Week 4: Biopsychosocial Approach to Pain Flashcards
What elements make up the biopsychosocial model of pain? Smallest circle to biggest
- Nociception
- Pain perception
- Attitudes and beliefs
- Psychological distress (suffering)
- Pain behaviour (disability)
- Environment
NPAPPE
Naughty penguins ate prominent portions everyday
Who designed the BSP model? Provide an example of how psychological beliefs can influence pain?
George Engel
High self efficacy eg I can move despite my pain = improved prognosis
True or false: acute pain is a result of tissue injury but resolves once homeostatic balance is restored?
True
What system is involved in the stress response?
Autonomic nervous system
What does the HPA axis stand for?
Hypothalamic pituitary adrenal axis
What are the four main hormones involved?
Cortisol
Norepinephrine
Epinephrine
Enkephalins
Goals of the HPA axis?
Reduce threat
Restore homeostatic balance
Where is the hypothalamus and pituitary gland located?
Just above the brainstem
What does the HPA axis do?
The HPA axis coordinates the body’s response to stress by regulating the release of cortisol. This hormone influences various physiological processes eg metabolism & immune function - aiding in stress adaptation. By maintaining this balance, the HPA axis contributes to overall homeostasis, ensuring stability in the internal environment.
What are the two responses to a stressor/nociception?
Pain & Physiological stress response (Ep/NorEpi/Cortisol)
When responded to positively the physiological stress response leads to what event? What components make up this? What does this do?
Adaptive response
- Comprehension, confrontation, understanding
Normal return to baseline = recovery
Chronic pain is a result of …..
Homeostatic imbalance
What do chronic threats result in?
Atrophy of muscle tissue
Impairment of growth and tissue repair
Morphological alterations of brain structures
Weakness
Pro-inflammatory cytokines
Fatigue
MAINTAIN OR INCREASE THREAT = PAIN
AIM W/PF
When responded to negatively the physiological stress response leads to what event? What components make up this? What does this do?
Maladaptive response
- Catastrophising
- Rumination
- Helplessness
- Magnification
= Prolonged or excess HPA axis activation –> cortisol dysfunction –> Chronic inflammation –> Depression (cycle continues…)
The maladaptive response consists of what four key elements? What does this result in?
- Catastrophising, rumination, helplessness & magnification
- Sensitised fear-based memory
True or false? Explicit validation is a helpful approach to discuss pain with a patient because it acknowledges and validates the patient’s experience, emotions, and concerns regarding their pain
True
Outline the cycle of fear avoidance?
High threat
1. Pain
2. Determine threat as high
3. Priority to pain control
4. Fear
5. Avoidance
6. Interference
7. Negative affect
8. Pain (cycle continues)
Low threat
1. Pain
2. Determine threat as low
3. Priority to value life goals
4. Approach
5. Recovery
Describe the relation between fear avoidance and kinesiophobia (fear of movement)
Pain –> rest –> become stiffer –> movement becomes more painful –> move less –> lose fitness –> movement is more painful (cycle continues).
Links in with fear avoidance - catastrophising –> pain-related fear –> avoidance/hypervigilance –> disuse, depression, disability
What are the five stages of self-efficacy?
Pre-contemplation: Unaware of the problem
Contemplation: Aware of the problem and of the desired behaviour change
Preparation: intends to take action
Action: Practices the desired behaviour
Maintenance: Works to sustain the behaviour change
What are the three elements of catastrophising?
Magnification eg becoming afraid the pain will get worse, thinking of other painful events, etc
Rumination eg I can’t seem to get it out of my mind
Helplessness eg I feel I can’t go on, there’s nothing I can do to reduce pain intensity
Define catastrophising?
The tendency to magnify the threat value of a pain stimulus and to feel helpless in the presence of pain, as well as by a relative inability to prevent or inhibit pain-related thoughts in anticipation of, during or following a painful event.
Outline the five steps in the treatment process in healthcare?
Assessment (1)
* Clinical interview
* Physical assessment / observation / tests, imaging etc.
