Chronic Pain, Depression, and Psychological Trauma – The Impact They Have on Each Other, and the Impact Physical Therapists Have on Them by Miranda Blizzard
Introduction
Physical therapists typically spend numerous hours with their patients over the course of their treatment and have the potential to make a great influence on them. The patients that attend physical therapy often suffer from some degree of pain, whether it’s from a recent injury or has developed over time, and rely on the physical therapist to help decrease their pain levels. With a goal of providing the best treatment to any patient being treated in physical therapy, the physical therapist should observe and consider all the factors that could be contributing to the patient’s pain and overall condition. The purpose of this paper is to encourage physical therapists to use the International Classification of Functioning, Disability and Health (ICF) Model when treating patients with chronic pain to identify the need to use a depression screening and how to use the results to guide the patient in further treatment if necessary. This information will be helpful in reminding the physical therapist how important mental health is along with physical health, especially for patients with chronic pain. It will also provide recommendations and resources for the physical therapist to discuss with their patients with chronic pain, depression, and/or a history of psychological trauma.
Chronic pain
In previous years, chronic pain has been described as “pain that lasts or recurs for longer than 3 months,” but recently has been reclassified to include two subtypes, primary and secondary, based on etiology and underlying pathophysiology.1 Chronic primary pain (CPP) includes the previous definition of chronic pain, but also has an association with significant emotional distress and/or significant functional disability, “and the symptoms are not better accounted for by another diagnosis.”1 If a person is experiencing pain longer than 3 months as a symptom due to an underlying disease, it is considered to be chronic secondary pain. Regardless of the type of chronic pain a person is experiencing, they are likely suffering both physically and emotionally as biological changes and psychological processes are closely linked.1 When treating patients with chronic pain, it is important to consider all factors that can be influencing their symptoms. It may be possible to focus treatment on one symptom and others will also improve, but better care could be provided to patients with chronic pain if physical therapists address all of their patient’s symptoms to the best of their ability.
Depression
Depression is different for everyone - how it’s caused, how it’s treated, how often it makes an impact on one’s daily life, and how one reacts to it. The complexity of this condition makes it difficult to diagnose and manage, which can lead to more frustration from the patient and any medical providers involved. When working with patients that have been diagnosed with depression, have feelings of depression, or may be at risk of being depressed, it is important to consider the neuroanatomical and neuro-chemical systems along with how they interact in people with depression.2 Although it is considered a mental disorder, depression is the leading cause of disability2 and should be taken into consideration when working with any patients as a healthcare provider, but especially patients with chronic pain.
It is a common misconception that depression is just extreme sadness, and sadness is just another emotion that people experience, and therefore, it is normal. For some, depression may be temporary; for others, depression may be persistent. For some, the feelings of depression can be overcome by good experiences; for others, the feelings of depression are so difficult to mask even during good experiences. As a healthcare professional, one must consider the patient’s diagnosis of or symptoms of depression as a critical factor of their behavior that may be impacting other health conditions they may have, no matter the severity. According to the World Health Organization (WHO), it is estimated that the current prevalence of depression is reaching 350 million people worldwide, affecting 16-17% of the population.2 In the United States, 4.5% of the population has experienced significant functional impairments due to an episode of severe depression.2
Psychological trauma
Trauma is another complex word that some may not completely understand until they have worked with someone with a history of trauma or experienced it for themselves. Trauma can be physical, such as a person falling from a ladder and fracturing one or multiple bones, or it can be emotional, such as a child growing up being neglected by their parents. Trauma can also be both physical and emotional, such as a soldier fighting in a war for 4 years and losing both legs due to an explosion. The soldier must learn how to live with a bilateral amputation but also has to learn how to live with the horrifying memories they may have as a result of being involved in war. All three of these examples are just a subset of the potential traumatic experiences people could have had in their past. There are many more possibilities of situations that can cause someone to feel the repercussions of a traumatic life event they have experienced in their past.
Physical trauma most often can be seen by the naked eye. For example, a patient comes in with their leg wrapped in bandages and they are using an assistive device to ambulate. It is likely they had something traumatic, like an injury or surgery, happen to that bandaged leg. However, emotional trauma cannot be seen by the naked eye, and often this trauma is not even verbalized or shown in any way to people who were not around to witness the event. As a healthcare provider, one must understand that this is a possibility for all their patients and the interaction between the patient and provider is variable from patient to patient based on people’s various life experiences.
