Week 4: Biopsychosocial Approach to Pain

Question 1

What elements make up the biopsychosocial model of pain? Smallest circle to biggest

Answer 1

1. Nociception
2. Pain perception
3. Attitudes and beliefs
4. Psychological distress (suffering)
5. Pain behaviour (disability)
6. Environment

NPAPPE
Naughty penguins ate prominent portions everyday

Question 2

Who designed the BSP model? Provide an example of how psychological beliefs can influence pain?

Answer 2

George Engel
High self efficacy eg I can move despite my pain = improved prognosis

Question 3

True or false: acute pain is a result of tissue injury but resolves once homeostatic balance is restored?

Answer 3

True

Question 4

What system is involved in the stress response?

Answer 4

Autonomic nervous system

Question 5

What does the HPA axis stand for?

Answer 5

Hypothalamic pituitary adrenal axis

Question 6

What are the four main hormones involved?

Answer 6

Cortisol
Norepinephrine
Epinephrine
Enkephalins

Question 7

Goals of the HPA axis?

Answer 7

Reduce threat
Restore homeostatic balance

Question 8

Where is the hypothalamus and pituitary gland located?

Answer 8

Just above the brainstem

Question 9

What does the HPA axis do?

Answer 9

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.

Question 10

What are the two responses to a stressor/nociception?

Answer 10

Pain & Physiological stress response (Ep/NorEpi/Cortisol)

Question 11

When responded to positively the physiological stress response leads to what event? What components make up this? What does this do?

Answer 11

Adaptive response
- Comprehension, confrontation, understanding

Normal return to baseline = recovery

Question 12

Chronic pain is a result of …..

Answer 12

Homeostatic imbalance

Question 13

What do chronic threats result in?

Answer 13

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

Question 14

When responded to negatively the physiological stress response leads to what event? What components make up this? What does this do?

Answer 14

Maladaptive response
- Catastrophising
- Rumination
- Helplessness
- Magnification

= Prolonged or excess HPA axis activation –> cortisol dysfunction –> Chronic inflammation –> Depression (cycle continues…)

Question 15

The maladaptive response consists of what four key elements? What does this result in?

Answer 15

• Catastrophising, rumination, helplessness & magnification
• Sensitised fear-based memory

Question 16

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

Answer 16

True

Question 17

Outline the cycle of fear avoidance?

Answer 17

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

Question 18

Describe the relation between fear avoidance and kinesiophobia (fear of movement)

Answer 18

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

Question 19

What are the five stages of self-efficacy?

Answer 19

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

Question 20

What are the three elements of catastrophising?

Answer 20

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

Question 21

Define catastrophising?

Answer 21

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.

Question 22

Outline the five steps in the treatment process in healthcare?

Answer 22

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)

Question 23

What is the coloured flags assessment guide?

Answer 23

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)

Question 24

Benefits of self-report questionnaires

Answer 24

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

Question 25

Limitations of self-report questionnaire

Answer 25

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

Question 26

Provide examples of self-report questionnaires

Answer 26

• Brief pain inventory (BPI)
• Depression anxiety stress scale (DASS)
• Pain self-efficacy questionnaire (PSEQ)
• Pain catastrophising scale (PCS)
• Tampa Kinesiophobia questionnaire

Question 27

What is the depression anxiety stress scale? How many items are there? What is deemed a clinically significant change?

Answer 27

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.

Question 28

What are the DASS severity ratings?

Answer 28

Normal 0-9
Mild 10-13
Moderate 14-20
Severe 21-27
Extremely severe 28+

Question 29

What are the depression ratings under the DASS?

Answer 29

Normal 0-9
Mild 10-13
Moderate 14-20
Severe 21-27
Extremely severe 28+

Question 30

What are the normal vs severe ratings for anxiety under the DASS?

Answer 30

Normal 0-7
Mild 7-8
Moderate 10-14
Severe 15-19
Extremely severe 20+

Question 31

What are the normal vs severe ratings for stress under the DASS?

Answer 31

Normal 0-14
Mild 15-18
Moderate 19-25
Severe 26-33
Extremely severe 34+

Question 32

Define pain catastrophising

Answer 32

A persistent pattern of thinking in which events are interpreted in the most extreme way possible without good evidence

Question 33

Severity categories for the pain catastrophising scale? What is clinically significant?

Answer 33

<20 mild
20-30 high
>30 severe

A score change of six or more points with a move to a different severity category

Question 34

What are some criticisms of the BPS model?

Answer 34

• 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

Question 35

What is the new adapted version of the BPS?

Answer 35

The enactive approach (considers environment and the person)

Question 36

What percentage of patients with depression report experiencing some physical pain symptoms? What are the consequences of this overlap?

Answer 36

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

Question 37

What are the neurotransmitters of pain?

Answer 37

Neurotransmitters eg serotonin, norepinephrine, glutamate and GABA

Question 38

What are the medications mentioned that are commonly referred to as antidepressants but may have an effect on pain?

Answer 38

Tricyclic compounds (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs) and selective serotonin uptake inhibitors (SSRIs)

Question 39

What is the goal of the Start back screening tool?

Answer 39

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