“Hi mate, how are you getting on?” “Really well mate, pain-free” “Oh, that’s brilliant. How’s your return to full duties been?” “Oh, I can’t do that. Doing that job is what put me here so I’m never doing those movements again it will break me. I need to take it easy”.
My daily consultations put me through a rollercoaster of emotions when listening to people talk about pain.
What is pain?
Pain is a complex issue that is multi-factorial and involves social, contextual, physical, and psychological factors; yet a large approach to the treatment frequently provided by musculoskeletal clinicians is focused on simply reducing the sensation of pain (Wainright 2019). This is an approach that is also favoured by patients as a study by Setchell et al. in 2019 demonstrated that people with persistent pain view passive modalities such as ice, heat, and manual therapy more than active modalities such as exercise (Setchell 2019). While not validating an individual’s experience and never focusing on reducing pain would be reductionist and unhelpful, there is an argument that solely focusing on reducing pain with passive modalities, could be dualistic and not address the multi-factorial nature of pain. I ask during this article whether an approach that solely focuses on reducing pain is sufficient and truly people-centred. My aim is to open up a discussion that suggests potentially more appropriate ways we can aim for a full recovery, beyond a reduction in sensation.
The effects of pain
Pain is having a significant economical, societal, and individual effect on governments, employers, and individuals (Becker 2019). Pain is extremely distressing and statistics show a strong correlation with suicide, long-term sickness absence, and unemployment (Becker 2019) further shining the light on how pain worms its way into an individual’s life and spreads until it impacts all factors of well-being. Interesting research has shown that it is not just the sensation that causes people to feel down, depressed and isolated, it is the perceived limitation that comes with the experience of being in pain, shaped by thoughts, beliefs, memories, and self-efficacy (Boutevillain 2017). While I appreciate focusing on desensitization in the short term is essential for an individual’s lifestyle and overall well-being, I would argue that the passive modalities and some frequently used strategies for communication are not beneficial for long-term health, potentially contributing to the perceived limitations of sufferers as they fail to address the physical, psychological, and contextual barriers that are posed by full rounded recovery, especially in cases where a long-term history of pain is present (Belavy 2021).
In an attempt to explain the limitations of these approaches I use a phrase with my patients “the worst thing about rest is that it works!”. When the desired effect is solely to reduce the sensation of pain, rest is perfect. The individual will find a comfortable position and the symptoms will reduce over time. As a result, this approach seems marvellous. It’s only when we start to consider other factors that influence recovery, such as deconditioning and fear avoidance, we realise that this approach falls desperately short (Borisovskaya 2020). Now let’s use heat intervention vs a graded exposure intervention to explain this concept further:
Initially, an individual presents with shoulder pain and following assessment, the clinician provides some advice and education to support continuing with all activities by reducing the load to a more manageable level. For an unspecified reason, this approach does not provide instant relief and the patient’s symptoms continue to worsen. During this time they start to notice specific movements that replicate their symptoms and as this happens more frequently thoughts and feelings towards these movements develop such as “I know my shoulder will be painful when I work overhead” or “doing the overhead movement is really bad for my shoulder which shows something is seriously wrong”. As more time passes, these thoughts and feelings are reinforced every time their symptoms increase, so “doing anything overhead is bad for my shoulder so I should never ever under any circumstances do overhead activities and this job is the sole reason I’m struggling now” becomes deeply imbedded and absolutely true. On the flip side, the individual is advised to try heat to reduce the discomfort so a hot wheat bag is placed on the affected area. As they relax with the nice feeling of the heat on their shoulder, the pain reduces almost instantly. Thoughts such as “heat is really good and really helped to reduce my pain”. Over time, a similar reward process is created, resulting in “heat is the best thing since sliced bread” (Risvi 2021).
The complexity of this is that the heat has failed to address any of the beliefs about the movements required to fulfil the demands of their role, and the context alongside the implementation of these attempts to reduce discomfort is forgotten; even though the amount the person enjoys their job could be a nocebo, and the comfortable environment with the heat application could be a placebo (Rossettini 2021). This can be problematic as the thoughts, feelings, memories, and beliefs of the patient may eventually influence their future employment and overall well-being (Becker 2019). We can see the negative impact and shortcomings of solely focusing on pain as an outcome in this short example alone.
Especially as the issue isn’t that nothing works to reduce pain, the issue is that the research shows that most things work for reducing pain we just don’t know why they work (French 2006). As humans in general we have strong beliefs about the causal effect (Dundar-Coecke 2022), and as clinicians, this is reinforced through University as we are told to be detectives and find the route of the pain, then fix it. This is great initially as we can seemingly help people directly and get lots of praise for this, but this approach can make some into guru-like healers that provide outdated treatments and advice filled with confirmation bias and posthoc reasoning, rarely addressing the complexity of the situation (Caniero 2020). Challengingly, this approach also fits in with patient expectations and the beliefs of the family members and friends of the patient (Beasley 2017), but I refer back to my previous point, does an approach that simplifies an individual’s struggle to a single factor that only you as a clinician can fix really help restore function in the heterogenous population we are exposed to in Occupational Health? Does person-centred care offer a menu for people to select their preferred treatment without evidence-based education? Ultimately, we do not know, and may never fully understand exactly why an onset of pain happens, or why specific treatments work (Dundar-Coecke 2022), but it is unlikely to be as simple as only posture, lifting technique, a lack of strength, or tight muscles (Powell 2021).
This is where our job as clinicians is so important! We have the opportunity to open up a person’s viewpoint. I believe that as a clinician we should provide a plan to people with short and long-term goals that reassure and builds confidence to reduce the reliance on specific modalities and increase self-efficacy to ensure the individual that they are strong, capable, and robust (Bernal-Urtrera 2020). Individuals do not have to be pain-free to return to work or live their lives (Shaw 2018). How often is the amount of anxiety we feel actually the amount of danger we’re in? The amount of hunger we feel replicative of the necessity for us to eat? There is a discrepancy between what our body tells us and reality; this also applies to pain. As musculoskeletal clinicians, we are blessed that we have more time with patients than most health professionals, especially in private practice and occupational health. This valuable time can allow a patient to be heard so we can work towards suitable goals. Can we use this time to build meaningful relationships and provide essential education? From my experience, here are a few ways we can maximise our clinical time:
- Explain the non-physical benefits of the treatments that we choose
- Alter the contextual factors of pain where possible through positive communication
- Modify hobbies and work tasks to create new, more positive experiences
- Encourage individuals that pain does not mean that they are broken
Ultimately, the reason I’m writing this article is because of the frustration I feel with people who have been given advice in the past that contributes to fear around returning to activities they enjoy due to reinforcing perceived weakness and fragility. I believe that our experiences in life are the most important thing. As musculoskeletal clinicians, we have a real opportunity to promote health and well-being, and support individuals in creating positive experiences. So, in summary:
- Provide short and long-term goals during your treatment
- Inspire people to continue with the things that they enjoy
- Listen and be empathetic to a person’s experience of being in pain, beyond the sensation
I hope that this article has given you some food for thought!
Luke Griffiths is an MSK Clinician at PAM Group