The Psychology of Back Pain: A Clinical and Legal Handbook, Publication No. 1091, American Series in Behavioral Science and Law.

The author of this comprehensive text on chronic back pain is a psychiatrist and a lawyer drawn to pain problems and the legal challenges that they present. In his words, the purpose of the book is "to assemble the core of what is known today about psychological aspects of back pain in order to provide a more meaningful and balanced framework from which decision making can proceed." His intent is to present a clinical handbook for psychiatrists and psychologists, but in a language that can be understood easily by other professionals or nonclinicians who deal with clients who have back pain. The focus is on the 10 percent of patients who do not get better within 3 months after an episode of back pain or those with chronic low back pain-related disability.

The information is comprehensive, but not exhaustive. An extensive list of 351 references supports the text and is a ready option for more in-depth or detailed study. Tables and charts summarize key points, and case studies add interest and clinical relevance.

The first chapter summarizes the scope of the problem and traces the history of treatment for chronic back pain. The author begins to lay the groundwork for the complexity of the mind-body connection, As the author states so aptly, "The psychological contribution and the social and cultural uniqueness of the individual weave in and out of the physical presentation and are entangled with it." In Chapter 2, Drukteinis summarizes the sources of back pain and the neuroscience behind the transmission of nocioceptive stimuli and the perception of pain. He also touches on the controversial subject of psychogenic pain.

The author focuses on psychiatric and psychological evaluations and various psychological measurement instruments in Chapters 3 and 4. He presents "a simple pair of criteria" that warrant referral for a psychological evaluation: "excessive pain behavior or psychological distress at any time ... and continuing disability or functional impairment after three months." This comprehensive chapter would be useful to psychiatrists and psychologists, but also opens a window for any professional on the importance of observational data, such as pain behaviors, in the effective management of chronic low back pain.

Chapter 5 addresses a variety of issues associated with chronic pain syndromes. The associated psychological features that are part of these syndromes can include a conditioning process that is secondary to the initial injury, psychological variables that are preexisting, or both. There is also a brief discussion of the legal aspects of back pain disability in Workers' Compensation claims and personal injury actions.

The chapter on developing an integrated model of care emphasizes what the author believes arc fundamental elements of successful treatment, which are the patient's ownership of the problem and coordinated care. In some of the case studies, physical therapy intervention is not presented very positively, but the author recognizes physical therapy as a core discipline in the treatment team. Various physical treatments are reviewed, including surgery, pharmacology, physical therapy, and manipulative therapies. An abbreviated but accurate portrayal of physical therapy intervention is presented that reflects current trends. Two specific examples of common physical therapy treatments are mentioned: the McKenzie approach and dynamic lumbar stabilization. It is interesting that the author includes a discussion of back schools and work hardening programs in the chapter on psychological treatment of back pain. He believes that they are essential behavior management techniques.

Although the focus of the book is clearly on chronic low back pain, there are important concepts that can be applied to almost any disabling condition. As the author summarizes in his conclusion, "Professionals ... must look beyond physical symptoms, and beyond the patient's subjective reports of disability and distress. They must look at the person who is suffering in the context of psychological history, family, workplace, social relations, and legal forces." The author is right. Regardless of our skill or expertise as physical therapy professionals, our interventions will be ineffective without consideration of psychosocial issues and without patient ownership and coordinated care among disciplines.

This book provides comprehensive up-to-date information about chronic low back pain in an easy-to-read style that would be of value to physical therapists and physical therapist assistants.