If you’re a clinician, you may be one of the many who dread having to treat a diagnosis of chronic pain (persistent pain, fibromyalgia, myofascial pain syndrome etc.). It’s just one of those diagnoses that makes clinicians want to wear garlic around their neck to ward these patients away. The real issue isn’t the patient or diagnosis, but the lack of understanding and tools clinicians feel they have for treating these populations. This begins with the model with which we approach care.

The biomedical model focuses on cause-effect and assumes tissue/structure pathology is the cause of pain.  It does not resolve unpredictable patterns of pain including: little pathology in the presence of a lot of symptomatology, no tissue pathology, or recognize the vast range of what normal movement and normal radiological findings are. Variability in imaging occurs with and without the presence of symptoms.[1] The assumption that any finding on any image or test is absolutely causative of symptoms is erroneous; that which is found on imaging might have existed for a long time prior to onset of symptoms. But still, this notion persists amongst patients and providers. As a result, the idea of “find it and fix it” is reinforced, and patients continue on their quest for a treatment to “cure” them. This perpetuates a patient’s dependence upon the physician/medical system and delays appropriate treatment.[2] Healthcare providers may be aware of the presence of yellow flags in a patient’s history, such as a major accident, depression, catastrophization, or prior trauma or abuse (to name a few), but not consider it related to the patient’s clinical presentation of pain. But it is. Prior pain experience shapes pain perception.[3]

A patient’s own acceptance and belief of her own disability and lack of self-efficacy is true disability. If you believe that you cannot do something, then you do not try to do it, and that activity or life role is absent.[4] We need to empower the patient with tools to better self-manage. An individual’s higher self-efficacy and belief that she has some control over her pain function is associated with decreased medication us.[5] This is why a different model of care is required. What we’re doing isn’t working, and it isn’t reducing disability or suffering.

The BPS model

This is where the biopsychosocial (BPS) model comes in. It all matters. Practicing in a biopsychosocial format means addressing the intersectionality of the individual. There is no protocol for chronic pain, there is only a framework.

As with any patient encounter, it starts with taking a good history. The purpose of the history is to guide the exam so that clinicians aren’t just randomly testing tissues. However, as clinicians, when we listen to a patient recount her experience of “I was playing soccer, landed, and felt a pop as I was turning,” we assume that we know what comes next and, thus, we tune out the rest of her narrative. But we don’t know what comes next; and we stop listening to the patient. Consider what happens when you’re talking to someone who looks up at you and says, “I’m sorry, what?” You probably repeat yourself and talk louder. We penalize our patients who have chronic persistent pain for repeating themselves and talking louder in an effort to be heard and believed.[6] These are learned behaviors, and they represent what patients with chronic persistent pain have had to do over years of seeking treatment with numerous clinicians, with their family, and with their friends. Patients “turn up” their narrative out of desperation to have their experience legitimized.

When I speak to other therapists about their patients in chronic pain, I hear their disbelief in the patient’s re-telling, incredulity at their seemingly exaggerated descriptions, and revulsion towards the patient’s emphatic communication. I’ve seen this lead to assumptions about secondary gains or malingering. Even if there are secondary gains, it doesn’t preclude chronic persistent pain. BPS is about listening to your patient, believing her, and using her accounting to shape your treatment. This is the psychosocial in biopsychosocial. They’re telling you something, but you have to listen for it.

Let’s do this better.

How can we do this better? Ask questions, let patients iterate their narrative, and listen and believe them. The patient is the only witness to her pain experience. When taking her history, be attentive for flawed mental models such as “my doctor says it’s the worst they’ve seen” or “my pain will never get better.” Don’t argue or lecture. “But you can’t be a 12/10, because then I’d have to send you to the ER – and not to mention you are sitting still quietly.”

Hear their metaphors, “it feels like…” Use that again during intervention to help change their perception. Does the patient describe their pain as “tightness” or “stuck”? Then perform interventions with them using language such as “opening up,” “motion is lotion,” or “lubricate those joints” while performing a doorway pectoralis stretch or arm ergometer. Do they express disembodiment metaphors? “It feels like my top half is smooshed together with my bottom half,” or “I just want to cut it off.” Focus your language during treatment on what I like to call “body love” to reduce rejection of the painful body part. The dissociative metaphors in particular should guide you to other assessments that should be performed. Does your patient express seemingly odd correlations between her symptoms and experiences? I had a patient this summer tell me that all of her recent flare-ups were related to air conditioning.  After her initial frustration at my questioning and being unable to explain what it was about air conditioning that flared her up, I asked “when did air conditioning start hurting?” She immediately responded, “in 1995, when I fell down the stairs, the hospital room was freezing.” She was pregnant at the time and sustained a substantial ankle fracture that required plates and screws. Every time she was in air conditioning her brain was reliving a traumatic event from over 20 years ago. I knew this was the event that was the catalyst for her chronic pain. But she didn’t share this experience or this correlation with her flare-ups until her third visit. Sometimes it happens that way. Under the BPS model, taking the patient’s history doesn’t stop at the first visit. After this visit, the patient’s homework was a mantra “air conditioning is not dangerous.” She was immediately able to better self-manage and de-threaten her flare-ups as they related to air conditioning. They were shorter, less stressful, and she felt she understood them better and thus wasn’t as concerned about them.  Another patient expressed flare ups related to rain. As it turns out, when she was younger, she got caught in a downpour and ended up with pneumonia. I wouldn’t have known if I didn’t ask.