The connection between the three
As noted in the definition of chronic primary pain, patients with CPP may demonstrate feelings of depression along with their intense pain levels, but is it the pain causing depression, the depression causing the pain, or a mix of both? Additionally, could the depression and the chronic pain be a result of something else, such as a previous traumatic experience? The connection of these three conditions may seem insignificant, but people experience all three of these together more often than one may think.
In a study that was published in 2017, researchers examined the impact that traumatic life events have on pain-related outcomes in patients with chronic low back pain. Pegram, Lumley, Jasinski, and Burns found a positive correlation between traumatic life events and thought suppression, social constraints, and pain-related outcomes.3 Thought suppression and social constraints are directly related to depressive symptoms. After a traumatic event, it is crucial for the individual to confront their memories and emotions that come along with that event in order to start healing, but it is common to inhibit or suppress those thoughts to avoid the negative emotions. People will also typically choose to avoid social environments due to the risk of their post-traumatic symptoms being exacerbated around others.3 Most importantly, patients that have experienced a traumatic life event are often in more pain compared to those without a history of psychological trauma.
The ICF model
The International Classification of Functioning, Disability and Health (ICF) Model plays an important role in physical therapy as it is a way to improve the experience a human has when receiving treatment from a healthcare provider. The WHO adopted this model in 2001 with many goals, one of which was to make a change in the delivery of health care for improved patient participation. The ICF model is different from previous models of disability as it focuses on the person and not the specific health condition they may have been diagnosed with. When using the ICF model to guide decision making in physical therapy, physical therapists observe the impairments, activity limitations, and participation restrictions a person may have, and think about how those things impact the person along with environmental and personal factors that are specific to that person.
Patients that are suffering from chronic pain deserve the best treatment possible to resolve or decrease their pain to further improve their quality of life. As physical therapists, it is more common to receive a referral for a patient with chronic pain compared to a referral for depression or a history of a traumatic event, but it must be considered that the patient with chronic pain may also have a diagnosis of or symptoms of depression that may or may not be related to a traumatic experience. Additionally, if the patient includes depression on their past medical history form and they express they are suffering from chronic pain, the physical therapist should also take into consideration that this patient may have a previous life experience that could potentially be traumatic for them, even if it is not visible to the naked eye (like a physical traumatic event could be).
In order to treat the patient and not the diagnosis they are being referred for or the health condition they may have, it is imperative that the physical therapist uses the ICF model to understand the multiple factors that may be playing a role in the patient’s symptoms and quality of life. If a patient presents to the clinic with a decreased ability to participate in their career as a teacher due to the inability to stand for prolonged periods of time as a result of their chronic low back pain, it may be simple to just focus on the facts and findings observed during evaluation. For example, the patient could arrive with a referral for low back pain, and the physical therapist may find a weakness of the hip flexors, hip abductors, and a preference for posterior pelvic tilt. Instead of paying attention to the environmental and personal factors that the patient chats about during the evaluation, the physical therapist is focused on documenting the objective findings and planning their home exercise program (the same one they give to all their patients with low back pain.) Had the physical therapist listened to the patient talking about their struggle to find connections in the new city they moved to following a divorce that was mainly due to financial problems along with the patient tearing up when asked about family medical history as her mother died of cancer a few years prior, they may have considered that the patient’s chronic pain could be more intense as a result of the traumatic events the patient has endured. Additionally, the patient may be suffering from depression and not be fully aware of it. There must be a better way to assess patient’s depressive symptoms to ensure they receive appropriate care, especially if they would benefit from seeing other medical providers or participating in an activity outside of physical therapy.
Depression screening
There are many depression screening tools that can be used to identify a possible diagnosis of depression. The gold standard for a diagnosis of depression is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM). According to the DSM, clinicians should use the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I).4 However, the SCID-I can take 60 minutes or more to complete and must be administered by a well-trained behavioral health specialist. Shorter tests and ones that can be self-administered are typically used before using the gold standard to diagnose depression.
