Introduction:
In addition to the physiological factors, there are a number of psychological factors that play a major role on musculoskeletal pain that can lead to disability. After the patient has healed from the physiological factors that led to the experience of pain, there are still fear avoidance beliefs that can take the form of chronic pain in the mind, so that the patient resists increases in physical activity levels. Ironically, the decision to reduce physical activity levels in response to this combination of physical pain and psychological fears keeps the back pain chronic, as the patient never overcomes the fears and does not strengthen the muscles in a way necessary to promote total healing.. The aim of this paper is to explain to the readers about the significance of psychological factors on musculoskeletal pain. It also describes how the transfer of musculoskeletal pain from acute to chronic is caused by psychological effects even in the absence of physical damage remaining in the muscles. Therefore, this paper explores how psychological factors affect human performance in chronic illness conditions. Thesis: Physical interventions such as strength training are a necessary remedy to help patients transcend the emotional fears that keep them from healing completely from injuries.
The term “fear avoidance beliefs” refers to a psychiatric model describing how patients experience acute musculoskeletal pain as the result of fear instead of actual physical damage. The fear of pain actually translates into the perceived sensation of pain. The two main ways that people respond to this phenomenon are the reduction of fear and increase of fear leading to a phobic state. According to Lethem et al (1983), it explains how the patients experience pain even without pathology.4,5 When a patient feels severe discomfort and avoids any activity for his treatment because of his/her avoidant attitude, this becomes a vicious cycle. The lack of activity leads to a lack of strength, and the lack of strength means that recovery does not fully take place.8 The fear of activity means that the perception of pain is more likely to keep taking place.1
Indeed, physical activity is one way to help patients overcome their fear of activity.9 Patients who are willing to try activities when their bodies are physically healed from injury often find that the fear that they have of the activity dissipates, because the discomfort level is not what they expected. Instead, they gain strength in their lower back and find that they can take on an increased level of rehabilitation.
One way to assess the fear avoidance beliefs is through a clinical questionnaire. Another way is by using the PASS or Pan Anxiety Symptoms Scale and the Fear of Pain Questionnaire. When it comes to the assessment of dysfunctional beliefs on physical activities, clinicians use the TSK or Tampa Scale for Kinesiophobia. For patients having acute low back pain, physical therapists use the PHODA or Photograph Series of Daily Activities to determine the harmful effect of engaging in daily activities. After completing these assessments, therapists begin treatment of fear avoidance beliefs that includes graded activity to regain the patient’s physical fitness. In this case, the clinician or psychologist focuses on the cognitive factors that can cause more intense fears. The patients engage in physical activities tailored to confront those fears head-on until they realize that they can do such activity without experiencing a catastrophe. After realizing the true level of their ability, many patients recover from their extreme fear expectancies.
Fear of pain is sometimes beneficial because it prevents the patients from engaging in physically harmful activities. However, this fear becomes dysfunctional when it involves an inaccurate assessment of one’s actual capacity. In the chronic phase of pain, the patient only avoids physical activities associated with it. However, because of excessive fear of pain, the avoidance of physical activities might extend to social and economic activities, such as going to work or interacting with others. When this happens, the social and economic costs of musculoskeletal pain increase as the patient’s fear of pain continues even after healing, in the form of lost wages, frayed relationships and potential psychological issues.2
Psychological factors that include decision latitude and work demands play a major role in the development of musculoskeletal pain, such as low back pain. Generally, the cause of musculoskeletal pain is categorized into psychological and mechanical factors. Psychological factors include monotony of work, fear of heavy workload, stress symptoms, lack of cooperation, and low job control. These factors contribute to the pain in the upper extremity. Mechanical factors include time pressure and heavy workloads. Fear of pain causes the avoidance of physical, professional, and social activities among the patients even after they have recovered from physical distress. Although relaxation promotes recovery, when fear avoidance beliefs continue even after healing of the injury, disability and distress take over.
ICF is a comprehensive model about function and disability developed by WHO or World Health Organization providing a universal classification for human functioning.3 The ICF model integrates into the MT or massage therapy research, practice and education. The MT intervention is successful in many cases, but in some cases it fails because of the excessive fear avoidance beliefs of the patient that affects the treatment. In this model, a massage therapist asks the person with back pain to bend slowly towards the left or right until he/she feels the pain. When the client experiences minimal pain according to his/her expectancy, he/she is willing to repeat the session until the pain heals. However, if the pain is too much and beyond his/her expectancy, the patient stops attending the next sessions, and might even withdraw from the first session. If this thing happens, fear avoidance beliefs can lead to disability. Typically, the MT practitioner examines the performance of this activity and looks for clues on how to apply direct treatment. This activity examination reflects how the MT practice fits into the ICF model. Under this model, musculoskeletal pain serves as the condition while pain is the body’s structure. Walking or inability to walk for a long distance is the activity limitation while leisure time and recreation serves as the participation. In many cases, massage therapy is a path to healing, both psychologically and physically.
