The relationship between pain and disability is a particularly vexing one in primary care. It would be great if it was possible to get rid of pain and be assured that any lingering effects on function would be similarly abolished, but it just doesn’t seem to be quite that simple.
Many different approaches to managing this situation have been suggested. One is to argue that people should be referred for a quick pain reduction injection – for those who have pain that is thought to respond to this approach. Another is to just “reassure” and review often. And still another is to provide a cognitive behavioural approach usually reserved for those referred to a secondary or tertiary treatment centre.
For several reasons I find the first and second options above not particularly satisfying.
For the avoidance of doubt, I want to make sure readers are aware that I am not agin pain reduction techniques. In fact, they’re a very good thing because, and this is the important point, they allow people to get back doing what is important to them. There are a few “provided that’s” to this because, as I’m going to show, people who have had a bout of pain don’t always “get back doing what is important to them”.
The second option of providing reassurance is also less than satisfactory because despite this approach being endorsed in numerous guidelines for managing acute musculoskeletal pain, very few specific recommendations as to how to provide reassurance have been given. Reassurance can be both unsatisfying to the person on the receiving end, and in some cases, increase the likelihood that the person remains fearful of moving and continues to look for more reassurance (Linton, McCracken & Vlaeyen, 2008).
Why doesn’t “taking the pain away” just return the person to the way they were?
Good question, glad you asked it! While abolishing the pain does, in many cases, return the peripheral nervous system and tissues to normal, this situation doesn’t apply to the central nervous system – and most particularly, those parts of the brain concerned with appraisals and judgements, anxiety and emotion, and memory. Let me explain.
When we are born, we arrive in the world with a functioning set of reflexes that respond quickly to input that startles the nervous system out of “comfort”. Loud noises, textures against the skin, new tastes – all of these provoke a startle response and we cry in protest. Thankfully most of these responses settle down as the nervous system habituates to those features of the environment that reoccur, but our responses are shaped by how adults around us respond to the same events, and how they respond to our behaviour. This is the effect of social and cultural influences. At the same time, we begin to develop preferences – some genetically shaped, others from what we observe and imagine about other people, and some from our own processing of the external and internal world.
It’s these factors that influence our responses to sensations that our brains ultimately determine are harmful or potentially harmful – and our brains let “us” know about this in the form of our experience of pain.
We develop tolerances to experiences as we’re exposed to them over time. Think of the sensation of biting into a
HOT CHILLI PEPPER.
Some of you will be thinking “Ouch! No way I’d do that!”, while others of you will be thinking “Yeah baby! Bring it on!”
The way we appraise, or think about/judge a situation influences our emotional response to it. This in turn influences what we are prepared to do about it.
Returning to the chilli pepper, even the next day after having had the HOT CHILLI PEPPER, you can remember the experience. (As an aside, this ability to remember what has happened – and then predict what might happen in the future – is what I drew on when I suggested that you think about it. ) You also made some decisions in your mind when I asked you to think of it, based on your appraisal of the sensation, and your emotional response to it.
When we experience pain, even if that pain goes after a while, we judge it and we have feelings about it, and we make decisions about what we will – or won’t – do if that situation arises again.
And this is why reducing pain but failing to also address thoughts and beliefs about what has happened and the possibility of it happening again does not always give the outcome we are hoping for.
The papers by Lamb and colleagues demonstrate that group CBT for low-back pain can be delivered in a cost-effective way in primary care, with good long-term effectiveness. Isn’t it time this approach was seriously implemented?
Sarah E Lamb, Zara Hansen, Ranjit Lall, Emanuela Castelnuovo, Emma J Withers, Vivien Nichols, Rachel Potter, Martin R Underwood (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-eff ectiveness analysis Lancet, 375 (9718), 916-923 : DOI:10.1016/S0140- 6736(09)62164-4
Lamb, S., Mistry, D., Lall, R., Hansen, Z., Evans, D., Withers, E., & Underwood, M. (2012). Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854) PAIN DOI: 10.1016/j.pain.2011.11.016
Linton, S. J., McCracken, L. M., & Vlaeyen, J. W. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1-2), 5-8.