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From acute to chronic back pain : risk factors, mechanisms, and clinical implications

Current Developments in Epidemiology Epidemiology of Back Pain, from the Laboratory to the Bus Stop: Psychosocial Risk Factors, Biological Mechanisms, and Interventions in Population-Based ResearchIntroductionGoals of epidemiology—improving healthRecent success of epidemiology in improving understanding of CLBPDefining LBP in epidemiology studiesRisk factors for LBP already established in population-based researchEvidence on management for LBP in primary carePotential biological risk factors hypothesized from existing researchNeurologicalEndocrine and immunologicalGeneticThe need and potential benefit of population-based studies of hypothesized biological risk factorsBeyond the bedsideReferencesDefining Chronic Pain by PrognosisDuration-based definitions of chronic painPatient APatient BPatient CConceptual bases for defining chronic pain Duration-based and prognostic approachesEpisode of low back painEpisode of care for low back painEpisode of work absence due to low back painChronic pain as a multidimensional phenomenonChronic pain—static or dynamic?Defining chronic pain by outcome probabilityDevelopment of the approachGeneralizability of the prognostic approach to other samplesComparison of prognostic and duration approachesClinical implicationsConclusionsReferencesRisk Factors of Chronic Back Pain and Disability: Biological Mechanisms Genetic Factors Modulating Chronic Back PainIntroductionPolymorphisms associated with subtle modulations of pain sensitivityGenetic polymorphisms associated with intervertebral disc diseasePolymorphisms in pro-inflammatory genesPolymorphisms contributing to chronic widespread musculoskeletal painPolymorphisms causing complex syndromes with a loss of pain perceptionSummaryReferencesPeripheral and Central Sensitization as Risk Factors of Low Back PainIntroductionNociceptor functionsTransduction and transformation processes in nociceptor terminals.Sensitization of nociceptor terminals and the initiation of pathological pain and hyperalgesiaNeuropathic components of CLBPAltered processing in the central nervous systemSynaptic plasticity in the spinal cord dorsal hornContribution of glial cells to neuropathic painCentral disinhibitionSupraspinal mechanisms of CLBPFunctional plasticityStructural plasticityConclusionsReferencesDysfunction of the Hypothalamic-Pituitary-Adrenal Axis and Associated Stress Axes in the Development of Chronic Low Back PainIntroductionAllostatic load: the molecular switch from acute to chronic pain?Stress and the HPA axisNormal HPA functionThe impact of acute stressThe impact of chronic stressStress and HPG axis functionNormal functionThe impact of acute stressThe impact of chronic stressStress and HPGH axis functionNormal functionThe impact of acute stressThe impact of chronic stressDoes stress system functioning underpin the transition from acute to chronic LBP?Stress system functioning in chronic LBPThe transition from acute to chronic symptomsCausal mechanismsConclusionsAcknowledgementsReferencesCentral Imaging of Pain and the Process of ChronicityIntroductionThe pain matrix: a short introductionBrain processes in chronic back painStructural and biochemical changes in the brains of patients with CBPThe role of learning and memoryThe role of cognitive factorsImaging and therapeutic interventionsConclusions and outlookAcknowledgementsReferencesStructural Brain Changes in Patients with Chronic Back PainIntroductionStructural brain imagingStructural imaging in chronic back painAre the brain changes in chronic back pain specific?Relating brain grey matter changes to white matter connectivityBrain changes in chronic pain: cause or consequence?ReferencesThe Psychophysiology of Chronic Back Pain PatientsIntroductionBiomechanical modelsPsychological models of chronic painSensitizationClassical conditioningOperant conditioningCognitive-behavioural approachDiathesis-stress modelPsychophysiological modelsAssessment of stress-related psychophysiological reactionsPsychological factors in chronification of painPsychosocial stressors in CBPPersonalityCognitionsPsychosocial adaptationPain behaviourComorbiditySummaryPsychophysiological variablesStatic and dynamic posturesSymptom-specific psychophysiological responseIndividual-specific psychophysiological responseInteraction between pain regulatory and cardiovascular systems: a new approachCNS and baroreceptor sensitivityLearningConclusionFuture