Canada

More than something to blame when the treatment doesn’t work


A friend of mine told me that during her physiotherapy training when they discussed “psychosocial” factors it was usually in the context of explaining why a treatment didn’t work.  This still happens. Even well-informed and scientifically savvy people can unintentionally “blame” those pesky psychosocial factors for getting in the way of complete recovery. What do I mean? Well, let’s think about it: when we’ve done the “explaining” or “educating” – and the person still doesn’t understand and/or their pain doesn’t reduce, what’s our explanation?

We know that pain is an experience, not a separate thing to be treated, but the experience an individual has when his or her brain determines there is a threat to the body (and that threat is more important than other competing goals). We also know there are numerous mechanisms underpinning this experience, many of which are biological. But what we are always left with is the fact that we cannot know anything about this other person’s world except through (1) their behaviour and (2) our interpretation of their behaviour.

I’ve emphasised this because recently I’ve heard one registration board suggesting that a profession should not talk about pain, nor consider psychosocial factors because their domain of influence is bodily tissues.

I’ve also emphasised this because in our efforts to become all sciencey and sound (at least) like we know what we’re talking about, I think we may have forgotten that the only reason we know someone is sore is because they are doing something that we interpret as a signal that they’re sore. And that this occurs within a social setting that has emerged from a combination of historical practices and assumptions, and we are part of that social setting.

The biological substrates for our experience of pain have received the lion’s share of research attention and funds. What has received rather less is understanding some of the social aspects – what individuals learn throughout their life, including the assumptions we develop about what is “normal” and what is not. Unique family and cultural factors influence each individual’s experience – what does this person pay attention to? What does this person ignore? When this person recognises something as “not normal” what is the usual way of dealing with it? Who does this person first see for treatment?

More than this, what about the research looking at treatment provider’s decoding and response to the social communication of the person seeking treatment? We know, for example, that healthcare providers who view video vignettes of people displaying pain behaviour with no medical evidence but with psychosocial factors rate those individuals as experiencing less pain and interference, they have less sympathy, expect medication effectiveness to be less, and those individuals were more likely to be rated as potentially trying to deceive the treatment providers (De Ruddere, Goubert, Stevens, Deveugele, Craig & Crombez, 2014). These responses appear to use both automatic (unintentional, reflexive) and controlled (intentional, purposive) neuroregulatory systems. Observers (ie health professionals) also incorporate automatic (unintentional, reflexive) and controlled (intentional, reflective) reactions. We seem more likely to demonstrate instant ‘‘visceral’’ emotional reactions to unintentional, reflexive expression, while controlled expression characterised by purposive (deliberate) behaviour appears more likely to suggest to health professionals (or observers) that we should think a little about the purpose behind that individual’s pain expression (Craig, Versloot, Goubert, Vervoort & Crombez, 2010). The point is: this occurs even when we know about it, and even if the individual is experiencing pain, and even though the individual is only trying to get the treatment provider’s attention!

Pain behaviour as independent from the individual’s experience of pain is one of the key features of the behavioural model of pain. Pain behaviours were what Fordyce and Loeser and Turk and the very great original thinkers about chronic pain management first thought could and should be dealt with. The reason? Because despite all the surgical and pharmacological treatments available in the late 1960’s, 70’s and 80’s,  many people were still left experiencing pain and were also highly disabled by it. By helping people reduce their pain behaviour (eg stop guarding that body part, start moving more quickly and fluidly, be more relaxed, groan less) they noticed that people were also reporting that their pain bothered them less.

Cognitive behavioural therapy (or a cognitive behavioural approach, to be more accurate) incorporated more “education”, or helping people understand the mechanisms involved in their experience of pain, helping them understand the difference between hurting vs doing damage. A CBT approach meant people were acknowledged as being able to think differently about their pain, reduce their distress and begin to do more. A CBT approach combined education with behavioural experiments and encouraged people to get on with life.

Much more recently we have physiotherapists deciding that giving people pain neurobiology education (sounds almost exactly like the CBT education/explanation to me) is really good and reduces the threat value of the experience. And combined with graded reactivation, exposure to doing things that have been avoided, using methods to reduce distress and by avoiding flare-ups of pain, people are helped.

Two or three important points for me:

  1. Health professionals need to be aware of their own psychosocial responses/background/biases when they observe another person who is indicating they are sore.
  2. If we are two people interacting, all the messy psychosocial factors are immediately present – whether we attend to them, or not.
  3. Given how important those factors are in both our response to another person and their response to treatment (eg placebo, expectancy) it is critical that we integrate effective communication skills into every clinical interaction.

