expectations

Expectations – and communicating


There are times when I look at the research on persistent pain and treatment, and I begin to wonder why I’m still so positive about this field! After all, it seems that although a biopsychosocial or multidimensional framework for pain has been around since the 1970’s, I’m still encountering reasonably recently-graduated clinicians who sincerely believe that whatever treatment they’ve learned is the Bee’s Knees, and Will Truly Fix All Pain. And people who firmly believe that All Pain Is X. Or Y. Or Z. And surely we should do what they say (pay the fee, get the certificate, perhaps even levels 3, 4 and 5!) and the people we see will get completely cured.

Maybe I’m just being a Grinch because it’s coming into Christmas.

Perhaps, too, we’ve all forgotten that treatments for persistent pain don’t happen in a vacuum. The people we work with have first had to recognise that their problem is something they think should be treated. Then they’ve chosen to see someone – and maybe chosen to see us, or been referred to us by someone else. These two steps in treatment response alone make an incredible difference to outcomes.

Imagine if I’m someone who thinks my lumbago is normal, something everyone gets, and don’t see it as something unusual. I might choose not to seek treatment until I’m about to embark on a long trip. I choose to see an osteopath because I think they’re more gentle than a physio (who will only give me exercises), or a chiropractor (who will hurt me!), and I don’t like needles so I avoid acupuncture. I don’t think my problem is serious enough to go see a medical practitioner and besides I think my GP will just send me to the physio.

Now imagine instead that I’m a young woman who loves to dance. I’ve had little niggles in my back before, but last night I got on the dance floor and partied like it’s 1999 (oh, that’s right, we’ve been there, done that!). Anyway I partied the night away until I slipped on some beer on the floor, landed on my butt and now my back is really bothering me. I head to my GP feeling pretty hung over and like I cannot walk because my back is SO sore.

Two reasonably common stories.

Now let’s take a look at a study looking at expectations from people seeking help for chronic pain (persistent pain). Wiering, de Boer, Krol , Wieberneit-Tolman and Delnoij (2018) examined the results of data collected from people with persistent pain. Over 2000 people took part in this study, mainly between the ages of 55 – 64. Most were women, most had been living with pain for a long time (on average 14.9 years). Most (50.7%) obtained treatment intended to reduce or stabilise (27%) their pain, and for many people the pain did stabilise (26%), or reduced to a degree (29.4% + 34% to a lesser degree). BUT, and here’s the thing: 41.8% expected a better result, while 33.3% got a better result than they thought they would.


The killer point is that although nearly 70% of people achieved or did better than they expected, and nearly 40% of patients didn’t expect very much, 30% of people were unsatisfied.

Curiously, there was little relationship between how the clinician communicated and the accuracy of the person’s expectations. It didn’t matter whether the clinicians used shared decision-making, patients felt their outcomes should be better than they were.

BUT importantly, attentive listening, having time available for the person, whether the patient trusted the clinician, and whether the patient thought the clinician had done all he or she could were important predictors of satisfaction.

What points do the authors make about communication and expectations? Well, one is that although communication is important only certain aspects of communication really rated with patients: clinicians thought “instrumental” communication was important. This is things like seeking information, asking questions of the person, asking for consent. Instead what actually helped was “affective” communication: responding to the person’s emotional subtext. Things like taking time to listen, building trust, giving people the idea that the clinician is doing all that he or she can.


There’s a caveat though, and I’ll quote directly “Low scores on the important communication aspects were related to expectations that were too high, while high scores were related to too low expectations. Apparently the perfect level of communication is somewhere in the middle. The relationship between low patient expectations and good affective communication may be a sign that it worries patients if health care providers show too much empathy and therefore come across as concerned.” (p. 6)

What can we do with this information? Well I think we can begin by recognising that helping people establish what’s important to them – what is the outcome they most value – is something often not tabled by us. We think we’re communicating clearly, but maybe not. We should also personalise treatments – help people realise that we’re not just delivering some sort of template or algorithm, but that we’re concerned about their unique needs, wants and lifestyles. We should also be warned that people seeking help from us have very high hopes that we’ll be able to achieve a lot. And of course, if we read the research, we should recognise that in general we don’t have a great track record in persistent pain. Let’s not over-promise!

I think using personalised outcome measures like the Patient Specific Functional Scale or the Canadian Occupational Performance Measure, or Goal Attainment Scaling could help us be more focused on what people want from their treatment. While pain reduction is the ideal – it’s not the only outcome! What point is there to have no pain if you’re still afraid to do things you want to do?

