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The Journal of Bone and Joint Surgery (American). 2009;91:2014-2018. doi:10.2106/JBJS.H.01512 © 2009 The Journal of Bone and Joint Surgery, Inc.
Psychosocial Aspects of Disabling Musculoskeletal Pain
1 Orthopaedic Hand and Upper Extremity Services, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring{at}partners.org
Disclosure: In support of their research in the past year, one or more of the authors received outside funding or grants (unrestricted, without clear designation) from Small Bone Innovations, Acumed, Tornier, Smith and Nephew, and Wright Medical (in excess of $10,000 in total). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Psychosocial factors are important determinants of pain intensity and disability in patients with disabling musculoskeletal pain. The psychosocial aspects of disabling musculoskeletal pain include cognitive (e.g., beliefs, expectations, and coping style), affective (e.g., depression, pain anxiety, heightened concern about illness, and anger), behavioral (e.g., avoidance), social (e.g., secondary gain), and cultural factors. The effectiveness of cognitive behavioral therapy and other treatments that address the psychosocial aspects of disabling musculoskeletal pain has been confirmed in numerous high-quality studies.
In the context of disabling pain, psychosocial factors are better predictors of pain intensity, pain-related disability, and response to treatment than are physical or pathophysiological factors1. Psychological treatments are as effective as or more effective than standard medical treatment for a variety of pain syndromes (e.g., nonspecific hand and arm pain, back pain, headache, and fibromyalgia)1-4. Multidisciplinary treatment teams that address chronic pain as a biopsychosocial rather than a purely biomedical experience offer several advantages but have not been widely implemented. This paper reviews the evidence regarding specific treatment of the psychosocial correlates of disabling musculoskeletal pain.
The traditional biomedical model of illness assumes a direct correspondence between nociception (the pathophysiology of tissue damage) and pain (the experience of discomfort). In other words, it is assumed that once the discrete nociceptive stimulus has been identified and addressed the pain will be cured. In contrast, the biopsychosocial model emphasizes the limited correlation between nociception and pain and acknowledges the complex influences of biological, psychological, cultural, and social variables on an individual's experience of pain. Orthopaedic surgeons are familiar with some of these psychosocial mediators between nociception and pain, such as secondary gain, and recognize that some illness behavior reflects a real or perceived benefit from illness. They may be less familiar with the influence of depression, the tendency to misinterpret or overinterpret nociception (known to psychologists as pain catastrophizing), heightened concern about illness, and social and cultural factors on illness behavior.
Disabling musculoskeletal pain disorders are prevalent in the United States and other resource-rich countries5,6. For instance, low back pain is the most common cause of disability in persons under the age of forty-five and is the most expensive benign condition7. More than 1% of the working-age population is permanently disabled by low back pain6. Each year, about 3% to 4% of the population has a temporary episode of disabling low back pain, and it has been estimated that 70% to 85% of all people have a disabling episode of back pain at some point in their lives8. Low back pain—like many types of musculoskeletal pain—is generally a time-limited condition, the pathophysiology and etiology of which are poorly understood; the relationship between treatment of low back pain and outcome is also unclear6. Other common types of musculoskeletal pain include trapeziometacarpal arthrosis, a normal part of human development to which most people seem to adapt9, and lateral epicondylosis, a generally self-limited enthesopathy affecting middle-aged people for which no treatments have been found to be consistently effective in scientific investigations10. These examples emphasize important aspects of musculoskeletal pain: (1) it is very common and, for the most part, reflects normal human experience and development, with most people able to adapt and cope; (2) many painful musculoskeletal conditions are self-limiting, and many others wax and wane in terms of symptom severity; (3) the true prevalence of these conditions and their natural history are unknown because people do not consistently seek medical care for them; and (4) the biomedical model of illness has not been as successful as we might have hoped in terms of decreasing pain intensity and pain-related disability. Evidence that the intensity and disability of musculoskeletal pain are determined as much, or more, by treatable psychosocial factors than by pathophysiological processes offers patients great hope.
