Back in Business Physiotherapy - Walker St, North Sydney, Australia - Musculoskeletal Physiotherapy, Chronic low back pain

Do you remember how much you used to have to concentrate when you learnt to drive? Eventually, the task became automated and effortless. However, what happens when you are in an unfamiliar area, you need to look at a map, there is lots of traffic and the mobile phone rings because you are running late for the meeting that you have to chair? Your cognitive systems are bombarded with competing information trying to make itself the priority in your limited processing systems. Similar to RAM in those old computers which couldn't keep up with newer and better software programmes, everything starts to slow and grind to a halt.

Back pain can have similar effects on your processing capacity. Reduced variability of postural strategies has been considered to prevent normalization of motor strategies induced by low back pain (Moseley & Hodges 2006). Together with a 'viscious cycle' of nociceptive input,and altered muscle spindle proprioceptive input as well as a motor derived pain adaptation can create considerable input-output ambiguity within the nervous system (Madelaine 2008). With constant cognitive hyper-vigilance, a person in pain can have their RAM slow because they have less redundancy to cope with new stimuli. The glutamate-NMDA receptors of the prefrontal cortex and noradrenergic receptors of the locus coereleus may be viewed as the RAM of pain processing. The locus coereleus in particular has been considered an integrator of cerebral activity, helping maintain 'neural synchrony' like a conductor of an orchestra. However these nuclei can undergo neurocytotoxic effects in the presence of excessive and ambiguous interoceptive and exteroceptive inputs. This, may reduce the ability to cope with fear and anxiety in the amygdala and limbic systems. Furthermore, the anterior cingulate cortex (ACC) with its connections to the hippocampus may have it's memory for pain and disability amplified. This is significant as the ACC is active in 'anticipation' of noxious stimuli (see figure by Koyama below). Connections with the hypothalamic-pituitary axis can result in hormonal imbalance. It is probable that interoceptive bombardment of the CNS by inflamed peripheral nociceptors may be reduced through musculoskeletal physiotherapy hands-on techniques designed to reduce pain and muscle spasm. However, more frequently after the initial injury no inflammation exists and hence to prevent chronicity, clear explanations by the physiotherapist and structured goal oriented exercise regimes are used to help the person filter ambiguous intero and extero-ceptive information, thereby adding clarity to 'feed-forward' anticipatory mechanisms. Never-the-less muscle imbalance and atrophy due to inactivity as a result of 'fear-avoidance' behaviour can be addressed using specific exercises for the anti-gravity endurance stabilising muscles, whilst addressing co-ordination of the global mobilising muscles. Such an activity programme of specifc exercises must be accompanied by a desensitization process of graded exposure to 'fearful' activities. Hereby, hypervigilance and excessive hormonal stress responses (such as the release of adrenaline and cortisol) to 'perceived threats' is reduced. Thus, cortical 'clarity' is obtained whereby clients will often makes comments such as " the cloudiness has lifted from my brain" or "that they have awakened from a bad dream"

Moseley et al (2001 Abstracts - Society for Neuroscience) used attentional demands such as the stroop test to examine motor control and pain. They found that it was the fear of pain rather than the attention-demanding nature of pain which could partially explain changes in motor control. Fear connotes an identifiable threat (eg King Brown snake), whereas anxiety connotes the possibility of threat. Fear-avoidance relates to the behaviour that an identified activity may have (real or imaginary). Kinesiophobia refers to the patient experiencing "an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury" (Kori SH et al Pain Management 1990; Jan/Feb:35-43)

A persons initial reaction to an injury is usually one of shock. This is generally followed by a self appraisal of the situation "can I cope with this?", "do I have a strategy to cope with this?" If the answer is 'yes' then the normal process of recovery (in 90% of the population) within 6 weeks takes place. If the answer is 'no' then panic may set in and a process of 'catastrophizing' and 'rumination' begins. The latter strategy leads to 'activity avoidance' behaviour and desperate search for answers. Even at this stage, this can be an 'adaptive' process whereby the person seeks and finds the answers with the aid of a health professional and develops a active strategy for recovery. However, this becomes 'mal-adpative' when a passive coping strategy is enlisted which leads to 'learned helplessness'. Generally, a past history of 'passive coping' strategies can be gleaned on questionning. Some people who have had multiple painful procedures as children (e.g. premature baby) learn that active escape from pain was impossible. Generally, people in chronic pain will have also enlisted the help of mutiple practitoners, as well as used the internet to find an explanation for the 'unexplained chronicity' of their pain.

