4 Clinical Considerations for Persistent Pain
Persistent pain is one of the most significant challenges facing clinicians; with approximately 20% of the Australian population living with persistent pain (1), it’s clearly not only a burden on the health system, but has a huge impact on the quality of life of millions of people worldwide.
As physios, we see persistent pain across all facets of our work. If you’re a new or seasoned physio, working anywhere between acute, rehabilitation or community settings, it is more than likely you have encountered at least one tricky persistent pain case. Whether it be a back, neck, knee or all of the above, treatment can be complicated and it’s difficult to know which approach to take. The individual factors associated with persistent pain can make it incredibly difficult to manage, and a multidisciplinary approach is appropriate in most cases. Below are some considerations for practitioners treating people with persistent pain.
If you’d like to learn more about this tricky topic and improve your care, check out this excellent Masterclass; Know Pain: A Practical Guide to Persistent Pain Therapy by Mike Stewart here.
1) Consider the biopsychosocial factors
This is a no brainer when talking about management of persistent pain – in every case it is important to look at the person as a whole and consider the factors which may be contributing to their pain. But the treatment of persistent pain can become overwhelming and convoluted. Nonetheless, a recent study has outlined what these considerations might be and management tips for persistent pain.
So, for all of those systematically minded physios out there, here is a useful checklist (2):
- Belief that pain and activity are “harmful”
- Depression, anger, frustration
- Anxiety, fear, aversion (intention to avoid factors associated with pain)
- Catastrophization (tendency to exaggerate the severity of pain or associated outcomes) Reduced activity level, withdrawal from daily activities
- Sleep disturbance
- Dependence on medication and increased use of health care services
- Over-dependence on family and other carers
- Social withdrawal, social anxiety
- Extended rest, disability, problems at and absenteeism from work, poor performance/dissatisfaction at work
- Adverse impact on social relationships, social isolation
- Poor self-image, low self-esteem, role confusion
- High intake of alcohol or other harmful substances
- Compensation issues
- Financial difficulties
- Suicide risk
- Spiritual emptiness, lack of meaning, religious needs
- Perceived injustice (‘’Why did this happen to me?’’; ‘’Nobody understands me’’)
General management considerations (2):
- Assess pain and its impact on functioning.
- Assess and manage risk factors for chronic pain, including mood and sleep.
- Discuss realistic expectations of treatment outcomes (ie, improvement in function). Validate the patient’s experience and empower them to take responsibility for self-management. Involve other health professionals from the onset
- Avoid unnecessary additional special investigations.
- Assess and rationalize current medication, including an assessment for analgesic-induced pain (eg, rebound, withdrawal).
- Opioids (including codeine-containing formulations) should be tapered and preferably discontinued.
- Pharmacological management should be carefully considered and may require rational polypharmacy.
- Encourage increased movement, healthy nutrition and socialization.
- Encourage early return to normal daily activities and work.
2) Consider the locus of control
A recent systematic review suggests the presence of an internal locus of control is a predictor for better outcomes from physiotherapy treatment (3). One study also suggested that for those with higher external locus of control based around health professionals, the outcomes were better during physiotherapy treatment, but did not continue when treatment ceased (4). So, it is important to consider what the patient’s locus of control is, and whether this can be altered- this should ultimately guide decision-making when developing an appropriate treatment plan with the patient.
3) Consider your own beliefs and think outside the box
For many people experiencing persistent pain, explaining their pain experience can be considerably difficult and frustrating. Traditionally, the rhetoric has been that patients need to be flexible in their thinking – this may be so, but maybe we as clinicians need to think outside the box as well.
In his masterclass on persistent pain which you can view HERE, Mike Stewart explains the value in using strategies such as drawing, or identification of pain through graphics which may enable a person to better describe their pain. Additionally, alternative treatment options such as music intervention have been found to be beneficial in pain and anxiety/depression reduction (5).
Being in a profession grounded by science, it can be difficult to think outside the box, and while abstract thinking may scare us, it could be just the thing your patient needs to express themselves and feel heard.
4) Consider the power of metaphors
Physios love a metaphor, and for good reason – 73% of people understand pain science when given metaphor compared to standard education (6). Most of us know to use metaphors when trying to provide pain education. However, it must be noted that some metaphors can be useful, while others can be detrimental. Using battle-based metaphors in which the patient is fighting against an unfriendly opponent can evoke negative emotions, and an unwanted fight/flight response (7).
Similarly, it may be important to be conscious of some sport-based metaphors for the same reason. In general, patients should be encouraged to stop fighting, to provide solutions rather than a constant battle. In his Masterclass here, Mike Stewart discusses the usefulness of patient-generated metaphors, associated with relatable things such as their work or hobbies – this makes the metaphors meaningful, and consolidates understanding of pain science; in many cases, understanding is the first step in managing persistent pain.
Management of persistent pain can be difficult. We all want what’s best for our patients, however, in some circumstances we can be limited by our own education and beliefs. While pain education is important, we should be aiming to talk less in our sessions, not more – use and explore the patient’s own beliefs, because ultimately this may be the most meaningful and individualised way to address their pain.
If you found this useful, then you won’t regret checking out Mike Stewart’s Masterclass on A Practical Guide to Persistent Pain Therapy here.
Want to learn more about communicating with patients?
Mike Stewart has done a Masterclass lecture series for us on:
“Know Pain: A Practical Guide to Persistent Pain Therapy”
You can try Masterclass for FREE now with our 7-day trial!
- Australian Institute of Health and Welfare (2020). Chronic pain in Australia. Canberra: AIHW Retrieved from https://www.aihw.gov.au/getmedia/10434b6f-2147-46ab-b654-a90f05592d35/aihw-phe-267.pdf.aspx? inline=true.
- Salduker S, Allers E, Bechan S, Hodgson RE, Meyer F, Meyer H, Smuts J, Vuong E, Webb D (2019). Practical approach to a patient with chronic pain of uncertain etiology in primary care. J Pain Res. 3;12:2651- 2662.
- Álvarez-Rodríguez J, Leirós-Rodríguez R, Morera-Balaguer J, Marqués-Sánchez P, Rodríguez-Nogueira Ó (2022). The Influence of the locus of control construct on the efficacy of physiotherapy treatments in patients with chronic pain: A systematic review. J. Pers. Med. 12, 232.
- Stewart JA, Aebischer V, Egloff N, Wegmann B, Von Känel R, Vögelin E, Holtforth MG (2018). The role of health locus of control in pain intensity outcome of conservatively and operatively treated hand surgery patients. Int. J. Behav. Med. 25, 374–379.
- Guétin S, Giniès P, Siou DK, Picot MC, Pommié C, Guldner E, Gosp AM, Ostyn K, Coudeyre E, Touchon J (2012). The effects of music intervention in the management of chronic pain: A single-blind, randomized controlled trial. Clin J Pain. 28(4):329-37.
- Gallagher L, McAuley J, Moseley L (2013). A randomized-controlled trial of using a book of metaphors to reconceptualise pain and decrease catasrophising in people with chronic pain. Clin J Pain. 29(1): 20-25.
- Wiggins NM (2012). Stop using military metaphors for disease. Brit Med J. 345 (7867): 31.
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