implicationsReferencesRisk Factors of Chronic Back Pain and Disability: Biomechanical MechanismsElectromyographically-Determined Muscular Fatigue in Low Back PainThe theoretical basis for a link between back muscle function and back painMeasurement of back muscle fatigueReliability of EMG measurements of back muscle fatiguePhysiological/anatomical factors governing fatigability/ muscle enduranceThe evidence for back muscular fatigue as a predictor of back painThe evidence for changes in back muscular fatigue as a consequence of back painChanges in fatigability through exercise training and their clinical relevanceReferencesUnmasking the Deconditioning Paradigm for Chronic Low Back Pain PatientsIntroductionThe level of physical activity in patients with CLBPHealth-related fitness in patients with CLBPBody composition and bone strengthMuscle strength and endurancePostural controlAerobic capacityMetabolic factorsConclusion on health-related fitness in patients with CLBPFuture researchFuture research on physical activity in CLBPFuture research on health related fitness in CLBPGeneral conclusionReferencesRisk Factors of Chronic Back Pain and Disability: Sociodemographic and Psychosocial Mechanisms Screening of Psychosocial Risk Factors (Yellow Flags) for Chronic Back Pain and DisabilityIntroductionTerminologyRisk factors, predictive factors, and prognostic factorsFlags as a method of risk identificationThe nature and focus of risk identificationUnderstanding the natural history of chronic low back pain (CLBP)Defining the outcomeRisk identification in population studiesRisk identification in clinical epidemiologyConceptualizing risk identification for individualsFrom risk identification to screeningPrinciples of screeningPurposes of screeningMethods of screeningActuarial versus clinical methodsAccuracy of screeningThe importance of timing (lead time of screening)The determination of optimal cut-off pointsCombining different screening tools to improve predictionFeasibility of screeningMethods for screening yellow flagsDistress Risk Assessment Method (DRAM)Recommendations for useThe STarT Back Decision Tool (SBDT)Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ)The Risk Screening of Back Pain (RISC-BP)Summary and conclusionReferencesDispositional Fear, Anxiety Sensitivity, and HypervigilanceIntroductionPain-related anxiety and fearAssessment of pain-related fear and anxietyTreatment of pain-related fear and anxietyAnxiety sensitivityAnxiety sensitivity and pain-related anxietyIntolerance of uncertaintyIllness/injury sensitivityFear of negative evaluationHypervigilanceConclusionReferencesProcesses Underlying the Relation between Catastrophizing and Chronic Pain: Implications for InterventionIntroductionCatastrophizing: the constructProcesses linking pain catastrophizing to adverse pain outcomesExpectanciesAttentionEmotionCopingEndogenous pain modulationProcesses mediating the relation between pain catastrophizing and pain outcomesTreatment implicationsSummaryReferencesFear-Avoidance as a Risk Factor for the Development of Chronic Back Pain and DisabilityIntroductionChronic low back painGeneral explanatory modelsFear and avoidanceFear-avoidance learningFear-avoidance model of painEmpirical support for the main components of the fear-avoidance modelPain catastrophizingPain-related fearAvoidance behaviourHypervigilance and attentionDepressionDisuseVulnerabilities for fear of painAssessment of pain-related fearSelf-report measuresFear of painFear of pain-causing activitiesFear of movement and (re)injuryPerceived harmfulness of movements: the PHODAInterviewSelf-assessmentObservational measuresPhysiological measuresAdditional measuresTreating pain-related fearMain components of exposureAssessmentDefining goalsEstablishing hierarchiesEducationGraded exposureBehavioural experimentsEvidence for exposure in vivoFuture directionsAcknowledgementsReferencesEndurance-Related Pain Responses in the Development of Chronic Back PainIntroductionThe occurrence of endurance-related pain responsesTheoretical considerations: the Avoidance-Endurance Model (AEM) of painBasic assumptionsFear-avoidance responses and physical disuseEndurance-response pattern and physical overuse/overloadAdaptive pain responses and balancing of physical/mental loadEvidence for endurance-related components of AEMMeasurement of endurance-related pain responsesMeasurement of behavioural responsesMeasurement of cognitive responsesMeasurement of endurance-related affective responsesAEM-based subgroupsEndurance and pain-related outcomesEndurance and