* Psychometric assessment
Case formulation (2)
* Collaborative, comprehensive
Treatment planning (3)
* Goal setting (SMART)
* Problem solving
Treatment delivery (4)
Treatment evaluation (5)
What is the coloured flags assessment guide?
Red flags - serious pathology (biological factors)
Orange flags (mental health)
Yellow flags eg poor coping strategies, unhelpful beliefs about the injury (psychological factors)
Blue flags eg low social support, unpleasant work, non-english (social factors)
Black flags eg threats to financial security, litigation (other factors)
Benefits of self-report questionnaires
Benefits:
1. Efficient data collection – complete them before appointment
2. Norms – can locate patient in population as better/worse than avg Comprehensive – cover more ground than an interview
3. Patient feels supported; clinician is interested in them; easier to disclose on paper
4. Assist with diagnosis
5. Can use as a screening tool for further assessment
6. Confirms clinically significant change when used pre-post treatment
Limitations of self-report questionnaire
Limitations
1. They are not measuring the construct directly, they are measuring what we are calling the construct e.g. self efficacy – so they are not fool proof.
2. They require language, fine motor skills, concentration They can be frustrating for patients
3. They can detrimentally affect rapport if reasons for use not explained They are no substitute for good clinical interview
Provide examples of self-report questionnaires
- Brief pain inventory (BPI)
- Depression anxiety stress scale (DASS)
- Pain self-efficacy questionnaire (PSEQ)
- Pain catastrophising scale (PCS)
- Tampa Kinesiophobia questionnaire
What is the depression anxiety stress scale? How many items are there? What is deemed a clinically significant change?
Used to diagnose depression, anxiety and stress. 21 items (7 under each category). Five or more point change on the full scale is clinically significant, combined with a move to a different severity level.
What are the DASS severity ratings?
Normal 0-9
Mild 10-13
Moderate 14-20
Severe 21-27
Extremely severe 28+
What are the depression ratings under the DASS?
Normal 0-9
Mild 10-13
Moderate 14-20
Severe 21-27
Extremely severe 28+
What are the normal vs severe ratings for anxiety under the DASS?
Normal 0-7
Mild 7-8
Moderate 10-14
Severe 15-19
Extremely severe 20+
What are the normal vs severe ratings for stress under the DASS?
Normal 0-14
Mild 15-18
Moderate 19-25
Severe 26-33
Extremely severe 34+
Define pain catastrophising
A persistent pattern of thinking in which events are interpreted in the most extreme way possible without good evidence
Severity categories for the pain catastrophising scale? What is clinically significant?
<20 mild
20-30 high
>30 severe
A score change of six or more points with a move to a different severity category
What are some criticisms of the BPS model?
- Lack of clarity - how much does each factor (physical, psychological or social) contribute?
- Overemphasies psychological and social factor
- May be hard to clinically apply unlesss involved in the pyschological/social elements
What is the new adapted version of the BPS?
The enactive approach (considers environment and the person)
What percentage of patients with depression report experiencing some physical pain symptoms? What are the consequences of this overlap?
50% with depression also report experiencing some physical pain symptoms
Depression –> greater pain –> a worse prognosis –> more functional disability
Chronic pain patients with co-morbid depression have higher health care costs
NOTE: depression and pain are bidirectional ie worse depression = worse pain/worse pain = worse depression
What are the neurotransmitters of pain?
Neurotransmitters eg serotonin, norepinephrine, glutamate and GABA
What are the medications mentioned that are commonly referred to as antidepressants but may have an effect on pain?
Tricyclic compounds (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs) and selective serotonin uptake inhibitors (SSRIs)
What is the goal of the Start back screening tool?
Designed for initial treatment planning for LBP and categorising patient’s based on risk. <4 = low risk, >4 but <4 on the psychosocial subscale = medium risk and >4 on both = high risk. Low risk = more likely to use self-management (30 min assessment) & education vs high risk = 60 minute assesssment