Greater exposure to past traumatic life events and depressed mood were most predictive of chronic pain whilst depressed mood and negative pain beliefs were most predictive of chronic disability. More cummulative traumatic events, higher levels of depression in the eraly stages of a new pain episode, and early beliefs that pain may be permanent significantly contributed to increased severity of subsequent pain and disability (Young Casey et al 2008, Pain, 134, 69-79)

Avoidance behaviours occur in anticipation of pain and generally persist because there are few opportunities to correct the eroneous expectations which drive them. This has a deliterious effect in the engagement of ADL which then in turn can lead to mood disturbances, irritability, frustration and depression. The fear-avoidance behaviour leads to secondary consequences of deconditioning whereby even normal activity such as walking, stair climbing or carrying the shopping leads to excessive fatigue, heart palpitations, nausea and distress.

Education and reassurance

Simply reassuring a person suffering pain can be seen as a lack of understanding of the legitimacy of their complaint. Even a series of positive results such as MR imaging can decrease a patients reported well-being (LInton et al 2008, Pain, 134, 5-8). Moreover, educating a client to the pain matrix or virtual pain brain can have its limitations if it isn't experience-based in its methodology. Cognitive, emotional, and behavioural factors have a combined impact on the effect of reassurance. Acknowledging and understanding what the patient is experiencing includes elements of respect and acceptance which reflects the practitioners use of empathy when dealing with the multiple impacts that pain is having on a persons life. This in turn may influence their fear and worry which should result in more positive impact on avoidance behaviour patterns (Linton et al 2008, Pain, 134, 5-8). Interested readers should also review the Explain Pain Book by Lorimer Moseley and David Butler (NOI Publications, Adelaide, Australia)

Education and Constructivism

Constructivism describes the process of learning and acquiring knowledge through experiential reasoning. The assumption underlying 'constructivism' is that we are 'life long learners' (3 l's) and that each and every clinical encounter allows a unique opportunity to learn, relearn and refine as well as reorganise and restructure the knowledge base. Furthermore, constructivist theory suggests that learning occurs which is based on each individuals unique prior experiences. Truth is considered relative to the individuals construct and hence diverges from logical positivism of science where 'truth' can exist alone without reference to the observers perceptions. This is similar to scientific philosophy of 'relative truths' or the 'relativity of knowledge' espoused by Feyerabend (1975), Kuhn (1970), Popper (1963). All of us would agree that science isn't just a collection of laws, or a catalogue of unrelated facts. Rather, it is a creation of the human mind relating to making sense of the world. Hence, in musculoskeletal physiotherapy we must endeavour to match the science with our clinical reasoning which should make sense to the individual or organisations with whom we are interacting.

Candy (1991, p 263) states that "the constructivist perspective differs significantly from the view of knowledge as deriving from a process of copying or replicating." Hence, "we know reality only by acting on it.....The active interaction between the individual and the environment is mediated by the cognitive structures of the individual......and what we learn from the environment is dependent upon our own structuring of those experiences." (Nystedt and Magnusson 1982, p34)

People who are suffering from chronic low back pain need to be engaged in education by being included in the dialogue of the clinical reasoning process. The person suffering chronic pain needs to be able to suspend or alter beliefs if perceptions are to be changed. Changes in perceptions allow the opportunity for the construction of a new movement reality. Therefore, the therapist needs to ascertain what the clients values and beliefs are and how these impact on the clients life.