pain intensityEndurance and pain-related disabilityEndurance and overt physical activityEndurance and neurocognitive functionsEndurance and feelings of self-control and self-efficacyEndurance and affective responsesPositive mood despite painEndurance and pain-related fear and depressionStability versus variability of pain-related endurance responses and AEM patternConsequences for clinical practice: implication for differentially targeted approachesSummary and conclusionReferencesCognitive Processing and Self-Pain Enmeshment in Chronic Back PainIntroductionCognitive processing and schemasCognitive biases in chronic painAttention biasInterpretation biasMemory biasCognitive models of chronic painGeneral model of pain processingEnmeshment and chronic painPain and the selfThe Schema Enmeshment Model of PainEmpirical support for the main components of the SEMPClinical implicationsRecommendations and future directionsAcknowledgementsReferencesSignificant Others in the Chronicity of Pain and DisabilitySupport for theoretical conceptualizations of the role of close relationships in painOperant modelCognitive-behavioural modelsCommunal coping modelEmpathy modelsTreatment research on couples and spousesSpouse involvement in education and coping skills trainingCouple therapyRecommendations and future directionsAcknowledgementsReferencesEffects of Workers' Compensation Systems on Recovery from Disabling InjuriesIntroductionIs there an effect?Shape of the recovery curveMoral hazardsComparisons between IWs and other patient groupsHow does the workers' compensation affect the behaviour of IWs?Possible explanations for the negative effect of WCMalingering and secondary gainMalingeringSecondary gain and related termsInternalExternalCured by a verdict?Perceptions of IWsSense of being distrustedConflict with the WC systemStress; personal loss; family lossAnger with the WC systemOther possible causes of the negative effect of WCLack of access to careInvolvement of unionsInvolvement of attorneysThe need to prove incapacitationMoral hazards: another lookConclusions: implications for social policyReferencesWork-Related Risk Factors for Transition to Chronic Back Pain and DisabilityIntroductionWorkplace risk factorsScreening for workplace factorsIntervention strategies based on workplace risk factorsOpportunities for future research and practice improvementReferencesPractitioner's Role in the Process of Care The Physician as Disability Advisor for Back Pain PatientsIntroductionMagnitude of the physician role as disability advisorThe content of physician recommendationsPhysicians' characteristics that influence disability recommendationsPhysician-patient relationship factorsPatients' perceptions of disabilityFactors external to the physician-patient relationship that influence disabilityEfforts to influence physician recommendationsMedical educational effortsGuidelinesSystems effortsLegislative effortsSummary and conclusionsAcknowledgementsReferencesThe Attitudes and Beliefs of Clinicians Treating Back Pain: Do They Affect Patients' Outcome?IntroductionHow could clinicians increase the risk of long-term problems?Measuring clinicians' beliefsThe effect of clinician's beliefs on clinical decisions and behaviourCan practitioners' beliefs be changed, and if so, is the change reflected in clinical behaviour?Differences between professional groupsSummary: current knowledge on clinicians' beliefsConclusionReferencesClinical Implications: New Approaches to Diagnostics and TreatmentInternational Guidelines for the Diagnostics and Treatment of Acute, Subacute, and Chronic Back PainBackgroundGuidelinesQuality of guidelinesRecommendations on diagnostics and treatmentEuropean guidelinesImplementation of guidelinesSummary of recommendations for diagnosis of acute non-specific low back painSummary of recommendations for treatment of acute non-specific low back painSummary of diagnosis in chronic low back painSummary of treatment of chronic low back painDiscussionReferencesClinical Approaches for Patients with Acute and Subacute Low Back PainEngaging Patients in their Own Care for Back Care: The Role of Education and Advice in the Prevention of Chronic Pain and DisabilityIntroductionCurrent state of knowledgeThe educational processGeneral educational principlesResearching the effectiveness of educational interventionsEducation about the nature of LBPEducation about the management of LBPTypes of interventionPublic health initiatives and media campaignsEducation and advice within a cognitive-behavioural approachSpecific