Wiering, B., de Boer, D., Krol, M., Wieberneit-Tolman, H., & Delnoij, D. (2018). Entertaining accurate treatment expectations while suffering from chronic pain: an exploration of treatment expectations and the relationship with patient- provider communication. BMC Health Serv Res, 18(1), 706. doi:10.1186/s12913-018-3497-8

The positive power of what we say during treatment


Expectations form one of the important predictors of response to treatment, especially in the case of treatments for pain. A person’s belief or expectation that a treatment will reduce their pain is thought to be part of the response to placebo – and indeed, part of the response to almost any treatment.  Much of the research into expectancies has been carried out in experimental models where healthy people are given a painful stimulus, then provided with some sort of treatment along with a verbal (or written) instruction that is thought to generate a positive belief in the effectiveness of that treatment. The people we see in a clinical setting, however, are in quite a different setting – they experience pain sufficiently disruptive to their sense of well-being that they’ve sought treatment, they may not know what the pain problem is, they may have other health conditions affecting their well-being, and for some, their pain may be chronic or persistent. Do expectations have a clinically-relevant effect on their pain?

Luckily for us, a recent meta-analysis published in Pain (Peerdeman, van Laarhoven, Keij, Vase, Rovers, Peters & Evers, 2016) means the hard work of crunching through the published research has been completed for us! And given 15 955 studies were retrieved in the initial pass through the databases, we can be very relieved indeed (although only 30 met the inclusion criteria…).

What are expectations?

Before I swing into the results, it’s important to take a look at what expectations are and how they might relate to outcomes. According to Kirsch (1995) response expectancies are expectancies of the occurrence of nonvolitional responses (ie responses we’re not aware we make) as a result of certain behaviours, or specific stimuli.  Kirsch points out that nonvolitional responses act as reinforcement for voluntary behaviour, so that by experiencing a nonvolitional response such as relief, joy, reduced anxiety and so on, people are likely to engage in  behaviours associated with that experience again. For example, if someone is feeling worried about their low back pain, just by having a treatment they expect will help and subsequently feeling relieved, they’re likely to return for that treatment again.

How are expectations created?

Some expectations are generated within a culture – we expect, for example, to see a health professional to relieve our ill health. In general, simply by seeing a health profession, in our developed culture, we expect to feel relieved – maybe that someone knows what is going on, can give a name to what we’re experiencing, can take control and give direction to whatever should happen next. This is one reason we might no longer feel that toothache as soon as we step into the Dentist’s waiting room!

Peerdeman and colleagues outline three main interventions known to enhance positive expectations for treatment: verbal suggestion “You’ll feel so much better after I do this…”; conditioning “If I give you this treatment and reduce the painful stimulation I’ve been giving you, when you next receive this treatment you’ll have learned to experience relief” (not that you’d actually SAY this to anyone!); and mental imagery “Imagine all the wonderful things you’ll be able to once this treatment is over”.

I think you’d agree that both verbal suggestion and mental imagery are processes commonly used in our clinics, and probably conditioning occurs without us even being aware that we’re doing this.

How well does it work for people with acute pain?

As I mentioned above, expectations are used in experimental designs where healthy people are poked and zapped to elicit pain, and hopefully our clinical population are not being deliberately poked and zapped! But in clinical samples, thanks to the review by Peerdeman and co, we can see that there are quite some impressive effect sizes from all three forms of expectancy induction – g =  0.67 (95% CI 0.49-0.86). That means a good deal  of support from the pooled results of 27 studies to suggest that intentionally creating the expectation that pain will reduce actually does reduce pain!

And now for chronic pain

Ahhh, well…. here the results are not so good, as we’d expect. Small effects were found on chronic pain, which is not really unexpected – chronic pain has been around longer than acute pain, so multiple reinforcement pathways have developed, along with pervasive and ongoing experiences of failed treatments where either neutral or negative effects have been experienced.

What does this mean for us as clinicians?

Probably it means that we can give people who are about to undergo a painful procedure (finger pricking for diabetes, dressing changes for ulcers, getting a flu jab) a positive expectation that they’ll feel better once it’s over because the strongest effect was obtained for people undergoing a painful procedure who received a positive verbal suggestion that the procedure would help.

Chronic pain? Not quite so wonderful – but from this study I think we should learn that expectations are a powerful force in our treatments, both individually with the person sitting in front of us, but also socioculturally – we have an expectation that treatments will help, and that’s not something to sniff at. Perhaps our next steps are to learn how to generate this without inducing reliance or dependence on US, and on helping the person recognise that they have generated this themselves. Now that’s power to the people!