Beliefs and Avoidance

Pain caused by length differences in legs -> avoidance of running and squatting

Pain caused by spine 'worn out' and back bones ' pressed together' pain warning signal to stop -> avoidance of heavy lifting, painting and craft, jogging

Pain caused by 'no cartilage between the 5th and 6th lumbar vertebrae leading to bone pressing on nerves' -> avoidance of vacuum cleaning, shopping, cleaning windows

Pain caused by 'crack in arch of one of my back bones' and 'inflammation in muscles' -> avoidance of rotating body, heavy manual labour, hroseback riding, bending forward

Pain is caused by my scoliosis and leg length difference -> avoidance of wiping floor, making bed, vacuum cleaning, bending foward

(Boersma et al 2004, Pain, 108, 8-16)

Cortical Plasticity

The motor and sensory hormonculus describes use dependent and bilateral representation of peripheral receptive fields in the cortex

Changes in cortical representation after deafferentation damage ot a peripheral nerve

Cortical reorganisation after training

Pain and altered movement behaviour are likely to alter the somatotopic representations in the brain. This is probably because pain redefines percepetion and perception redefines the meaning of pain, thereby altering the weighting and meaning of peripheral sensory inputs. Expectations become blurred which reduces the capacity of the fine filtering mechanisms. The good news is that it may be possible to alter the somatotopic representation back again with appropriate therapy and training.

Areas of the brain associated with pain processing

- Hippocampus & Amygdala

Pain activation of the Amygdala and Hippocampus were first shown by Hsei et al (1995). The Amygdala has an intimate involvement with 'fear avoidance' behaviour. The Hippocampus does not have a direct involvement in pain processing, however it is involved with the consolidation of long term memories (Zola-Morgan et al 1989). In particular, hippocampal damage inhibits the assimilation of contextual information preventing animals solving tasks that require the use of mapping strategies or from responding to contextual cues indicating danger (Morris et al 1982). Several neuroanatomical studies have shown that the ACC receives substantial input from the amygdala (Price 1984, Vogt et al 1987). Additionally, there are widespread hippocampocortical connections with the orbitofrontal cortex, ACC and the PHG (Van Hosen et al 1993). The connections between the ACC, insula and amygdala-hippocampal-prefrontal circuits consititute a network within which fear and contextual information relevant to pain can be integrated (Derbyshire et al 1997, Pain, 73, 431-445)

- Anterior Cingulate Cortex

The midcingulate is likely to be involved in functions relating to motor response and has been implicated in response selection during divided attention tasks (Pardo et al 1990, orbetta et al 1991, Bench et al 1992). Processes associated with affective emotional content are liable to involve the perigenual cingulate region, where electrical stimualtion of this region can evoke 'fear' and other emotional responses (Bancaud & Talairach 1992). Additioanlly, this area has been shown to be activated in PET scans when recalling 'sad' events (George et al 1995).

-Thalamus

The medial pain system project to structures such as the ACC, Insular and Prefrontal Cortex and may be involved in the motivational-affective features of noxious stimuli, whereas the lateral pain system which incorporates the VPL projects to the somatosensory cortex and is likely to bew involved in sensory-discriminative aspects of noxious stimuli (Derbyshire et al 1997, Pain, 73, 431-445).

- Insula

The insula connects reciprocally with somatosensory II (S2), receives input from spinothalamically activated posterior thalamic nuclei and projects to the amygdala and perirhinal cortex (Firedman & Murray 1986), which makes it well suited for the integration of information related to the affective and reactive components of pain (Coghill et al 1994, Hsieh et al 1995). Activation of the anterior insular arises due to the anticipation of pain, whereas the posterior insular is activated during the actual experience of pain (Ogino et al 2007, Cerebral Cortex, 17, 1139-1146)

- Prefrontal cortex and inferior parietal cortex

In general the prefrontal cortex is involved with planning involving the behavioural and attentional organisation during pain (Derbyshire et al 1997, Pain, 73, 431-445, Hsieh et al 1995, 1996). The PFC is therefore associated with 'vigilance'. Neuroanatomical studies suggest that the DLPF cortex works closely with the posterior parietal cortex (PPC). When considering the attentional systems of the brain, these can be conceptualised into the anterior focal attention system and the posterior preconscious orientation (Possner & Rothbart 1991)

- The lateral Premotor Cortex

Loss of premotor cortex impairs the ability to develop an appropriate strategy for movement. It receives its input principally from the posterior parietal cortex (PPC) and from thalamic neurones relaying information from the globus pallidus

- The somatosensory cortex (S1)

Probably involved in the sensory-discriminative aspects of pain processing. Sensory discriminative training for phantom limb pain (Flor et al 2001, Lancet357(9270), 1763-4), and tactile discrimination training for complex regional pain syndrome (Mosely & Wiech 2008, Pain), both target body maps in the primary somatosensory cortex and both show a clear increase in tactile acuity, which is a marker of primary somatosensory cortex organisation and decreased pain (Moseley 2008 Manual Therapy, 475-477). Moseley (2008) speculated that it may be these body maps which hold the key as to why some patients respond better to comprehensive examination than they do to treatment.