evaluations of educational interventions in LBPEducation and advice within psychologically informed re-activation.Suggestions for a way forward (Wave 4)Effectiveness and sustainabilityInfluence of patient characteristicsThe decision to consultInfluences of beliefs, expectations, and preferences on participation in treatment and on treatment outcomeThe influence of HCPs' beliefs and treatment orientations.The nature of HCPs' beliefs and treatment orientationsInfluences on design/delivery of interventions and clinical outcomesFrom evidence to action: some suggestions for improving the effectiveness of educational strategies in secondary preventionEducational contentBeliefs about the nature of painSpecific fears of hurting, harming, and further injurySelf-efficacy beliefsSuch beliefs therefore would seem to have considerable potential as targets within clinical management.The educational contextDeveloping an educational strategyReconsideration of the role of education and advice in behaviour changeGuidelines as a vehicle for educationThe challenge of implementationPatient-mediated strategiesRolling out LBP education at a systems level: example of the flags frameworkConclusionReferencesMotivational Issues in Pain ManagementModels of motivation and a motivational model of pain self-managementMeasurement of motivation in pain self-managementThe Pain Stages of Change Questionnaire (PSOCQ)The Multidimensional Pain Readiness to Change Questionnaire (MPRCQ)RationaleInitial developmentThe MPRCQ2Brief versions of the MPRCQ2Future researchClinical and research implicationsMotivational InterviewingImplications of the motivational model and motivational issues for understanding and addressing the process from acute to chronic painReferencesPharmacotherapy of Low Back PainIntroductionStrategies for drug therapyCOX inhibitors: drugs with proven effectiveness in ALBPOpioids: drugs with moderate effect in CLBPMuscle relaxants may enhance the effect of analgesicsAntidepressants: sometimes useful as co-therapeutics in CLBPConclusionReferencesSubgroup-Specific Approaches for Patients at Risk For or With Chronic PainReviewing the Concept of Subgroups in Subacute and Chronic Pain and the Potential of Customizing TreatmentsThe conundrum of painContributions to individual differencesGenotypePrior learning histories and psychological variationsEnvironmental contributionsA diathesis-stress-environment conceptualizationPatient uniformity mythIdentification of patient subgroupsEmpirically-derived classification of patients with painSubgrouping on the basis of the MPISubgrouping on the basis of pain-related fear and emotional distressSubgrouping on the basis of endurance-responses and emotional distressFuture directions and conclusionDual-diagnostic approachCustomizing treatments to patients' needsThe transition from acute to chronic pain: secondary preventionOvergeneralization based on pain clinic samplesChronic pain should be treated like other chronic diseasesReferencesRisk Factor-Based Cognitive- Behavioural Therapy for Acute and Subacute Back PainIntroductionPreliminary considerationsFinding the right time point for treatmentFinding the right patientFinding the right treatmentEarly psychosocial interventions for LBP patients in primary careRisk factor-based cognitive-behavioural interventions (RCBIs)Conclusion and future directionsReferencesClinical Approaches for Patients with Established Pain and DisabilityPhysical Exercise Interventions and Low Back PainIntroductionTreatment aimed at increasing physical fitness and/or activitySpecific spinal stabilization exercisesMcKenzie therapyPhysical exercises from a cognitive-behavioural perspectiveExercise interventions to improve work enduranceConclusionReferencesContextual Cognitive-Behavioural Therapy for Chronic Pain (Including Back Pain)IntroductionThe history of behavioural and cognitive-behavioural approaches to chronic painWhat is CCBT?Acceptance of chronic painCognitive de-fusionValues clarification and values-based actionMindfulnessChronic pain in a social contextTreatment outcome from contextual approaches to chronic painSummaryReferencesRehabilitation Programmes to Prevent Severely Disabling Chronic Back PainIntroductionA conceptual framework for assessment and multidisciplinary rehabilitationImportance of treatment settings and contextsTiming of rehabilitation and decision rulesIntegrating/combining with other treatment modalitiesIntegrating with the social environmentResearch agenda: the futureReferences
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