Human Thought and Behavior Although we naturally tend to conceive of illness in biomedical terms, this is an oversimplification when it comes to the perception and experience of symptoms. Even within the biomedical model, the relationship between symptoms and disease is complex. For example, if a patient reports relief after a corticosteroid injection for lateral epicondylosis, he or she may be experiencing the placebo effect (in which an inactive or inert intervention results in symptom relief), regression to the mean (i.e., because all illnesses wax and wane with regard to symptom severity, the patient may have received the injection when the symptoms were at their peak and may be experiencing a better symptom level as a result of regression alone and not as a result of any influence of the intervention itself), and the normal self-limiting course of the disease (the illness would have improved with or without the injection).
Cognitive Processes Research has established that a patient's attitudes, beliefs, expectations, and coping resources can increase or diminish pain intensity and pain-related disability11,12. Examples include misinterpretation or overinterpretation of pain as tissue damage rather than a temporary problem that will improve or a normal part of daily life, a belief that pain and disability will last forever (which leads to a passive, fatalistic approach to coping), and interpretation of pain as a sign of serious disease or a reminder of our mortality. A cognitive error is a negatively distorted belief about oneself or one's situation. There is a common set of cognitive errors that affect perception of pain, affective distress, and disability13-15. The most common cognitive errors regarding pain reflect an intuitive tendency to misinterpret or overinterpret nociception (e.g., "This pain in my arm means that my whole body is degenerating and falling apart."), all-or-nothing thinking (e.g., "I can't enjoy anything until I am completely pain-free."), negative predictions (e.g., "I know that learning coping techniques will not work for me."), and selective abstractions (e.g., "Therapy and exercises will make me feel worse than I already do."). Self-efficacy, or the belief in one's ability to successfully achieve a desired outcome, is a cognitive factor that strongly predicts success in coping with pain and reducing disability16,17. Greater self-efficacy leads to reduced anxiety and its physiological concomitants, an increased ability to use distraction as a coping strategy, increased determination to go on with planned activity in spite of pain, and avoidance of rumination on the pain17,18. Self-efficacy can be practiced and learned. Studies have shown that active coping strategies such as efforts to function in spite of pain or to distract oneself from pain are associated with adaptive functioning, while passive coping strategies such as depending on others for help in pain control and letting pain dictate and restrict one's activity level are related to greater pain and depression15,19.
Affective Factors Given that normal responses to pain include both the cognitive (uncertainty, and misperceptions of danger) and physiological (autonomic arousal) aspects of anxiety, it is not surprising that an excessive pain response often exacerbates pain intensity and pain-related disability24. Anxiety in the context of disabling chronic pain often takes the form of fear and harm-avoidance behaviors (pain anxiety).
Illness Behavior Pain-avoidance behaviors can exacerbate pain intensity and pain-related disability24-26. Avoidance of activity leads to anticipatory anxiety about pain (e.g., muscle tension and other symptoms associated with fight or flight or sympathetic activation), which may act as a conditioned stimulus for pain that is maintained after healing. Over time, more activities are perceived as dangerous or aversive and are avoided. This may lead to deconditioning and less effective coping strategies27. The avoidance of painful activities perpetuates and reinforces the belief that pain is an indicator of tissue damage and therefore retards healing. Avoidance also prevents the opportunity to have a corrective experience—that is, the chance to discover that many types of musculoskeletal pain eventually subside regardless of the activity level. Avoidance of situations that are perceived as dangerous and anxiety-provoking is a common mechanism in the maintenance of anxiety disorders, and it probably holds true for disabling pain as well, with patients increasingly avoiding activities that are anticipated to cause pain27.
Social and Cultural Factors Perhaps the best modern example of sociocultural influences on illness behavior is the Internet and other media. Advertisements, articles, and blogs—particularly those about commercial treatments for pain—offer cures and imply that miraculous results are possible. In addition, normal aspects of human development such as the effects of aging on appearance (such as wrinkles, gray hair, or hair loss) are stigmatized. Promotion of a desire to stay forever young interferes with the necessary adaptation, whether to the visual or painful aspects of aging, that gives people a sense of well-being and puts them at ease as they age. Suggestions that patients request other treatments or change their doctor if their pain is not cured promote the illusion that it is possible to be pain-free. The impact of such marketing on disabling musculoskeletal pain, although incompletely defined, should not be underestimated.
