PAIN-RELATED ANXIETY AMONG PATIENTS WITH CHRONIC LOW BACK PAIN in HUKM (An article from MPA)

Chronic low back pain is the most common cause of disability in adults, with one percent of the population considered “totally and permanently disabled”. (Price and Bushnell, 2004). During the last 50 years, theories of pain have gradually moved from simple, singlecause explanations to more complex, multicausal formulations (Coons and Hadjistavropoulos, 2004).
Attempts to manage chronic pain through a biomedical model have led to
(1)dismal failures in pain control;
(2)frequent iatrogenic complications (including iatrogenic disability);
(3) inappropriate use of medical tests, procedures and medication; and
(4) the perpetuation of disability when it occurs (Litt, 1996).

The past decade has seen remarkable developments in studies of psychological factors that influence pain, including, emotions, suggestions and improved developments of psychological methods of pain control (Waddle, 2000). Interactions between pain and various emotional states such as anxiety, fear and depression have been of interest in recent years because conventional theories of pain that focus on nociceptive input alone do not adequately account for emotional, behavioral and cognitive factors that are experiential along with pain (McNeil,1998).

While it is clear that anxiety, in one form or another is concurrently related to the pain experience, the extent to which the various anxiety- related constructs are predictive of long term
adjustment to pain remains unclear. Individuals with chronic low back pain may experience prolonged psychological distress, impaired physical functioning, decreased independence and often an uncer tain prognosis (Thomas, 1998).

Effective treatment of chronic low back pain usually requires a multimodal approach, comprising drug therapy, physical therapy and psychological counseling, rather than a single therapy. Patients’ understanding of the cause of pain, possible treatments and long-term prognosis guides their behaviors and reduces anxiety regarding their existing condition (Vowles et al,2004). Concurrently, what patients know, do and feel exerts a profound impact on their subsequent pain and disability. Thus, to adequately treat chronic low back pain disability, the primary pain sources and situational factors that are relevant to patients and their families must be evaluated in order to reduce perceived pain-related anxiety (Vowles et al, 2004).

Treatment emphasis should shift accordingly from an exclusively diseasecentered
framework to a more patientcentered focus. According to Carson et al (2005), clinicians must be able to select specific therapies to target the responsible central and peripheral mechanisms and to mitigate the painexacerbating impact of situational factors, recognizing that the multiple causes and contributing factors will vary over time.

RESEARCH AIM The aim of this study was to :
Identify the relationship between level of pain-related anxiety and level of disability among patients with chronic low back pain in Hospital Universiti
Kebangsaan Malaysia (HUKM).

DESIGN AND SUBJECTS
The study was carried out with a quantitative approach, by means of
a questionnaire survey. Purposive, convenience sampling and data
collection was carried out at the Physiotherapy Unit out-patient clinic
of Hospital Universiti Kebangsaan Malaysia (HUKM) within August to
December 2005.

The inclusion and exclusion criteria’s were as follows :

Inclusion criteria’s :
• Adult chronic low back pain patients (aged above twelve years old at time of referral) undergoing physiotherapy at HUKM Physiotherapy out-patient clinic.
• Adult chronic low back pain patients newly referred for physiotherapy at HUKM Physiotherapy out-patient clinic.
• Chronic low back pain patients with no other co-existing physical disabilities e.g. paraplegia/p a r a p e r e s i s , h emi p l e g i a /hemiparesis

Exclusion criteria’s :
• Chronic low back pain patients who are having an acute exacerbation of symptoms such as acute pain coupled with inflammation. • Patients with previous or current
physical disabilities e.g. paraplegia/p a r a p e r e s i s , h emi p l e g i a /
hemiparesis. Data was collected via a questionnaire that included two standardi zed
questionnaires that are namely the Oswestry Low Back Pain Disability Questionnaire and the 20-item Pain Anxiety Symptoms Scale (PASS).
The Oswestry Low Back Pain Disability Questionnaire has been shown to be reliable and valid for use with patients with low back pain (McNeil, 1998, Vowles et al 2004, Crombez et al, 1999).

The Oswestry Low Back Pain Disability Questionnaire is self-administered by patients and can be completed in about five minutes (Rainwater and McNeil,1998 )
The Pain Anxiety Symptoms Scale (PASS) was developed to measure fear of pain along four dimensions,including fear ful interpretat ion,avoidance and escape,physiological
response and symptoms of cognitive interference (Burns et al, 2000).Since its development, PASS has been recognized as a useful measure of pain-related anxiety for individuals with chronic pain disorders (Zvolensly et al, 2001).
The measure is of importance because pain-related anxiety has predictive value
in identifying depression and disability in patients with chronic pain (Vowles et
al 2004). For further reading, go to : http://www.mpa.net.my/bulletin.html