For patients with chronic spinal disorders, depression should be screened and treated if found due to the connection of chronic pain and depression.4 A study was conducted in 2014 to determine which screening test is best for depression in patients with chronic spinal pain, and they looked at four outcome measures: Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), The Patient Health Questionnaire 9-item (PHQ-9), and Short Form-36 (SF-36).4 The researchers compared the results from these screening tools with the findings of the SCID-I for the same patient along with determining the sensitivity and specificity of each assessment. The SF-36 looks at overall health and quality of life, so only the mental health sections were used for this study. Due to this generality, the SF-36 was found to have the lowest sensitivity, specificity, and overall accuracy. The other assessment tools, however, were found to have similar abilities to identify which patients were depressed. Out of those three, the best tool with the greatest overall accuracy was the HRSD, which was also the only instrument that was clinician-rated instead of self-reported. The PHQ-9 and the BDI had comparable results with each other and are shorter and easier to administer in the clinic. Overall, the PHQ-9 was determined to be the most preferred depression screening to use from both a validity and economical perspective, and it was created using criteria from the DSM.4
What can PTs do to improve the treatment of patients with chronic pain and possibly depression?
As most physical therapists know, it is important for them to stay up to date with clinical research and be a lifelong learner while in the career. This includes being adaptable to change and willing to implement new things in their practice, even if it makes them uncomfortable at first. Mental health is being talked about more now than ever. In the past, people were typically embarrassed to admit they had poor mental health, or they may have had mental instability but did not recognize it and reacted negatively to others around them. As the discussion of mental health continues to become a part of more people’s daily lives, it is being normalized just as much as the importance of physical health. Because of the negative stigma that was behind mental health for many years in the past century, not everyone acknowledges the importance of checking in on their mental health, practicing self-care at home, and receiving treatment for depression if necessary.
Physical therapists spend a large amount of time with their patients in comparison to other health professionals and should take advantage of this opportunity to have meaningful conversations with these patients. Education is a large part of treatment in physical therapy. Many patients that attend physical therapy are in pain and many of those patients suffer from chronic pain. With this information in mind, physical therapists should speak up about the connection between chronic pain, depression, and psychological trauma. This may not be necessary at the first visit or initial evaluation, but as the physical therapist gets to know the patient more and as the patient becomes more comfortable talking to the physical therapist, it may be a discussion that could be life changing for the patient, especially if the patient is not familiar with how mental health can impact a person’s physical wellbeing.
There are many resources that the physical therapist can use to become knowledgeable about the importance of mental health and how to start the conversation such as articles, books, podcasts, videos, etc. Just like everyone’s body is physically different, every-one’s brain and mental health is different. Physical therapists are movement professionals and are confident in prescribing activities for their patients, but if they move slightly out of their comfort zone and begin to discuss other treatment ideas for chronic pain with their patients, it may decrease the patient’s pain and improve quality of life. Isn’t that the overall goal of being a healthcare provider?
Application into PT practice - To identify the need to have a discussion with a patient regarding mental health and possible treatment options outside pf physical therapy, a screening must first be done. The PHQ-9 would be a great option to use in the clinic as the patient can complete it on paper without the need to talk to the physical therapist about their responses. Based on their results, the physical therapist can provide a possible diagnosis of depression if the patient scores five or more.4 The score can be further interpreted to indicate the severity of the depression:4
5 = mild depression
10 = moderate depression
15 = moderately severe depression
20 = severe depression
The physical therapist can use their clinical reasoning and decision making skills to decide if the patient’s score warrants a discussion or referral for further depression treatment. It is important to pay attention to this screening tool with the patient’s results and not just file it under the patient’s medical record and move on with physical therapy focused treatment. If necessary, the physical therapist should be able to discuss different options for the patient to try themselves or refer them to a specialist for more diagnostic testing (such as the SCID-I) and psychological treatment options that are more mental health focused (such as talk therapy). If the patient only has a few symptoms or the PHQ-9 results show mild depression, a specialist may not be necessary, but the physical therapist should still be able to provide recommendations to improve their symptoms, quality of life, and chronic pain.
Self-care and lifestyle modifications
Yoga – Yoga can be used as an intervention that is non-pharmacological and a holistic approach. It is a way to treat the whole person as it focuses on multiple needs of the individual, including physical, cognitive, and emotional.5 Physical therapists may recommend yoga to their patients with chronic pain, especially if they have been screened for depression and have a score of 5 or more on the PHQ-9. A randomized control trial conducted in 2017 found that by implementing yoga as an intervention for patients with chronic pain improved their occupational performance, increased their engagement in activities, and decreased their depression.5 These findings were based off pre and post outcome measures. This study also mentioned that yoga as an intervention can improve pain severity and pain-related disability.