Apkarian et al (2005) referred to 'pain matrx' consisting of the dorsolateral prefrontal, insular, anterior cingulate, primary and secondary sensory cortices and the thalamus.

The medial pain system has been implicated during tactile stimulation with 'imagined allodynia'. Kraemer et al (2008) demonstrated activation of the ACC and bilateral activation of secondary somatosensory cortex (S2), insular cortex and prefrontal cortices in people experienced in allodynia who imagined their pain intensity (J Pain 9(6), 543-51). These results were replicated by Ogino et al (2007), where people viewed images of painful events and were told to imagine their pain. Additional to the areas mentioned, these investigators also found activation of the amygdala which may be associated with fear, and the activation of posteror parietal which may be associated with self-body centred co-ordinates. Activation of S2 was considered to be associated with the cognitive evaluative aspects of pain (Cerebral Cortex, 17, 1139-1146).

Investigations into brain function have demonstrated neuroplasticity including multiple changes seen on PET and fMRI. Although fMRI can now delineate areas (voxels) smaller than 1mm3, this area contains about 25000 neurones and 200 trillion synapses. Never-the-less changes seen include

map expansion
sensory reassignment (eg visual to auditory)
compensatory masquerades
mirror region takeover

Multiple studies indicate that activity in the mPFC and DLPFC are inversely related (Mayberg et al 1999, Northoff et al 2000). Moreover, Apkarian et al (2004) demonstrated that DLPFC gray matter density is decreased in chronic back pain. Together, mPFC activity reflects intensity of chronic back pain which is likely to be enhanced by DLPFC atrophy. The mPFC is also involved in emotions, response conflict and detection of unfavorable outcomes. Emotional reasoning enhances mPFC whilst depressing DLPFC. Since the DLPFC is involved with working memory, this may have implications for cognitive function such as emotional decision making (Apkarian et al 2004; Bailiki et al 2006, J Neuroscience, 26, 47, 12165-12173)

Both mental and physical trauma resulting in chronic pain affects higher centre processing of sensory information which in turn affects motor and hormonal responses. Concepts of brain neuroplasticity can be used by the practitioner in a positive manner to ameliorate mal-adpative changes to which the brain may have undergone (Doidge N 2007, The Brain That Changes Itself, Viking Penguine publications).

Cognitive behavioural therapy (CBT) focuses on the content of the disorder which has lead to the excessive behaviour. Through progressive cognitive appraisal and re-appraisal the irratitionality of the behaviour is reduced. Another method of dealing with mal-adaptive behaviour is to recognise the behaviour for what it is and attempt to associate this behaviour with positive thoughts, experiences and activities. Hereby, neurons that fire together, wire together into a positive movement experience. The original fear & anxiety may not be extinguished but the ability 'to move on' and the ability to neither dwell on the anxiety nor on the content of that anxiety is taught and learned. Importantly, education into how the brain processes and deals with information, using PET scans, fMRI's, flow diagrams, etc become very useful tools when explaining the usefulness of graded motor imaging (GMI) tasks. Recently, however, Lorrimer Moseley has suggested to firstly use computer generated images to distinguish any signs of cortical laterality bias either towards or away from the affected region. This appears to be particularly useful for CRPS, frozen shoulder and neuropathic limb pain, but may not be so relevant to spinal pain. Never-the-less, recognition and education of the problem are paramount to successful outcome.

Hsieh et al (1995)

click on image for greater resolution

"Living in the past is dwelling upon what cannot be changed, living in the future is creating the milieu for fear and anxiety, living in the now is the right environment for action and change"

Anticipation of pain affects the subjective experience of pain where expectations become reality

Treatment success and understanding the clients needs and preceptions can result in positive outcomes. In contrast, failed treatment or unrealistic expectations, unrealistic timeframes and undefined, poorly conceived goal setting may result in the 'nocebo' effect.

