This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World " edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.
To experience severe, protracted back pain is to live in a world of uncertainty. Except in cases of injury, the cause of the pain is usually unclear, and even the sensations being experienced often fluctuate unpredictably. The multitude of diverse approaches to the diagnosis and treatment of pain—ranging from highly-trained spine surgeons to charlatans huckstering unproven “cures”—can create profound confusion, distrust and even self-doubt. And, as the pain progresses, the future becomes more clouded, as quality of life and ability to function diminish.
The uncertainty of chronic back pain can both create emotional and behavioral problems. Further, the pain and uncertainty can act upon pre-existing psychological or interpersonal difficulties, creating a self-perpetuating cycle of disability and distress. Yet, individuals often have strengths and experiences in dealing with difficulties that they can bring to bear in order to push through the uncertainty of pain—keeping focused, positive and resilient in the face of all this uncertainty.
In this article we explore the ways in which the aversive, elusive nature of pain can engender a host of negative emotions, ones which threaten the ability to recover. We also discuss psychological strengths that can overcome these negative emotions, and provide a path to return to normalcy.
Negative Emotions
Depression and Demoralization. The most frequent and most adverse emotion experienced by individuals with chronic pain is depression. Sadness, lethargy, demoralization and depression may be expected responses to the disruption of lifestyle, financial and interpersonal problems, and continued noxious sensations experienced by patients. Further, for some individuals, depression and demoralization are chronic conditions, predating the onset of pain, and are greatly exacerbated by it. Unfortunately, depression has been found to decrease the effectiveness of many treatments for chronic pain including spine surgery, physical therapy and interdisciplinary pain management programs. This may be partly a function of the fact that depression makes it more difficult to recognize positive aspects of life, and to gather the motivation necessary to improve function. For chronic pain patients experiencing clinical depression, a combination of antidepressant medication and cognitive-behavioral psychotherapy can greatly improve responsiveness to medical/surgical treatments.
Anger and Guilt. Almost as frequent as depression among chronic pain patients is anger. This can arise from many sources. Patients may be angry at an individual perceived as the cause of the pain. They can be angry with employers or spouses who they feel may lack understanding of their condition or are holding them back from improving. The anger may be self-directed, especially if the individual feels guilty about lifestyle changes, such as loss of income or inability to fulfill family roles. Further, just like depression, anger can be a chronic issue, and one which is worsened by pain. Whatever the source and focus of the pain, anger can impair an individual’s ability to prioritize—to recognize that improvement in function and reduction in pain are more important than proving a point or seeking revenge upon those perceived as the source of the pain. Further, anger can lead to poor lifestyle choices, such as drug or alcohol abuse, that can have adverse effects on both the patient’s overall health and ability to bond with treatment providers. For individuals experiencing high levels of anger a client-centered approach, involving the patient in treatment planning and decision-making, as well as psychotherapy to help the patient prioritize and focus, may be of great value.
Anxiety and Fear. Anxiety and fear also frequently accompany pain. Here uncertainty may take its greatest toll. As patients face a plethora of treatment choices, and some of the choices they make are ineffective or even worsen their pain, patients may begin to doubt their own pain experience. After all, if they were truly experiencing pain, why would proven treatments not work? Further, as pain is exacerbated-- sometimes provoked by movement and sometimes unpredictably—the fear of increased pain can lead cause individuals to be severely restrict activity. Decreased muscular strength, flexibility and loss of enjoyment follow, increasing the grip of pain’s uncertainty on individual’s quality of life.
Psychological Strengths
Health Engagement. Individuals vary widely in addressing their physical health. For some, activities such exercise, diet and weight control are highly prioritized. Others, for a multitude of reasons, may never have given health issues much focus, expending their energy in other ways. One’s engagement in health-related activities becomes particularly important in dealing chronic pain, as this condition can create many adverse health effects—sleep loss, activity restriction and weight gain. There is even growing evidence that pain predisposes individuals towards poorer resistance to infection and cognitive deficits. Health engagement is an important key in countering these adverse effects of pain. Not simply confined to diet and exercise, health engagement includes more general involvement in one’s medical care—asking questions of health care providers, discussing potential treatments and outcome expectations.
