Biopsychosocial factors associated with headaches ● Depression —the prevalence of chronic pain is higher among those with a diagnosis of depression. Conversely, the prevalence of depression among individuals with chronic pain is also higher (Adams et al., 2015). According to Adams et al. (2015), depression seems to exacerbate the experience of pain and is a strong determinant of pain-related disability. ● Anxiety —individuals with chronic pain often report being anxious and worried about their pain. In addition, there is strong evidence to support the influence of anxiety on pain perception. ● Posttraumatic stress disorder (PTSD) —when a formal diagnosis of posttraumatic stress disorder is present, the prevalence of chronic pain is 50%. The diagnosis of PTSD means a person has been exposed to a traumatic event that can in and of itself can cause pain. PTSD can also prolong the pain experience, with one study finding that PTSD symptoms were the only baseline factor that predicted persistent pain three years after involvement in serious accidents (Adams et al., 2015). ● Substance misuse and dependence —the relationship between substance misuse and chronic pain is seen often in clinical practice (Adams et al., 2015). ● Anger —people with central sensitization often report feelings of frustration and anger related to their situation, the intensity of their symptoms, the lack of a cause or cure, and challenges within the healthcare system. One possible explanation for the relationship between pain and anger is the finding that people who have high levels of anger expression may have deficits in their endogenous opioid function, resulting in increased pain sensitivity (Adams et al., 2015). ● Symptom appraisal and symptom belief —how a person looks at and interprets a situation can have a profound influence on their experience. The following specific beliefs have been identified as particularly maladaptive in managing chronic pain: pain is a signal of damage; activity should be avoided when pain is present; pain leads to disability; pain is uncontrollable; and pain is a permanent condition (Adams et al., 2015). ● Hypervigilance is an attentional bias for pain that might lead to increased fear-avoidance behavior. ● Perceived control versus helplessness —when individuals believe they can influence the duration, frequency, intensity, or unpleasantness of symptoms, they are often more motivated to pursue solutions to managing these symptoms. By contrast, persons with low perceived control report worse outcomes, including greater pain intensity and poorer physical and psychological adjustment to illness. As expected, patients with higher perceived control function better (Adams et al., 2015). ● Self-efficacy refers to the extent to which a person believes they can successfully complete the tasks necessary to achieve the desired outcome in each situation. Patients with higher self-efficacy have better outcomes with pain (Adams et al., 2015). ● Psychological inflexibility refers to an inability to act in accordance with one’s own values in the midst of interfering thoughts, feelings, or bodily sensations. High levels of psychological inflexibility (i.e., low levels of psychological flexibility) are associated with avoidant coping methods such as denial, behavioral disengagement, and self-blame (Adams et al., 2015). ● Social learning provides a framework for how a patient’s symptom behaviors develop and are maintained. Ideas about symptoms are learned from parents, culture, and environment. For example, people whose pain behavior
is reinforced are more likely to continue to display those behaviors. ● Social stigma and skepticism —individuals with central sensitization often report that the stigma arising from other people’s response to their illness is a relevant issue for them. According to Adams et al. (2015), social stigma has negative implications for psychological well-being, quality of life, and health maintenance, with the potential to result in decreased self-esteem and higher rates of depression. This can result in lower rates of engagement with the healthcare system. Chronic pain patients often feel stigmatized by healthcare professionals (Adams et al., 2015). ● Social support —there is very strong evidence to support the idea that social ties and feeling cared for by others is positively associated with mental health, physical health, and life span (Adams et al., 2015). Patients with chronic headaches have been shown to exhibit central sensitization as detected by various methods (Filatova et al., 2008). The biopsychological model of pain and the concept of central sensitization make evaluation of the patient with chronic headache much more complex for the physical therapist. Training in pain neuroscience, which encompasses the biopsychosocial model of pain and the concept of central sensitization, is an important part of effective evaluation and treatment of patients with headaches. It is the perspective of the author that clinicians with the highest level of education in neuroscience, the highest levels of compassion for their patients, and the highest levels of understanding regarding each patient’s personhood and past are best able to use their skills and knowledge to effectively help clients with headaches and The Central Sensitization Inventory has been developed for the purpose of assessing the dimensions of central sensitization and quantifying the degree of central sensitization symptoms. The test consists of two parts. Part A consists of 25 items and is an inventory of presenting symptoms. Some of the items include: ● I am unrefreshed when I wake up in the morning. ● I get tired very easily when I am physically active. ● I feel pain all over my body. ● I have low energy. ● I have muscle tension in my neck and shoulders. symptoms of central sensitization. Assessing central sensitization The second part of the inventory is a list of diagnoses that the patient has been given by a medical provider. These include restless legs syndrome, chronic fatigue syndrome, fibromyalgia, and migraine or tension headaches. This tool has been shown to help identify patients whose presenting medical issues may be comorbid with symptoms of central sensitization (Mayer et al., 2012). It can be a useful tool for physical therapists treating headache patients, as central sensitization can be a significant contributor to chronic headaches. In particular, it can help measure psychosocial factors related to central sensitization and headache symptoms (Nishigami et al., 2018). Nishigami et al. (2018) developed a short form of the central sensitization inventory for use with patients with musculoskeletal pain. Statistical analysis was used to shorten the inventory to nine questions while maintaining the integrity and purpose of the test. The items remaining are as follows: 1. I feel unrefreshed when I wake up in the morning.
2. My muscles feel stiff and achy. 3. I feel pain all over my body.
4. I have headaches. 5. I do not sleep well.
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