 

Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189.

Peerdeman, K. J., van Laarhoven, A. I. M., Keij, S. M., Vase, L., Rovers, M. M., Peters, M. L., & Evers, A. W. M. (2016). Relieving patients’ pain with expectation interventions: A meta-analysis. Pain, 157(6), 1179-1191.

Attributions regarding unmet goals after treatment


ResearchBlogging.org

After searching for a while, and finding not that much about goals in the peer-reviewed pain management literature, it’s nice to have an article that specifically discussed goals and the effect of not meeting goals on participants. This article by Guck and colleagues from the University of Nebraska, examines how a group of participants in a pain management programme view their achievement of goals – do they blame themselves, or external factors for their ‘lapse’ or ‘relapse’.
It’s interesting that this piece of research is based around the concepts of relapse prevention, because one of the main reasons for considering the place of goal-setting is to ensure participants make changes in their lives that matter to them – and retain those changes over time. So relapse prevention theory will have much to add for therapists wanting to help their clients stick with the ‘programme’. I’m not sure that many therapists would have really considered this body of knowledge in relation to physical exercise or using coping skills, because much of the theory is directly related to smoking cessation, dietary change or alcohol abstinence.

Anyway, onto the research.
In this study 100 particpants from 263 people who entered an interdisciplinary programme over a five-year period were asked to participate. Of the original 263, 30 failed to complete the programme, and of the remaining people, 100 provided complete information.

From the description, the programme sounds very similar generic and consisted of a four-week programme of exercise, medication review, active coping strategies and other issues such as work, family and social issues were also addressed in both individual and group sessions.

In the final week of the programme, relapse prevention sessions were held, covering high risk situations, and how to reduce the likelihood of the rule violation effect.

Interestingly, the group developed their goals for after the programme at the time of this discussion – in full awareness of the role of ‘slips’ and ‘lapses’. Participants develop between 4 – 6 goals, and staff assisted them to ensure goals met the ‘SMART’ goal schema. The goals were to be achieved in the next six months.

Six months after discharge from the programme, participants were contacted with a copy of their goals list, and were asked to identify whether they had met the goal, and for each unmet goal, to record on four attributional rating scales, the reason for not doing so. The attributional scales were 1 – 7 likert-type scales, with ‘internal’ to ‘external’, ‘stable’ to ‘unstable’, ‘gobal’ to ‘specific’ and ‘uncontrollable’ to ‘controllable’ factors as the anchors.

Results – Overall, the 100 participants identified 487 goals they intended to meet – 322 of these goals were recorded as met, while 165 goals were not. 46 of the 100 participants met most of their goals, while 16 failed to meet more than 2/3 of their goals. Chi-squared analysis indicated that more goals than not were met in most of the goals categories – except for work.

The causes for not meeting work and social activity goals were attributed to external rather than internal factors more often than were causes for not meeting coping skills, medication change, or exercise goals. Work goals were more often to be thought to be uncontrollable.

So, it seems that goals that were set during this programme by and large were met – except in the two areas that depend a lot on other people (social and work). And the attributions that people made as to why these goals were met or not met differed depending on the type of goal. This suggests that it’s not helpful to use the same relapse prevention model for some of the goals – that is, people do tend to believe that when they can’t manage work or social goals, it’s about external factors, uncontrollable factors, and global factors that are stable.

This makes it very difficult for people to reconsider how to cope with these demands, and from other research in relapse prevention, makes it more likely for them to feel there is nothing they can do to change the situation, and reduce the likelihood they will attempt again.

The researchers in this study suggest that people who need to set goals in social and work areas need to be taught how to cope with factors that affect work and social goals that are external and uncontrollable – unfortunately, as many pain management programmes don’t even consider return to work as a goal, and certainly don’t seem to break that goal into manageable ‘chunks’, this may remain a concern within New Zealand at least.

Once again I’m left with the impression that developing pain management skills and goals to help people return to work despite chronic pain is different from and more complex than simply helping people develop generic pain management skills. The workplace is different from the home – and goals made for using pain coping strategies, exercise and medication at home seem to be much more easily achieved than those about using them at work. Food for thought: perhaps pain management at work is a specialised area for pain management, and not simply the same as ‘any old pain management’?

Gluck, T.P., Willcockson, J.C., Schmidt, R.L., Criscuolo, C.M. (2008). Attributions regarding unmet treatment goals after interdisciplinary chronic pain rehabilitation. Clinical Journal of Pain, 24(5), 415-420.