Perhaps the simplest way of answering the question, "Why are psychological evaluations important for injured patients?" is to say that it is an accepted part of general clinical practice. The most widely accepted definition of pain is that developed by the Taxonomy Committee of the International Association for the Study of Pain. It describes pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage." Its definition goes on to note that:
Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience which we associate with actual or potential tissue damage. It is unquestionably a sensation in part or parts of the body, but it is also always an unpleasant and therefore also an emotional experience... Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain... [Pain] is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.
Psychological factors have not only been found to be associated with the experience of pain, but also with the onset of pain disorders. The National Institute of Occupational Safety and Health (NIOSH) is a part of the Center for Disease Control in the Department of Health and Human Services. After extensive study, NIOSH concludes that psychosocial factors have a role in the onset of musculoskeletal disorders:
While the etiologic mechanisms are poorly understood, there is increasing evidence that psychosocial factors related to the job and work environment play a role in the development of work-related musculoskeletal disorders (MSDs) of the upper extremity and back.
While NIOSH has studied factors leading to the onset of MSDs, other organizations have studied the treatment of these conditions. The North American Spine Society is the parent organization of Spine, perhaps the most prestigious journal on the orthopedic care of back and neck injuries. NASS has spent years developing it's clinical guidelines for treatment of these injuries, and these protocols are internationally recognized. Although they were developed by orthopedists, these guidelines strongly advocate the role of psychology. NASS suggests that for "Phase II" patients (20-30% of patients), a psychological consultation is often warranted for the purpose of preventing psychosocial deterioration or address return to work issues. For "Phase III" patients (5-8% of patients), active multidisciplinary treatment including psychology is advocated to effect recovery or reduce disability. It is the position of NASS that:
Chronic pain is now understood as a complex psychophysiological behavior pattern ... While intensive rehabilitation approaches to spinal disability present society with high short-term costs, long-term benefits of such treatment approaches ensue because of decreased long-term indemnity and medical costs, reduced incidence of permanent injuries, and improved job performance.
Along these same lines, the American Academy of Pain Medicine has produced a consensus statement entitled "The Necessity for Early Evaluation of the Chronic Pain Patient." This statement notes that:
The diagnosis and management of chronic pain is a complex process requiring intensive, comprehensive, and interdisciplinary services for optimum treatment outcomes. Thorough and effective pain evaluation and control must be the primary goals.
It should be noted here that the term "interdisciplinary" indicates that this evaluative process is not simply medical, but rather includes input from other professions such as psychology. This statement is clear in advocating early diagnostic workups, and is consistent with our position here. The above guidelines were also used in the development of some state regulations, such as those in Colorado.
Mayer, T. G. et al (1994). Spine rehabilitation: Secondary and tertiary nonoperative care. Rosemont, Illinois: North American Spine Society.
Mersky, H (1986). Classification of chronic pain, descriptions of chronic pain syndromes and definitions of pain terms. Pain Suppl 3, S10-S24.
NIOSH (1997). Musculoskeletal disorders (msds) and workplace factors: A critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Washington DC: US Department of Health and Human Services.
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