Yoga typically includes multiple body positions, from supine to sitting to standing, and can be modified based on the person’s physical abilities. For example, an entire yoga session can be completed from sitting in a chair or standing upright and does not have to involve laying supine on the floor at all. Yoga is a good option for people that are not normally physically active as it is low impact, and the intensity can be variable. The participant can also choose when to take breaks throughout the session as people are encouraged to “listen” to their body and be mindful of what it is experiencing during the activity. This option should also be considered when a patient is hesitant about going to a public gym or concerned about the price because there is an abundance of free videos online; the patient can search YouTube for their chosen intensity and even positions they prefer to find the best yoga option for them. They will also be able to find various durations, instructors, and areas of the body to focus on during their yoga practice. Physical therapists can advise their patients to try yoga outside of physical therapy and have the patient share their feelings and experiences with them at following visits. The physical therapist should educate the patient on what yoga is and how it can help with physical, cognitive, and emotional wellbeing for the patient to decide if they want to try it outside of physical therapy. Also, the physical therapist can incorporate yoga into their session by having the patient focus on their breaths while performing movement or hold an isometric pose to improve strength and balance.
Mindfulness – If the patient is hesitant about starting a new physical activity such as yoga, the physical therapist can talk to them about how mindfulness has also been proven to improve pain and depression along with both physical health and mental health related quality of life.6 Mindfulness is based on ancient Eastern medication practices and is a way for a person to focus on the present moment with guidance to be open, curious, and accepting. The individual that practices mindfulness can refocus their mind and increase their awareness of their external surroundings and internal sensations. This allows them to step back and reframe experiences more positively.6 By implementing this into one’s daily life, they may be able to reflect on a previous traumatic experience, decrease their depression, and further decrease their pain levels. It is a wonderful suggestion for someone that is at risk of or has mild-moderate depression based on their PHQ-9 score. Like yoga, a person can search for mindfulness YouTube videos and have a person guide them in a meditation experience in the comfort of their own home for free.
Referrals
EMDR – Eye Movement Desensitization and Reprocessing (EMDR) is commonly used to treat Post-Traumatic Stress Disorder (PTSD), but the psychotherapeutic approach is not limited to only treat this one condition as it was once believed.7 The effect of EMDR has been studied with many mental health conditions including depression and chronic back pain. A systematic review completed in 2017 found positive evidence that EMDR can be a helpful tool in treating patients with unipolar depression and patients with a history of a myocardial infarction with depressive symptoms.7 Also, for patients with chronic back pain, it was concluded that they had reduced pain intensity and disability following EMDR therapy.7 Based on these findings, it would be beneficial for a physical therapist to recommend EMDR therapy to their patient if they discovered the patient could be diagnosed with depression, had a previous traumatic event, and/or were being treated for chronic pain. The physical therapist should educate themselves before educating the patient on what EMDR is, the basics of how it is conducted, and what the benefits are (in this case, decreased pain and depression symptoms). It is necessary to become trained and certified in the delivery of EMDR, so the physical therapist should refer the patient to a provider, such as a talk therapist, that could use EMDR within their session.
Acupuncture – Acupuncture has been used for thousands of years as it began with traditional Chinese medicine and has been used as an alternative and complementary to traditional therapeutic interventions.8 With a simple operation, relatively low cost, and minimal side effects, it is able to have a curative effect on both pain and depression individually while improving the patient’s quality of life. For patients with chronic pain and depression, acupuncture can be used along with medication or alone to relieve pain and depression better than medication alone, according to a systematic review completed in 2020.8 Acupuncture is not in the scope of practice for physical therapy, and requires a licensed professional to perform the technique, so the physical therapist should refer the patient to a certified professional if they feel acupuncture may benefit the patient. The physical therapist can bring this idea up into conversation during a treatment session to see if the patient would be interested in adding acupuncture to their treatment of chronic pain and/or depression. If the patient had questions on the techniques and outcomes of acupuncture, the physical therapist should be educated enough to provide the basic information while discussing the potential benefits it may have for their patient.
