A common cry from various clinicians who work in the field of pain management but who are not psychologists is “but now what?” when they recognise that a key factor in recovery is something psychosocial. The answer is not, I suspect, heading off to become a psychologist!
For several reasons, I think it’s critical for non-psychologists to get comfortable with psychosocial language and principles.
- All clinicians use psychological principles in their interactions with patients. Like it or not, when we give advice or encouragement we’re using knowledge gleaned from psychological study. We might call it something like “developing rapport”, but no matter what we call it, these interpersonal skills are psychosocial in nature. If we use these approaches, it’s pretty important to make sure we’re doing it effectively.
- If the patient is being seen within an interdisciplinary or multidisciplinary team setting, being consistent in the use and management of psychosocial factors is critical for treatment success (IMHO). There’s nothing quite like working in an interdisciplinary team that has coordinated and synthesised the model they’re working with so that the patient hears the same messages from everyone. Conversely, imagine what it’s like for a patient to hear different things from different clinicians working in a team. Especially for a patient who needs to feel confident that the team working with him or her know what they’re doing.
- Psychosocial factors consistently present as the most potent variables in recovery. And even though we may not yet know the most effective ways to manage psychosocial factors, every clinician needs to be open to identifying them and beginning to work with them because the factors are so incredibly pervasive.
It’s this last one that I want to briefly mention today. Sub-acute low back pain is probably one of the most common pain presentations for which people seek treatment. While most acute low back pain can get better quite quickly without too much interference from health providers, for people with sub-acute low back pain, getting treatment is a major step. Sub-acute low back pain is pain that has persisted for a couple of weeks (give or take!) maybe up to six weeks, and doesn’t appear to be getting any better. It’s at this six week point that many authorities and clinical guidelines suggest that additional assessment and targeted intervention should occur.
Assessment at this point seems to need to include psychosocial factors so that they can be identified and managed as soon as practicable. The tools that seem to have the most support are below, and are all open for use by health practitioners with training in basic statistics, and who READ the original research so are able to interpret the findings. (Anyone who uses an assessment without doing so should be ashamed.)
The Orebro Musculoskeletal Questionnaire is a common measure used to identify risk of ongoing disability, and it’s been shown to have good predictive validity (as well as other good psychometric properties). But there are three other measures that are also often used as ‘early’ screening instruments – the Pain Catastrophising Scale (scoring and interpretation here), and a depression or mood/anxiety measure such as the Hospital Anxiety and Depression Scale (here’s a nice brief summary of interpretation). And of course, there is the Tampa Kinesiophobia Scale.
Once a person is identified as having an elevated score, or one in the ‘clinical’ range, what then?
“The patient’s beliefs, especially any alarmist or catastrophic beliefs, about their pain should be sought. “ is the advice given by Linton, Nicholas, MacDonald et al., (2011). It’s these catastrophic beliefs about pain, combined with low mood (particularly thinking patterns that involve ruminating on, or brooding about how bad the pain is and the negative implications of having pain).
Then, “encouragement to upgrade activities and exercises, as well as education and attempted reassurance about pain may be sufficient to achieve meaningful changes in many”, as these authors say. It’s part of everyone’s role to be cautious about the words we use and the advice we may give.
Here’s the HealthSkills advice for nonpsychologists:
- Give precise advice about what to do. State these in positive language “Sit for five minutes, then stand up and stretch” rather than “Don’t sit for too long.”
- Give reasons for your advice. This makes you think about why you’re giving advice! If you can’t think why the person should do as you suggest, or you can’t find an evidence-based rationale, then don’t give it out!
- Ask the person about their understanding of their pain. Gently give them an accurate explanation if what they believe differs from reality – show them their records, even phone their original clinician up in the patient’s presence to discuss the findings if you need to, use illustrations and diagrams. But at the same time, encourage them to ‘test’ the helpfulness and/or accuracy of these beliefs by carrying out mini experiments within daily life.
- Make sure you give clear timeframes for any activity restrictions. Review restrictions regularly and give the ‘green light’ for getting back to normal. Don’t just leave this as being ‘common sense’ – you have no idea how often patients carry on with activity restrictions long after any physiological need to do so has passed.
Wait, there’s more – but that’s for tomorrow!
Linton, S., Nicholas, M., MacDonald, S., Boersma, K., Bergbom, S., Maher, C., & Refshauge, K. (2011). The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain, 15 (4), 416-422 DOI: 10.1016/j.ejpain.2010.08.009