Can Chronic Pain be Prevented? The Role of Fear and Distress
How can chronic pain be prevented? Oh that I and the insurance companies knew the answer to that question!
The key is to identify those patients at risk for the development of chronic pain.
Musculoskeletal pain is a significant problem in this country: 85% of the population suffers from this affliction at some point during the employment years. Fortunately, the majority recover rather quickly from acute back pain. It is the 3% to 10% that develop long-term disability due to their chronic pain, which is a deceptively small percentage if one considers that this minority consumes significantly more than 50% of the health care dollars for this problem.
If the chronic pain group could be identified, perhaps an intervention could occur which might avoid the suffering and costs associated with pain and loss of income. Unfortunately, musculoskeletal pain is such a frequent occurrence, it would be prohibitively costly to attempt psychological interventions upon every individual suffering the back pain. Again, those most at risk must be identified, to allow early intervention and avoid chronic pain.
Psychological factors have been shown to be strong predictors of long term disability and sick leave. These cognitive and behavioral variables have a huge role in transforming acute pain into chronic (and often debilitating) pain. The most powerful of these factors include fear, distress, and avoidance of physical activities.
Research has shown that fear-avoidance is related to chronic pain, and often chronic disability. It is a potent predictor of self-reported disability. It is a predictor of future disability in individuals suffering from acute low back pain. If fear-avoidance could be harnessed, so to speak, perhaps acute pain would remain acute, and not become a chronic disability.
Studies have shown the importance of fear-avoidance and depressed mood in the development of chronic pain and disability. Individuals with these characteristics took much more sick leave in the year since the original injury. Perhaps simple screening questionnaires could be used during treatment of acute pain, particularly in patients who do not seem to be responding to the treatments that often work well for others.
Clinical research of graded exposure in patients with chronic low back pain who reported fear of movement and/or re-injury has shown rapid changes in self-reported pain-related fear and cognition. Education appears to contribute to what appears to be a positive insight. Graded exposure to situations that might result in pain resulted in further improvement. And it is this exposure that improves the performance of daily activities.
Think of Jimmy Stewart grading his way upward in "Vertigo."
It would be so very helpful to have the regular input of psychologists when dealing with injuries that may result in a chronic pain syndrome. Instead, these patients often end up in the assembly line of a workers' compensation mill. It is the psychologist who could help in identifying the depressed and the fearful, and perhaps also assist in interventions that could potentially keep the acute pain acute.