And probably another important point:

In the enthusiasm for pain neurobiology education and the potential for the person to no longer experience pain, we need to remember that reducing disability is arguably more relevant than reducing pain. Despite the impressive results reported by clinicians and some researchers there are many many people who continue to live with chronic pain. As clinicians we may even inadvertently delay recovery if our focus is inappropriately on pain reduction. I say this because there is SUCH clear evidence that pain intensity is less of a factor in ongoing disability than unhelpful beliefs and avoidance (Froud, Patterson, Eldridge, Seale, Pincus, Rajendran et al, 2014; Shaw, Campbell, Nelson, Main & Linton, 2013; Wilkens, Scheel, Grundnes, Hellum & Storheim, 2013).

To conclude, it seems to me that it’s high time for health professionals to take a hard look at what they consider to be “their” domain of concern. Not only must we avoid “blaming” psychosocial factors for poor outcomes from treatments we provide, we also must begin to recognise our own biases as we work with people living with pain. One of these biases is the temptation to believe that we are not influenced by our own psychosocial factors. Another is to recognise that delicate moment when it’s time to take our attention away from reducing pain and towards reducing disability. We need to elevate the status of effective communication – not just “can I make myself understood” and “can I establish rapport”, but that much more nuanced scope of implementing reflective listening, truly hearing our clients, and responding in a way that upholds client choice and self efficacy. I think this belongs to all health professions, not simply those tasked with dealing with “psychosocial” factors.

 

Craig, K.D. (2015). Social communication model of pain. Pain, 156(7), 1198-1199.

Craig, K.D., Versloot, J., Goubert, L., Vervoort, T., & Crombez, G. (2010). Perceiving pain in others: Automatic and controlled mechanisms. The Journal of Pain, 11(2), 101-108. doi: http://dx.doi.org/10.1016/j.jpain.2009.08.008

De Ruddere, L., Goubert, L., Stevens, M.A.L., Deveugele, M., Craig, K.D., & Crombez, G. (2014). Health care professionals’ reactions to patient pain: Impact of knowledge about medical evidence and psychosocial influences. The Journal of Pain, 15(3), 262-270. doi: http://dx.doi.org/10.1016/j.jpain.2013.11.002

Froud, R., Patterson, S., Eldridge, S., Seale, C., Pincus, T., Rajendran, D., . . . Underwood, M. (2014). A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskeletal Disorders, 15, 50.

Shaw, W.S., Campbell, P., Nelson, C.C., Main, C.J., & Linton, S.J. (2013). Effects of workplace, family and cultural influences on low back pain: What opportunities exist to address social factors in general consultations? Best Practice & Research in Clinical Rheumatology, 27(5), 637-648.

Wilkens, P., Scheel, I.B., Grundnes, O., Hellum, C., & Storheim, K. (2013). Prognostic factors of prolonged disability in patients with chronic low back pain and lumbar degeneration in primary care: A cohort study. Spine, 38(1), 65-74.

7 comments

  1. Bronnie, thanks for a most timely and, as usual, thoughtful article. May I recommend to health professionals that they take the time to also read “Time to flip the pain curriculum” by Carr & Bradshaw? It is a short paper that speaks admirably to the theme of your article. Reference: Carr DB, Bradshaw YS. Time to flip the pain curriculum. Anesthesiology 2014; 120: 12-14.

    1. Yes! It’s getting to the heart of the matter – and something that has progressively disappeared from our language when describing pain. The book by Joanna Bourke brought this back into focus for me.

    2. I also meant to add – the Intro to Pain paper I teach has one module (of eight) dedicated to neurobiology and the first module is about the historic views of pain and what we take from these historic models. Then a couple of modules looking at pain and behaviour and pain and cognitions and emotions. Next step: to have a paper dedicated to refining skills of observation and communication.

      1. We have found that by including “Pain Champions” in our 2-day workshop – Making Sense of Pain – health professionals do get to have the important experiences (thereby refining their observational and communication skills) to which you are referring.

  2. Your northern compatriot Dr Alice Theadom recently authored a Cochrane review of mind & body therapy for fibromyalgia. Even after removing the fabrications, falsehoods and bias, the effect of mindfulness was weak albeit significant. Near identical in fact to Lauche & Schmidt et al 2013: ~1/3 of a Std Deviation in improvements across domains of QoL, pain, and depression.

    There seems to be a failure to adopt multi-disciplinary guidelines in addressing the multiple factors of chronic pain, and I suspect it stems from the trials that are informing the practitioner’s evidence, which focus on a single intervention vs placebo/std care. I suspect that a Minimum Clin Impt Difference will only be met once mind&body therapy in conjunction with pharmacotherapy undergoes more rigorous testing.

  3. Great post Bronnie
    I think we need to take the time to reflect on how we feel about the experience our patient is having because this indeed influences the treatment we as clinicians facilitate

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