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  • Daniel Rockman

Stop using pain to measure your recovery

I've mentioned in previous posts (1,2) that there is a lot more going on with pain than we first imagined. Not only is pain not a great indicator of tissue damage, but it also can be affected by a number of contextual factors.


By measuring someone's recovery through pain alone, we may not get an accurate picture of the effects of the treatment. That is because pain is not taking in the whole picture of the situation the individual is in.


That is where the biopsychosocial model comes in.


The biopsychosocial model may sound like a high-scoring word on scrabble, but it's also a really simple idea when we break it down.


Throughout this post I will be using this journal article as a reference:

Domains of Chronic Low Back Pain and Assessing Treatment Effectiveness: A Clinical Perspective (2020)


In order to get a holistic view of a patient's health, we need to look at the biological, psychological and social factors which are making up their experience. Applying this theoretical model to the treatment of all healthcare patients, results in better outcomes.







We know now that back pain is multidimensional in nature - you can't just apply a massage to the back and expect it to get better. Each patient will be impacted to different degrees by each level of the biopsychosocial model. To provide a better service to patients, it is important that healthcare practitioners understand and deal with the patient's most prominent problems. This line of thought has created a huge shift in western medicine towards what is called patient-centered care - treating the patient in front of you, not just treating the condition.


To understand things better, let's go through an example in lower back pain (LBP). Here are 12 outcome measures that use the Biopsychosocial model, so that you can measure your recovery without using the potentially inaccurate and invalid scale of pain.


Biological factors


Physical disability


Defined as a restriction when performing activities of daily living (ADLs). This can be measured via questions about daily function using simple questionnaires such as this one. LBP creates a huge global burden on the healthcare system and through missed work, so assessing physical disability can provide an insight into your current level of function.


Muscular endurance and strength


Individuals with chronic LBP often have lower strength and endurance through their trunk muscles. This may be related to the reduced physical capacity in this population. It is unclear if the weak trunk muscles cause the lower back pain, or if the back pain causes the weakness. Nonetheless, strengthening the trunk muscles can reduce physical disability and should be considered for those with LBP, especially if they have a physically demanding job.


SIDE NOTE: Training your "weak core" muscles isn't a scientifically valid way to reduce back pain. This was a widespread myth; full body training is more beneficial! Source


Adiposity (fat levels)


Individuals with chronic LBP often have an increased body fat percentage, which may have many negative impacts on treatment. It may increase pain through peripheral sensitisation due to systemic inflammation, and fat tissues have also been shown to creep into trunk muscles, therefore making them weaker. Finally, a higher body mass index (BMI) also means a greater risk of remaining highly disabled for a longer period of time. Measuring adiposity can be a useful tool to establish expected functional impairments as well as comorbidities.



Psychological factors


Kinesiophobia and fear avoidance


Kinesiophobia is the fear of movement and interferes with the ability to complete ADLs in individuals living with LBP. Fear avoidance is avoiding that which brings you fear. Well duhh. The fear of movement could add to disability and deconditioning, as well as affecting compliance in regards to exercise programs. Individuals with high fear-avoidance beliefs were two times worse in terms of recovery after one year compared to individuals with low fear-avoidance beliefs. Removing these fear barriers may be important for promoting participation in ADLs and therefore reducing disability and deconditioning.


Pain catastrophising


Pain catastrophising is a state of anxiety towards pain. Common beliefs are held that the lower back is vulnerable and fragile, because this is what we've all been told (completely untrue by the way), which then leads to greater catastrophising. Catastrophising may be better than pain intensity for explaining disability in those with LBP. Those with high catastrophising are 56% more likely to be disabled than those with low catastrophising. Reducing this catastrophic thinking may help reduce the burden of disability in LBP sufferers.


Pain self-efficacy


Pain self‐efficacy reflects an individual’s ability to engage with ADLs despite the presence of pain. As the course of pain intensity in chronic LBP fluctuates, it may be important to understand how individuals psychologically deal with times of high pain intensity and if they continue to engage in normal activities. Those with lower pain self-efficacy are more likely to have higher levels of disability.


Sleep quality


Impairments to sleep are commonly reported in individuals with chronic LBP, with a 55% decrease in sleep quality observed in this population. There is a bi-directional relationship between sleep and pain: as sleep decreases, pain will increase and as pain increases, sleep can decrease. Each will make the other worse. Furthermore, disturbances to the quality of sleep in individuals with chronic LBP is moderately correlated to physical disability. Therefore, sleep quality should be an important psychological factor to consider in recovery.


Depression and anxiety


There is a bi-directional relationship between LBP, depression, and anxiety. They all influence each other negatively. There is a higher prevalence of depression and anxiety in people living with LBP when compared with the general population. These psychological states can become barriers to treatment and so should be addressed as part of a holistic treatment.


Social factors


Social functioning


Social functioning is considered as the individual’s ability to engage in social activities. Individuals with LBP often feel like they struggle to meet social expectations which can then impact their social identity. For example, if your friends enjoy going for a kick of the footy each week but your back pain flares up when you join in, you may not want to go, and this can impact how sporty you see yourself in the long run. This commonly affects engagement in domestic chores, recreational activities, and work tasks.


Work absenteeism


The majority of the burden of cost from LBP comes from work absenteeism and early retirement. Work absenteeism has been linked with a 31% lower chance of functional recovery! That means if you want to recover from your back pain, you should be prioritising getting back to work as soon as you safely can.


On a side note, my partner has recently been absent from work due to a knee injury, and I can see the effect it is having on her. Work can make you feel a useful member of society and give you a sense of purpose. As nice as it can seem on some days, taking time off work gets old very quick, as I'm sure some of you have found out over these lockdowns. GET BACK TO WORK AS SOON AS YOU ARE ABLE. It's an important measure in your health.


Health related quality of life


Quality of life is the self-evaluation of well-being and functioning. LBP has a negative impact on the quality of life of an individual, particularly through perceptions of physical and mental health. Measuring quality of life can provide insight into areas of life that the individual is having difficulty with, allowing targeted treatment to improve these. Importantly, improvements in quality of life may be dictated to a greater extent by disability and psychological improvements rather than pain intensity.



So, at the end of the day, don't be surprised if your pain doesn't slowly decrease over time. Pain is a multi-faceted sensation which is influenced by loads of factors, and there will be good periods, as well as flare ups over time. While pain is still an important measure for injury management, it shouldn't be the only measure.


Instead of basing the success or failure of a treatment entirely off the pain you're feeling today, try looking to one of these 12 measures that take into account the biopsychosocial model.


Biological

  • Physical disability

  • Muscular endurance and strength

  • Adiposity

Psychological

  • Kinesiophobia and fear avoidance

  • Pain catastrophising

  • Pain self-efficacy

  • Sleep quality

  • Depression and anxiety

Social

  • Social functioning

  • Work absenteeism

  • Health related quality of life


Stay strong and prosper.

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