Medical marijuana – The opioid epidemic is not new news, but the solution is still being researched. Opioids are commonly prescribed for acute pain, cancer-related pain, and chronic nonmalignant pain. Although patients have received this drug as a prescription from their trusted doctor, there has been an increase in health risks that come along with the prescription, “such as risks of diversion, overdose and addiction.”9 Due to the potential dangers with the use of opioids, medical marijuana is being considered as an alternative for the treatment of chronic pain. A study conducted in 2017 observed pain and depression symptoms in patients taking prescription opioids, medical marijuana, or both. Those patients receiving only opioids “had higher rates of depression and anxiety compared to” those in the medical marijuana group.”9 For the patients receiving both treatment options, they were at a higher risk of depression compared to using medical marijuana alone. This group receiving both treatments also “reported lower levels of depression and anxiety compared to those in the opioid only group."9 It should also be noted that 57.1% of patients using opioids exclusively to treat their pain screened positive for depression while only 22% of the patients using medical marijuana for their pain screened positive for depression.9 The use of medical marijuana is still being researched, but if the patient asks the physical therapist about alternative or additional options to treat their pain besides the use of prescription opioids, the physical therapist may bring this up in discussion. Since the legality of the use of marijuana is not nationwide, and some people still view this as a harmful drug, it is up to the physical therapist to decide if their patient would welcome this information without judgement. Ultimately, the physical therapist can provide their knowledge on the topic and allow the patient to do their own research before referring this patient to another medical provider to prescribe medical marijuana as it is not in the physical therapist’s scope of practice to prescribe medications.
Conclusion
Patients with chronic pain are often also suffering from depression and may have experienced a psychological traumatic event in the past that has led to an increase in pain and/or depressive symptoms. Physical therapists have the perfect opportunity to discuss the impact mental health has on physical health, especially with their patients that are suffering from chronic pain. The PHQ-9 is a great tool to use in the physical therapy clinic to screen for depression and identify if it is mild, moderate, or severe. The physical therapist can use these results to discuss options for lifestyle modifications or referrals to other medical professionals if necessary. By using the ICF model and clinical reasoning skills, the physical therapist can provide superior treatment to patients with chronic pain and ensure they are receiving other necessary forms of treatment if a diagnosis of depression is suspected or reached.
References:
Nicholas M, Vlaeyen J, Rief W, et al.. PAIN. 2019; 160 (1): 28-37. doi: 10.1097/j.pain.0000000000001390.
Varela AJ, Melvin A, The theratre of depression: a role for physical therapy. Physiotherapy Theory and Practice. 2023; 39 (7): 1325-1341. doi: 10.1080/09593985.2022.2041136
Pegram SE, Lumley MA, Jasinski MJ, Burns JW. Psychological trauma exposure and pain-related outcomes among People with chronic low back pain: moderated mediation by thought suppression and social constraints. Annals of behavioral medicine. 2017; 51 (2): 316-320. doi:10.1007/s12160-016-9838-0
Choi Y, Mayer TG, Williams MJ, Gatchel RJ. What is the best screening test for depression in chronic spinal pain patients? The spinal journal. 2014: 14 (7): 1175-1182. doi:10.1016/j.spinee.2013.10.037
Schmid AA, Van Puymbroeck M, Fruhauf CA, Bair MJ, Portz JD. Yoga improves occupational performance, depression, and daily activities for people with chronic pain. Work (Reading, Mass). 2019; 63 (2): 181-189. doi:10.3233/WOR-192919
Hilton L, Hempel S, Ewing BA, et al. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Ann Behav Med. 2017; 51 (2): 199-213. doi:10.1007/s12160-016-9844-2
Valiente-Gómez A, Moreno-Alcázar A, Treen D, et al. EMDR beyond PTSD: A Systematic Literature Review. Front Psychol. 2017; 8: 1668. doi:10.3389/fpsyg.2017.01668
Yan B, Zhu S, Wang Y, Da G, Tian G. Effect of Acupuncture on Chronic Pain with Depression: A Systematic Review. Evidence-based complementary and alternative medicine. 2020; 2020: 7479459-10. doi:10.1155/2020/7479459
Feingold D, Bril S, Goor-Aryeh I, Delayahu Y, Lev-Ran S. Depression and Anxiety among Chronic Pain Patients Receiving Prescription Opioids and Medical Marijuana. Journal of affective disorders. 2017; 218: 1-7. doi:10.1016/j.jad.2017.04.026