As clinicians striving to change our framework to a BPS model, we need be cautious of pain score ratings. A pain rating tells you nothing about a person’s self-efficacy, catastrophization, fear avoidance, disability, or how to treat them. Additionally, there are inherent biases with a pain rating, which leads patients to give scores of 12/10 and to arguments about the patient’s subjective pain experience. Instead, reframe the pain schema for her to compare her baseline pain level versus a flare-up. There is a broader message in doing this. Implicitly, it reminds her that flare-ups are temporary and emphasizes the message that “there will be relief.” This is key in a patient’s ability to reduce catastrophization, as it increases hope and optimism that she won’t be in a flared state forever. You can also derive better, quantifiable information from your patient than would be discerned from a pain score. This might include the frequency and duration of flare-ups, when she notices them begin, and what tools (explore this with her) she uses to address the pain before it quintuples. 

Let's practice.

Let’s practice. A patient comes with a long history of pain following no clear pattern or physical event at onset. Or, the event at onset was so long ago that it’s likely healed and not the source of her symptoms.  Her recounting of her history involves several body regions; she describes her pain as moving “all over.”  She has seen multiple practitioners over the years.  She hands you a document which lists all of her specialists and all of the tests that she has undergone with the correlating results. During physical exam, you find no substantial findings that would indicate a tissue or movement source of her pain. You have ruled out the “bio.” Now what do you do? What do you ask? Where do you go with this patient? BPS indicates that we need to address the psychosocial aspects. What was going on in the patient’s life at the time her pain began or leading up to it? What is currently stressful in the patient’s life?  It’s appropriate to ask if she has any history of trauma or abuse if you think it is relevant to the patient.  And yes, referring her to a psychological services provider is prudent based upon numerous possible responses.  But who will address movement without fear, tolerance to positions required for her vocation, wearing the footwear or clothing that she currently cannot, and returning to the life roles and recreation that she has abandoned? Physical and occupational therapists cannot simply refer out the psychosocial aspects of a patient’s pain experience. The patient’s disability needs addressing.

Treatment should be aimed at empowering the patient to self-manage her flare-ups to decrease threat. Help her to find the tools that work for her. Maybe it’s a mantra, a creative outlet, an abandoned recreational activity to which you “give her permission” to return. During an evaluation recently, a patient told me she had stopped running but couldn’t really give a reason why.  She was experiencing shoulder/neck pain. I “gave her permission” to return gradually. She was thrilled and went back to running for stress relief and health.

Address their disability. There are people who have no pain who cannot get out of bed and people with 10/10 pain that go about their business, go to work, and care for their families despite their pain.[7] Do you discern that the patient has fear avoidance/ kinesophobia?  Then intervene with graded return via part task training and a gradual increase in load and direction to build a sense of safety and confidence. If she experiences a flare, then grade it down if necessary. One of my current patients wants to return to lifting weights at the gym. We are starting with a dead lift set-up of a 3# bar lowered to boxes set 20 inches from the floor. Get creative, empower your patients and give them back their sense of control of their bodies to reduce their suffering.

[1] Jensen et al 1994; Herzog et al 2017.
[2] Glenton 2003.
[3] Bayer et al 1998; Jensen et al 2011.
[4] Riley et al 1988.
[5] Jensen et al 1991.
[6] Glenton 2003, Lillrank 2003.
[7] Soer et al 2012.

Meet Devra Sheldon

Devra is a physical therapist at Schwab Rehabilitation Hospital in Chicago, Illinois. With nearly fifteen years of experience, Devra's primary patient populations include chronic pain, stroke, brain injury, spinal cord injury, amputee, complex medical situations, and orthopedic. She also specifically manages incomplete spinal cord gain, spasticity, and psychosocially complex populations. Devra is an ardent advocate of a biopsychosocial approach to pain management and using graded motor imagery.  Devra is board-certified in neurology and is a member of the Midwest Pain Society. She lives in Chicago with her family. Learn more about her here.

Sources / Research:

Bayer, T. L., Coverdale, J. H., Chiang, E., & Bangs, M. (1998). The role of prior pain experience and expectancy in psychologically and physically induced pain. Pain, 74(2), 327-331.

Glenton, C. (2003). Chronic back pain sufferers—striving for the sick role. Social Science & Medicine, 57(11), 2243-2252.

Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 17(4), 554-561.

Jensen M.C., & Brant-Zawadki, M.N. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331 (2), 69-73.

Jensen, M.P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: a critical review of the literature. Pain, 47(3), 249-283.

Jensen, M. P., Moore, M. R., Bockow, T. B., Ehde, D. M., & Engel, J. M. (2011). Psychosocial Factors and Adjustment to Chronic Pain in Persons With Physical Disabilities: A Systematic Review. Archives of Physical Medicine and Rehabilitation, 92(1), 146-160.

Lillrank, A. (2003). Back pain and the resolution of diagnostic uncertainty in illness narratives. Social Science & Medicine, 57(6), 1045-1054.

Riley JF, Ahern DK, Follick MJ, Chronic pain and functional impairment: assessing beliefs about their relationship. Archives of Physical Medicine and Rehabilitation, 69(8): 579-582 (1988).

Soer, R., Vries, HJ, Brouwer, S., Groothoff, J.W., Geertzen, J.H., & Reneman, M.F. Do Workers With Chronic Nonspecific Musculoskeletal Pain, With and Without Sick Leave, Have Lower Functional Capacity Compared With Healthy Workers? Archives of Physical Medicine and Rehabilitation, 93(12), 2216-2222 (2012).

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