to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk
Factors for Long-Term Disability and Work Loss
Appendix 2: Inconsistent findings and pain behaviour are not the same thing as
Pain behaviours are a normal part of
the experience of pain and serve the important purpose of
communicating to others - it is normal for people suffering pain to
exhibit these behaviours.
The expression of pain behaviour is
influenced by our upbringing, our culture, and the circumstances at
the time. The behaviour observed in patients is usually a result of
fear of being hurt and injured.
Pain behaviour, like any other
behaviour, is subject to the effects of learning and reinforcement -
the longer a pain problem goes on, the more opportunity there is for
learning to occur from a wide range of influences. This is the main
reason that some individuals with chronic back pain present with what
appear to be unusual behaviours.
Learning often occurs by association.
It is very significant that many people with back pain learn to
associate irrelevant or less important factors with their subjective
experience of pain. That is, an individual may associate a particular
activity or movement with pain despite the lack of a real causal
connection. This learning is unintentional, usually due to inadvertent
reinforcement, and is often referred to as learned irrelevance.
For example, a person with back pain may inadvertently associate going
for a walk with a natural variation in their subjective pain severity
and subsequently feel fearful about this activity.
It may be thought of as the
development of a type of superstitious behaviour. Those
people who have developed learned irrelevance will present
with behaviours that are inconsistent with other aspects of the
clinical assessment. For this reason they may appear unusual to
clinicians with behaviours that are not easily explained. This should
not to be misinterpreted as a sign of psychological disorder.
To summarise, pain behaviour is a
normal part of being human, and is subject to wide individual
differences and the effects of learning.
In contrast, malingering involves the
intentional production of false or grossly exaggerated symptoms,
motivated by obvious external incentives. Malingering is not the
product of unintentional learning or emotions, such as fear of pain.
Interpreting the presence of pain
behaviours and inconsistencies as malingering has not been
demonstrated to help the patient or the clinician. The inevitable
consequence of making that interpretation is an adversarial them
against us situation. Inconsistent behaviours may exist because
the person with back pain perceives that they have little or no
control over managing the problem. Many risk factors are, or are
perceived to be, beyond the control of the person with back pain.
The goal of identifying Yellow Flags
is to find factors that can be influenced positively to facilitate
recovery and prevent or reduce long-term disability and work loss.
This includes identifying both the frequent unintentional barriers,
and the less common intentional barriers to improvement.