Placebo Response

Our subjective sensory experiences are thought to be heavily shaped by intereactions between expectations and incoming sensory information. Koyama et al (2005) found that as the magnitude of the expected pain increased, activation increased in the thalamus, insula, prefontal cortex, anterior cingulate cortex (ACC). However, when the expected pain was manipulated, the expectations of reduced pain powerfully reduced both the subjective experience of pain and activation of pain-related regions such as the primary and secondary somatosensory cortex (SI, SII), insular cortex, pre frontal cortex (PFC), mPFC (Raij et al 2005, PNAS, 102, 6, 2147-2151), ACC and cerebellum (PNAS, 102, 12950-12955)

Pain modulation by placebo have shown brain activations in the rostral anterior cingulate (rACC), insula, thalamus and mid-brain regions. During reduced pain expectation, increased acticvity in the orbitofrontal cortex (OFC) and dorsolateral prefrontal cortex (DLPFC) were seen (Watson et al 2009 Pain, 145, 24-30). Anticipation of pain reduction during placebo conditioning and post-conditioning activated fronto-cingulate structures included Prefrontal Cortex (PFC) structures DLPFC and MFC, anterior mid cingulate cortex (aMCC) and the dorsal posterior cingulate cortex (dPCC). The PCC is involved in visuospatial orientation and assessment of self-relevant sensation and the more dorsal PCC is associated with orientation of the body to both innocuous and noxious somtosensory stimuli, which combined are essential for the process of learning. Modulation of activity in the MCC has been associated with affective aspects of pain and pain intensity coding. The anticipation of reduced pain and actual perception of reduced pain could serve as the foundation of a self-reinforcing feedback loop underpinned by the previously associated learning (Watson et al 2009). Furthermore, for a placebo to be effective the memory of the effectiveness of a treatment developed during the learning conditioning phase must be retrieved and matched with the incoming sensory information, where the PFC with its role in memory retrievel and working memory plays an important part (Watson et al 2009).

All of these cerebral cortical areas receiving nociceptive informaton can be readily modulated by expectation-induced information. Because expectations are future predictions derived from both past experience and present context, this flow of expectation-related information may be crucial for the development of a 'perceptual set' . Given the highly distributed and parallel nature of pain processing, the 'perceptual set' needs to be a highly distributed process (Koyama et al 2005).

Nocebo Response

Kong et al (2009) found a significant fMRI signal increase to pain in bilateral ACC, left orbital prefrontal cortex (PFC), and right DLPFC. They speculated that changes in PFC and parietal lobule may imply multiple functions, including memory retrieval of previous experience, expectations generation, modulation of pain perception and pain ratings, as well as attention and emotion modulation (J Nueroscience, 28, 49, 13354-13362). Repeated negative responses to treatment may reinforce the nocebo response. Therefore it is important to establish in the clients past history their respose(s) to various interventions and to ascertain their expectations of what will and won't help them in future interventions.

Forebrain mechanisms of nociception and pain

"Pain is a unified experience composed of interacting discriminative, affective-motivational and cognitive components, each one of which is mediated and modulated through forebrain mechanisms acting at spinal, brainstem, and cerebral levels. The size of the human forebrain compared to the spinal cord gives anatomical emphasis to forebrain control over nociceptive processing" (Casey 1999, PNAS, 96, 7668-7674)

Philosophy and pain

An exciting approach to challenging realities is the examination of the Pain and Philosophy of the Mind (Alex Cahana July 2007, Pain Clinical Updates, Vol XV, 5). Cahana argues that 'mind-body supervenience' (physicalism or materilism) where pain always has a physical substrate, isn't enough to explain the qualitative nature/character of pain ("qualia" = what it is to be).

The problem with physicalism as argued by Cahana is that 'you are nothing but your synapses' ("eliminative") or 'you are ultimately your synapses' ("reductive" or "token").

Cahana (2007) concludes by stating that "pain cannot be seperated from the person experiencing it, and the human experience cannot be omitted from a scientific explanation of how our mind works. Therefore, a new subjectivist, interpretive, phenomenological stance is needed in order to capture the complexity of the patient's narrative experience (narrative dyad)".

Thoughts lead to feelings which lead to either action or inaction whereby either activation or deactivation of problem solving takes place. This applies as much to the therapist as to the client who is suffering from pain. Through clinical prediction, environmental prediction can be more finely tuned by the feelings which have preceeded the situation that has taken place. The therapist and the client need to embark in cognitive strategies which include ascertaining feelings and beliefs, appraising the adequacy of the response and then if necessary using problem solving to be able to use realistic goal setting (rather than fear -avoidance behaviour) to establish a paced response. Success (by the therapist and the client) leads to better predictive outcomes and thereby should become self-fulfilling.

