Clinical reasoning in persistent pain management

I think we need to take a cold hard look at clinical reasoning in pain management and especially at how we can integrate all the various factors influencing the person sitting in front of us. There are too few papers really addressing how different professions can put their assessment findings together to generate a truly multi-faceted model of why this person is having trouble with their pain. I could find only one paper detailing interprofessional clinical reasoning for chronic pain – and it’s inside a textbook dates from 2008 (Linton & Nicholas, 2008). So it’s no wonder, when a team gets together, that we collectively find it difficult to work together.

The approach discussed by Linton and Nicholas was the way I was trained to work, so I’m biased. Nevertheless I think this is a practical and useful way of putting the jigsaw puzzle together to see how each factor influences every other factor. I’m not suggesting that every case should be formulated this way – but I do find myself using the same strategy for every person I see.

We all do a bunch of assessments when we first see a person. But then what do we do with all that material? As Linton and Nicholas say, most assessments are used to document the intensity of the problem. Case formulations try to identify the main problems experienced by the person – and then generate hypotheses about the mechanisms supporting those problems for this person sitting in front of me.

So here’s a question for y’all – if you have information on the person’s pain intensity, how much it is interfering in their life, how depressed they are, as well as understanding their fear-avoidance beliefs and catastrophising; and if you know how their family responds to them, should we simply provide our standard treatment package ( e.g. analgesic medication, home exercises, and relaxation training)?

Wouldn’t it make more sense to only target catastrophising if they seem to add to the person’s problems? And wouldn’t it be better to add home exercises only if the person seems to be avoiding activities?

Or have we got to the place where everyone gets exactly the same solutions to what, for them, is a very unique and individual problem?

A key part of case formulation is involving the individual in the process. I think it’s crucial to actively be putting their perspective into generating the hypotheses about the factors maintaining their problem – this helps them see the relevance of each piece of the treatment puzzle, and ensures we don’t over-interpret (or under-interpret) factors.

Another really good reason for case formulation is to counter our cognitive biases. We know we jump to conclusions, find patterns where there aren’t any, look for things that confirm our own beliefs, look for simple options and ignore complex and ambiguous options – and so on, and case formulation can buy us time to avoid some of these really significant problems.

So, how do they work. Linton and Nicholas use a “spaghetti diagram” – looks like a bunch of arrows connecting various factors together. It looks a bit like this:

I personally use something that looks a bit different because I like Tim Sharp’s reformulation of a CBT model.

Whatever the approach, having a structure, taking time to “fill in the gaps”, including the person living with pain, and understanding the literature that clarifies those factors important in pain and disability, will allow us to avoid some of the major cognitive bias traps. Using a common formulation across all the clinicians involved really helps all of the team know why they’re doing what they’re doing – and why the other members of the team are so important. That means we can support one another!

But the bit missing, for me, is the “what do you do when you see these patterns?” To me, it’s about identifying the person’s main concerns – what are they primarily concerned about? Often it’s not the pain intensity, but instead it’s whether they’ll be able to still work, or their sleep, or their family reactions, or loss of roles. So we need to look for factors that are influencing these aspects of their situation so we actually address the problems that the person identified (rather than our own preference!). Shock and horror ensues! That might mean the person doesn’t need to see a physio for an exercise programme – they might prefer to work on sleep management, or work.

And if the person doesn’t avoid because they’re not too bothered by their pain, why would we need to give them “pain education”? Perhaps we’d do better to treat their depression, or help with their sleep. Similarly, if someone isn’t distressed, isn’t avoiding and just needs some medication – shouldn’t they get just that? Do we seriously need them to see a psychologist, occupational therapist, physiotherapist and go to the gym four days a week? Maybe less can be more.

I guess some of my frustration lies with the fact that despite all this talk of integrating the various parts of pain management, what we often end up with is a formulaic “education, exercise and mindfulness” for everyone – irrespective of their actual needs. Is it time to talk about what we might do differently for the person who might have a tendency to catastrophise but isn’t avoiding, or for the person who is very fit but doesn’t want to sit, or the person who is having such trouble sleeping because of their pain? Let’s be a bit nuanced, folks!

Linton, S. J., & Nicholas, M. K. (2008). After assessment, then what? Integrating findings for successful case formulation and treatment tailoring. Clinical Pain Management Second Edition: Practice and Procedures, 4, 1095.


  1. Bronnie, I am surprised that you make no mention of the intersubjective (“third”) space engagement. There may be more but for me this is the most critically important missing “bit” in what passes for contemporary pain management.

    1. I think the “third space” is inherent in my comments about the person being included in the formulation. I don’t think simply acknowledging is the only crucial element – there are practitioners who do acknowledge as an integral part of their consultation (counsellors, for one, and IMHO many so-called “complementary” or “alternative” practitioners) and yet their outcomes are no better. Validation, though important, isn’t the only important piece of the puzzle.

  2. It sounds like the type of treatment / therapy and management approach from my training through the last two decades or more.
    Feeling like I’m on the right track as a provider 🙂
    Thanks for all you teach.

  3. I agree totally Bronnie. I work in an MDT environment and have spoke to the MDT before about this model of case formulation. I think it’s so useful primarily for the fact that we focus on the patients primary concerns. Working in the MDT it is so easy to overwhelm our patients by flinging the kitchen sink at them from several clinical professions. What you end up with is patients who become confused and overwhelmed because they are told to practice mindfulness, pacing with a home exercise programme etc, which makes it impossible to elicit a behavioural change. Identifying the patients goals and expectations from the perspective of the patient is paramount.

  4. Sounds like things are already a lot more organised in NZ than in the UK. In the UK, it would be very rare for a patient to be recommended a whole range of treatments; in fact, usually in order to get anything they’d need to have heard about it themselves and asked for it specifically (be it PT, counselling, a pain management course or medication) as generally practitioners are not pro-active in suggesting things (and also, perhaps, have the strained NHS budget in mind).

    Going forward, a targeted approach could work really well here in the UK, as it would serve the cost-saving function as well as giving patients what they really need. This is probably something that could be implemented at the level of primary care practitioners.

    Again, you are so right to highlight that sleep management as this is routinely ignored. I can say from a personal viewpoint that this has been a big issue for me and, when well managed, many of my pain-related issues fade out and I am able to do much more.

    I was surprised by one thing though, when you say “And wouldn’t it be better to add home exercises only if the person seems to be avoiding activities?”. This can backfire if the exercises cause pain which leads the patient to avoid things even more, including socialising, cleaning, work etc. I’d have thought a better approach would be to find out what is being avoided and why and to see if pacing, medication, pain education etc can be of use to enable the patient to begin doing what they need or want to do again, even if in smaller amounts. (Also, exercises may help some patients experience less pain in the long run, but, as you note in another post, in some cases they may not have such an effect).

    1. My take on home exercises is – if the person is already engaged in all their usual and enjoyable activities, how much does an exercise programme add? I agree adding exercises (if someone is avoiding) should always be combined with an approach to see why they’re not managing their usual daily activities, along with using every other strategy available. I guess my concern is cookbook pain management where everyone gets exercise, mindfulness and pain “education” – it needs to be individualised.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.