Because of the fear avoidance beliefs of many people, they avoid information about major diseases and discomforts, including the pain at low back region of the body. The reason is that if they pay attention to the literature, it will just cause confusion, fear and mental discomfort to them. However, early communication studies assume that many people especially in the Western culture seek or have some sort of interest to sources of information. This is what is known as the “health belief model.”7 This observation is related to Aristotle’s concept that “all men seek for knowledge” which is a natural tendency of being human. But as culture develops, many people now avoid information because they think that giving attention to it will produce fear and mental discomfort. Maslow puts it this way: people seek knowledge to reduce their anxiety, but others avoid it because of the same reason. In simple terms, the people would prefer not knowing that they are at high risk for a major disease than knowing it because of fear avoidance beliefs. It is always the tendency that human beings ignore, deny, or avoid any information that declares them as a high-risk patient. So far, information-seeking models and communication theories deal with this problem by selecting the messages naturally according to their importance. The information is categorized as “selected” rather than “ignored.” In the field of psychology, avoiding information has a prolonged history just like in communication literature. Freud theorizes that human beings allow uncomfortable memories or thoughts to slip away through psychological defenses, such as repression, denial, and suppression. In the past, Hyman and Sheatsley cited the “selective exposure” as the reason for failure of the mass media to change the behavior or attitudes of the people in health promotional campaigns. They criticize some people as hard to reach and chronically uninformed. In their studies, it is observed that people are interested on information that complements their prior knowledge, opinions and beliefs. In essence, they avoid information that conflicts with their beliefs.1
On the other hand, fear avoidance beliefs show the degree that a person faces that contradicts his/her permanent trait. It shows whether a person has an open mind or a closed one. People with an open mind face new information than avoid it. Some persons scrutinize the information for threats while others avoid threatening information. In essence, the information-seeking literature portrays fear avoidance beliefs as an important aspect in approaching physical pain. It is an important reference to psychological literature about coping and stress. This model recognizes the intervening variables, such as psychological, environmental and demographic. The question as to what kind of motivation does a person need to seek for information, how, and up to what extent, are met by some activating mechanisms that serve as motivators. The intervening variables that affect these motivators are five types, such as the psychological predispositions, demographic background, factors about a person’s social role, environmental variables, and the description of the sources. The psychological predispositions include being curious or fear of risks, while the demographic background includes age or education. The factors associated with one’s social role include a person’s role as a mother or a manager, and the environmental variables include available resources. Lastly, the description of the sources includes credibility and accessibility. Thus, avoiding information is associated with fear and feeling of anxiety, along with other emotional and cognitive variables. These variables include treatment efficacy, level of control, and self-efficacy.1
Diagram illustrating the relationship between fear avoidance beliefs and physical activity:1
Intervention, specifically physical therapy, is important to eliminate or reduce the fear avoidance beliefs that serve as a personal factor affecting the musculoskeletal pain, such as strengthening exercise based on physical therapy. After exploring the effect of psychological factors to musculoskeletal pain in chronic illness conditions caused by rigid physical activity, this paper concludes that there is a direct relationship between chronic low back pain and physical activity, and indirect relationship with fear avoidance beliefs. This paper further concludes that a Physical Therapy Intervention is necessary to remove the patient’s fear that a disaster would occur if he/she attends a therapy session. The therapist should focus on handling the situation with utmost care to convince the patient and to avoid leading to disability.
References:
Impact of occupational stress and other psychosocial factors on musculoskeletal pain. 2005.
Integrating the International Classification of Functioning, Disability, and Health Model into Massage Therapy Research, Education, and Practice
Lethem, J.; Slade, P. D.; Troup, J. D.; Bentley, G. (1983). "Outline of a Fear-Avoidance Model of exaggerated pain perception--I". Behaviour research and therapy 21 (4): 401–408. PMID 6626110
What is Physical Activity? National Institutes of Health.
Health Belief Model. Wikipedia.
Vlaeyen, Johnas WS & Steven J. Linton. “Fear Avoidance and its Consequences in Chronic Musculoskeletal Pain: A State of the Art.” Pain 85 (3): 317-332.
Moore, James E., et al. “A Randomized Trial of a Cognitive-behavioral Program for Enhancing Back Pain Self Care in a Primary Care Setting.” Pain 88 (2): 145-153.