Non-dermatomal somatosensory deficit (NDSD) in chronic pain disorders

Egloff et al (2009, Pain, 252-258) investigated 30 consecutive patients with unilaterally accentuated chronic pain not explained by persistent tissue damage and ipsilateral somatosensory disturbances including upper and lower extremities and trunk (NDSD). They found that all patients had mild to moderate depressive symptoms (HAMD-17), all had experienced a prolonged antecedent phase of severe emotional distress such as childhood abuse, torture, war, physical or sexual violence, persecution, imprisonment, etc), and most remembered a 'trigger episode of somatic pain' on the affected side. Pain quality was often described as 'burning' associated with 'numbness', a 'sense of swelling' or 'heaviness'. Somatosensory deficits were a replicable hypersensitivity to touch and heat perception of non-dermatomal distribution. Almost 1/3 of patients had hyposensitvity extending to the facial area including hyposensitivity, slightly hanging mouth corner or pseudo-ptosis. Parodoxically, the hyposensitvity to touch was combined with increased sensitivity to deep muscle palpation (similar to fibromyalgia) and joint palpation in the painful area. Imaging with FDG-PET showed a significant hypometabolic pattern of changes in cortical (primary somatosensory cortex) and subcortical areas, mainly in the post-central gyrus, posterior insula (regarded as a secondary centre of temperature and vibro-tactile discrimination in space and also of pain perception), putamen, and ACC. Prevelance of NDSD ranges from 25% to 45% in chronic pain complaints (Gagnon & Nicholson 2009, Pain, 12-13)

Motor control in the presence of pain

A 'Pain-Adaptation' model was coined by Lund et al (1991) which hypothesised that movement velocity and amplitude is reduced in the presence of pain with reduced agonist activity and increased antagonist activity in limb and jaw movements. In the trunk this may mean increased coactivation of the superficial muscles at the expense of the deeper postural muscles. This is significant as Bergmark (1989) differentiated muscles based on their segmental stabilising role versus their global mobilising role. The pain-adaptation hypothesis suggests that the global mobilisers inappropriately become the stabilisers of the spine, which can lead to excessive splinting and compress spinal structures.

Pain Processing

Clearly, chronic pain may change the structure of the brain. Traditionally, pain impulses were though to affect cortical activity in a fixed manner. However, it can be seen by the previous discussion that cortical interaction not only is influenced by pain impulses (bottom - up) it can also change the interpretation of pain impulses, as well as change the behaviour towards those impulses (top - down). The brain is remarkarbly malleable to change, demonstrating functional (and dysfunctional) plasticity to various management strategies.

The brain exhibits plasticity and therefore is malleable to change.

The role of values in a contextual cognitive behavioural approach to chronic pain

The experience of chronic pain can be an overwhelming one. Pain and other unwanted experiences can become the focus of daily efforts while less time is devoted to family, intimate relations, friends, work, health, or developing as a person. This can be viewed as a failure of their efforts to serve important interests, or a failure of their 'values' to guide their actions (McCracken & Yang 2006, 123, 137-145). Acceptance of pain can be viewed as a weakening of pain to guide their actions whereas 'value-related' processes, involve a strengthening of guides for action that are unrelated to pain, but rather actions guided by the individual to live their life according to what they care about most deeply. McCracken & Yang (2006) examined patient values in the domains of family, intimate relations, friends, work, health, and growth or learning. They found that highest importance was placed on the values in the domains of family and health and the least importance in friends and growth or learning. Highest success was reported in domains of family and friends and the least success in health and growth or learning.

Values are essentially verbally constructed desired life directions. Values clarification can be seen as the adding of cognitive influences to patterns of behaviour. Values based methods can bring into therapy a focus on whether the patient is taking action in their life that serves what they care most about (McCracken & Yang 2006)

Contextually based clinical approaches to human suffering and behaviour problems address cognitive processes differently than is typically done within a traditional cognitive-behavioural approach (McCracken 2005). Rather than attempting to alter the form or frequency of maladaptive thoughts, contextually based approaches aim to alter their function, how they are experienced, or how they influence other behaviour. Therapeutic effort approaches concerns loosening unadaptive cognitive influences on behaviour and increasing behavioural flexibility by processes such as 'mindfulness' and what is referred to as cognitive de-fusion. Mindfulness has been significantly related to multiple measures of patient functioning (McCracken et al 2007, Pain, 131, 63-69).