Pain Coping. Pain begins as a sensation arising from tissue damage or disruption. However, the meaning one applies to this sensation, especially as the pain becomes chronic, can dictate one’s emotions, as well as the actions taken to alleviate the pain. To the extent that an individual engages in “catastrophizing”—i.e., believing the pain will never remit and will only worsen—negative emotions such as depression and anxiety develop, leaving one demoralized and lethargic. Fortunately, there are other ways to cope with pain. Distraction is one such effective technique—keeping the pain at bay by focusing on other events and activities such as work, music or relationships. There is evidence that meditation and prayer can help many stay more relaxed and less stressed. Living “in the moment” rather than projecting a future filled with inevitable, increasingly unacceptable limitation, also avoids the hopelessness that can undercut any treatment efforts.
Resilience. Everyone encounters difficult life circumstances—deaths, illness, interpersonal problems, job terminations, etc. While sadness and even grief accompany such events, most people are able to eventually bounce back and lead relatively normal, if changed, lives. These experiences of resilience--loss and recovery--can form the basis for the most effective ways to deal with pain. Just as adverse life circumstances have unexpected causes and lead to uncertain futures, so chronic pain has these same characteristics. Focus, support from others, persistence and hope, as well as acceptance of loss, all these form the basis of resilience, and are key elements in coping with and overcoming pain’s uncertainty.
Integrated Approach to Spinal Pain
The Texas Back Institute was among the first to recognize the extent to which patients’ psychological vulnerabilities, as well as their strengths, can impact both the experience of pain and responses to treatments and have been studying it for over 30 years. As a psychologist in the group, I work with the surgeons to sift through the uncertainty of pain, to help clarify and individualize treatment plans, in order both to maximize the likelihood of positive surgical and medical treatment outcomes, and to avoid worsening of symptoms. Working with the surgical team we have developed a systematic process for identifying and quantifying psychological risk factors for reduced surgical outcome. Our algorithm stratifies patients into good, fair and poor outcome prognosis categories. Our published studies indicate that about 15% of patients in the highest levels of psychological risk achieve good surgical results, despite having clear indications for surgery. This algorithm is now taught in many Clinical Health Psychology training programs, and is the most widely-utilized protocol nationally for conducting presurgical psychological evaluation.
To further assist in assessing the impact of psychological and emotional factors on surgery results we have developed two special reports, the Spine Surgery Candidate Interpretive Report (Spine-CIR), and the Spinal Cord Stimulator Candidate Interpretive Report (Stim-CIR). This report utilizes data from our 12-year research study, of over 2500 surgical candidates, centering on the Minnesota Multiphasic Personality Inventory-2, Revised Form (MMPI-2-RF). The MMPI-2-RF is the gold standard in psychometric testing, used in for purposes as diverse as pre-employment screening of first responders, assessment of psychiatric inpatients, and also for presurgical evaluation in many conditions including bariatric surgery and organ transplantation. In keeping with the culture of TBI, we provide learning opportunities to train psychologists in the techniques for conducting comprehensive presurgical psychological evaluation, integrating information from the Spine-CIR and Stim-CIR with other information gleaned through patient interview and medical record reviews. This comprehensive approach allows us not only to project how well the patient is likely to respond to spine surgery, but also to develop treatment plans that maximize patient strengths while mitigating psychological risks. In so doing, we help both the patient and the treating physician to cut through fog of uncertainty surrounding the diagnosis and treatment of chronic spine pain, thereby providing treatment plans that help the patient to obtain the best possible outcomes.
Conclusion
Chronic back pain is a debilitating, confusing physical and emotional experience. Adverse emotions arise which can worsen the impact of pain. However, individuals can draw upon their strengths to release the hold that pain has on their lives. In so doing, they can create for themselves a measure of control, direction and certainty, ultimately resuming a full and fulfilled life. Medical and surgical interventions that recognize the role of patient psychosocial characteristics in influencing treatment outcomes will achieve the most sanguine treatment outcomes and will avoid medical/surgical failures.
For further information about presurgical psychological evaluation, or the Spine-CIR and Stim-CIR contact author at: ablock@texasback.com
Previous chapters:
Challenges, risks and opportunities in today's spine world
Spine care - Balancing cost with innovation
What are big data and predictive analytics
Predictive Analytics and Machine Learning
The HSS Spine Care Model, Part 1
The HSS Spine Care Model, Part 2
The History of Texas Back Institute
Private practice vs. hospital employee: Where we are today and why
Episodes of care and bundled payments
Episodes of care and bundled payments, a sustainable approach
Dr. Scott Blumenthal on specialty hospitals