Psychology of the Health-Care Provider Musculoskeletal health-care providers often prefer intuition (experience, beliefs, and habits) over evidence33,34. Furthermore, many prefer a paternalistic model of decision-making, even though the patient, by assuming a passive role, may lose an opportunity to develop self-efficacy. A passive approach to treatment has been shown to increase disability and distress in many pain conditions12. The patient's distress, in the form of depression and anxiety, misconceptions about nociception, and heightened concern about illness, can be communicated to his or her provider (counter-transference). Thus, in the face of greater reports of pain and disability, health-care providers may come to believe that a patient's pathophysiology is worse than it is, even when the evidence does not support this line of thinking35,36. Health-care providers often feel pressured for time and may believe that they do not have sufficient time to understand and address their patients' goals and agendas in detail. Treating patients with complex pain conditions that are diffuse, vague, and ambiguous, with disproportionate pain intensity and disability, can also be very frustrating to providers37,38.
Several meta-analyses and reviews have delineated the most important psychosocial correlates of disabling musculoskeletal pain. The best studied is low back pain, but the findings are similar for spinal cord injuries and limb pain. Furthermore, the psychosocial correlates of disabling musculoskeletal pain are comparable with those in patients with other conditions causing disabling pain such as headaches, fibromyalgia, and irritable bowel syndrome5. Physical or sexual abuse (current or in childhood), depression, ineffective coping skills, stress, low socioeconomic status, unemployment, and perception of a demanding employer are strongly correlated with disabling pain of all types39. Depression and misinterpretation or overinterpretation of nociception are the most important factors, and they are interrelated40-44. Pain hinders the diagnosis and treatment of depression45, leading to unnecessary testing, increased health-care costs, and medicalization of the somatic expressions of psychological distress. An intuitive sense that pain is a signal of damage, danger, or hopelessness is the strongest correlate of phantom limb pain six months after a below-the-knee amputation46, of nonspecific or idiopathic hand and arm pain47, and of a lack of improvement with physical therapy in patients with neck pain48. There are effective treatments for depression and misinterpretation of nociception, and these may be the best targets for treatment in patients with disabling musculoskeletal pain. A review of 205 studies1, most of them randomized controlled trials, showed that psychological interventions such as cognitive behavioral therapy, relaxation, and biofeedback were on the average more effective than standard biomedical treatments, including surgery, for decreasing pain intensity, pain-related disability, and depression and for improving the health-related quality of life of patients with low back pain. Cognitive behavioral therapy is an evidence-based, time-limited, collaborative form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. The model predicates that thoughts, behaviors, and sensations are interrelated and mutually reinforcing. Patients disabled by pain tend to have negative appraisals of the pain sensation, pain-avoidant behaviors, and negative affect (e.g., depression and anxiety). With cognitive behavioral therapy, patients learn to (1) challenge their negative pain cognitions and replace them with positive/adaptive thoughts, (2) engage in activities in spite of pain, and (3) learn self-soothing (e.g., relaxation and mindfulness) techniques. As such, the goal of cognitive behavioral therapy for pain is increasing functionality and decreasing reactivity to pain—an important distinction from the typical (and often elusive) biomedical focus on a cure for pain. Research indicates that cognitive behavioral therapy, as part of a multidisciplinary treatment approach, is efficacious for migraines and daily headaches49, musculoskeletal pain50, pain in the elderly51, cancer pain52, arthritis pain53, fibromyalgia54, chronic low back pain55, wrist pain56, and chronic pelvic pain57.
Psychosocial factors are important and treatable correlates of disabling musculoskeletal pain. Orthopaedic surgeons may best diminish pain intensity and pain-related disability by collaborating with psychologists and other health-care providers in multidisciplinary teams. Biomedical treatments (surgery, injection, medication, exercises, and so on) are only one aspect of the care of disabling musculoskeletal pain. Specific biomedical treatments such as surgery or injection are best reserved for discrete, objective, verifiable pathological processes, and they should have a strong evidence base. The best targets for treatment of disabling musculoskeletal pain are often depression and the tendency to misinterpret or overinterpret pain. Comprehensive biopsychosocial treatment is more effective than traditional biomedical treatment alone and may lead to a better use of resources, decreased disability, and increased comfort and quality of life. 
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