Mindfulness can be defined as the practice of broad, present-focused, and behaviourally neutral awareness. It is a way to observe experiences, such as physical symptoms, emotions, or thoughts, such that some of the otherwise automatic behavioural influences attached to these experiences are reduced, leading to more balance, non-reactive, and realistic contact with situations, and more effective action (McCracken et al 2007).

The goal of mindfulness is not to alter the content of what is experienced but to change how it is experienced and the influences it exerts on behaviour. Mindfulness is best understood in a functional and contextual framework rather than challenging or modifying thoughts and feelings. In the chronic pain scenario, changing what is felt is far more difficult than changing the behaviour in relation to what is felt which suggests that mindfulness could play an important role in multifactorial treatment approaches. MIndfulness includes noticing and not reacting to pain, emotions, urges, thoughts, and other feelings in the body thus freeing the person for function and movement. "Full present focus and non-reactive awareness" (McCracken et al 2007) would be a goal of a multifaceted management strategy.

Assessment - Factor Web

Methods for assessing the influence of extraneous pyscho-social varaibles are many fold and generally reflect the multi-dimensional nature of pain and suffering. The NZACC has developed a clincal assessment guideline to aid in the management strategy. The results of this assessment are used to predict final outcomes. Hereby, the form of the optimal management strategy can be implemented at an early stage which should either lead to faster recovery or at least reduce the likelihood of the secondary affects of chronicity. These clinical decisions on whether to be hands-on, hands-off, or to use CBT focused on content versus a focus on education can be used by the clinician to rationalise expected treatment outcomes. This latter aspect of education is consistent with the concept of the malleable brain, where the recognition of the affect of reverberating dysfunctional neuronal generators can be used to help the client 'move-on' , and help themselves get out of the rutt which their sufferring has brought them.

WHO classification of pain

Hewitt, Hush, Martin, Herbert & Latimer (2007), AJP, 53, 269-276, established that measures of activity limitation and pain at 9 weeks, and work status at 6 months have the greatest predictive accuracy of someone developing chronic pain and disability.

Assessment - Psychometric evaluation

It is easy to be overwhelmed by such multiple factors which could contribute to chronic LBP. However, we must evaluate what is relevant and use this differentiation to determine what our strengths and weaknesses are as a profession and when to refer to other professionals. Importantly, there will be a significant subgroup of clients who have chronic musculoskeletal injuries due to mismanagement, which if identified could be resolved through multi-factorial physiotherapy which includes passive techniques, exercises and education.

The ICF - WHO has stipulated three seperate but related dimensions of functioning are defined as body dimension (functions and structure), individual dimension (activity), and social dimension (participation). Body functions are physiological or psychological functions of body systems. Activity describes daily purposeful integrated body systems execution of tasks. Whereas participation deals with the experiential and contextual setting of the persons life (social relationships, employment, and economic life), as well as societies response to the person's level of functioning.

According to Thonnard & Penta (2007), Eur Medicophys, 43, 525-541, "rehabilitation can be defined as a reiterative problem solving and educational process that focuses on disability (altered activities) and aims to maximise participation in society while minimising the stress on and distress of the patient and family". While the outcome of a particular physiotherapeutic intervention can be stipulated based on functional measures, these need to be validated not only w.r.t diagnosis but also their meaning w.r.t the participation of the patient in the community. The latter hasn't specifically been addressed and has frequently been assumed to correlate with functional status. Importantly, functioning and participation in the community are highly likely to be key measures when it comes to financing treatment interventions.

http://www.sf-36.org/tools/SF36.shtml

Modified Schober Test (MMST) tests range of movement in the lumbar spine in the ICF dimension of body function. Validity as correlated to X-ray is 0.67, reliability as an inter-rater score is excellent (ICC=0.95, 95%CI, 0.44-0.84), responsiveness (sensitivity) requires a change of over 1cm to be 95% confident of change.