosocial problems.
All should be considered in balance and tested in each patient from an unbiased standpoint. As such, there is no substitute for being an open-minded, diligent and skilled clinician willing to treat the relevant aspects, including the tissues.
MICHAEL SHACKLOCK
DPT, MAppS, FACP