Most clinicians working in chronic pain management are well aware that the time it takes for people to finally be referred for management of their pain is far too long and some of the readers of this blog who work with people who have acute pain may wonder whether anything I write about applies to them and the people they treat. To both groups of readers – today’s post should apply!
Arguably the most common reason for people seeing a doctor is because of a musculoskeletal pain. Treatment is usually quite simple: diagnosis, pain relief, anti-inflammatories and gradual return to function. It’s this last part of treatment that seems to cause the most trouble for people – what if the pain doesn’t settle, what if I’m damaging my body, how long should I “rest” it, how often should I move it?
Despite all the promotion of the psychosocial “yellow flags” as risk factors for ongoing disability, many doctors find it difficult to initiate the discussion, and even more difficult to know what to do if they happen to identify them. There’s also been discussion about whether identifying and managing risk factors is worth it – psychosocial interventions in the acute and subacute stages of pain haven’t been all that effective.
My thoughts are that maybe “psychosocial” is both scary for clinicians who usually work in a biomedical model (suitable, I hasten to add, for most acute pain problems), and is too broad a term. One psychosocial factor is not the same as another!
Breaking it down and learning more about the specific issues and how to address them might be worthwhile.
Söderlund and Åsenlöf, in this study looked at acute pain – whiplash associated disorders (WAD) and a “musculoskeletal disorder” group of patients who were recruited from a hospital emergency department and had ankle fracture or sprain, wrist fracture or sprain, shoulder joint luxation, upper arm or forearm fracture. All participants were asked to complete the Pain Disability Index, Pain Intensity Diary (using the numeric rating scale), and the Tampa Kinesiophobia Scale, the Self Efficacy Scale (not the Pain Self Efficacy Scale) and the Pain Catastrophising Scale. I should add that this study was conducted in Sweden, so these were all Swedish versions of these instruments.
Both groups were compared with each other – the whiplash group were significantly younger than the group with musculoskeletal disorders, but otherwise the groups were similar in ratio of men to women, education, socio-economic status, and even in terms of the variables of interest (scores on the tests above), the groups differed only on self efficacy with the whiplash group scoring more highly on the self efficacy scale.
After multiple regression wizardry on the scores from the musculoskeletal group, they found the indirect effect of pain intensity on pain-related disability via fear of movement and (re)injury was significant, with the relative magnitude of common variance in percent due to direct effect of pain intensity on disability 63%. The relative magnitude of indirect effect of fear of movement and (re)injury was 37%.
By comparison, in the whiplash group initially all of the variables were significant – what this means is that pain intensity directly influenced disability, but the effect of pain intensity was also mediated by catastrophising, self efficacy and scores on the TSK. After further multiple regression wizardry, the authors found that self efficacy mediated the effect of pain intensity on disability, as well as pain having a direct relationship with disability. In percents, common variance due to the direct effect of pain intensity on disability was 74%. The relative magnitude of indirect effect of self-efficacy was 26% in the whiplash group.
What does this mean?
Well, the first finding is that self efficacy, at least in the whiplash group, is an important aspect of recovery from acute whiplash. On the other hand, people with general musculoskeletal injuries were more influenced by their concerns about moving, and while pain intensity had an effect on disability, it was avoidance and fear that also made a contribution to their disability.
The authors suggest that one explanation for the different effect of self efficacy between the two groups could be associated with the different behaviour from treating clinicians – the usual sprains and strains may well have received somewhat cursory attention from staff, given crutches, told to be a bit careful and not put full weight on the limb and sent off into the distance. People with whiplash, however, could have been given more reassurance, and encouragement to move normally. This could have left those with musculoskeletal disorders wondering how best to recover, what the signs were that it was safe to use the limb normally, and perhaps quite anxious about the level of pain they were experiencing and what it meant.
At this stage, there is no data to support this interpretation of the difference between the two groups. Fuel for more research I think! However, it does raise the interesting possibility that different psychosocial factors may be influential within different injury types in the acute stage.
What this means for treating clinicians is that it’s important to be aware of the influence of lack of confidence (self efficacy) and heightened fear of movement and assess both. The sort of questions to ask might be “How confident are you about getting back into your everyday activities?”; “What concerns do you have about starting to use your [ankle/wrist/neck] normally?”; “What do you think might be going on in your [ankle/wrist/neck]?”
They’re not difficult questions to ask – but maybe they don’t get asked very much. Let’s break this “psychosocial factors” down into specific actions for clinicians to take.
Söderlund, A., & Åsenlöf, P. (2010). The mediating role of self-efficacy expectations and fear of movement and (re)injury beliefs in two samples of acute pain Disability & Rehabilitation, 32 (25), 2118-2126 DOI: 10.3109/09638288.2010.483036