Pitfalls and Pearls of Persistent Pain
By Zachary R. Stearns, PT, DPT, Marissa L. Carvalho, PT, DPT, OCS, TPS, and Morven A. Ross, PT, DPT, OCS, FAAOMPT
This clinician reflective narrative is written as a supplementary article to the Physical Therapy Journal May Issue: NonPharmacological Management of Pain. Guest editors Arlene Greenspan, DrPH, MS, MPH and Stephen Z. George, PT, PhD.
Persistent pain is a burden to those who suffer from it—and a behemoth to those who treat it. One hundred million adults in the United States suffer from pain that has persisted longer than six months, presenting significant costs for society.1 Pain costs 600 billion dollars per year in America, including healthcare expenses and lost wages, which surpasses the entire Medicare budget for 2018.2-3
Persistent pain is as expensive as it is daunting for some healthcare providers. Sixty-eight percent of internal medicine residents reported that persistent nonmalignant pain experienced by their patients had a negative impact on their clinic experience.4 Many physical therapists perceived that neither their training nor available continuing education opportunities provide the skills or confidence required to treat persistent pain.5
Healthcare providers’ frustrations may be rooted in a biomedical understanding of pain, by both providers and patients.5 But research disproves the notion that pain is a purely biomedical phenomenon; modern guidelines recommend a biopsychosocial approach to treating persistent pain.6-7
Healthcare providers’ stigmatization of persistent pain may stem from a lack of empathy with patients when pain fails to fit a biomedical definition of illness.8 Promoting empathy and a biopsychosocial approach to persistent pain may pave a path toward richer patient-provider relationships, more effective pain management, and more invigorated healthcare providers.5,9-10
The following three clinical examples highlight the challenges that healthcare providers face in treating chronic pain—and offer a few lessons for our development as clinicians in caring for patients with pain.
My first evaluation as a licensed physical therapist was with a woman who was in a traumatic motor vehicle accident. Both of her children were in the car. The other driver ran a red light, clipping the patient’s car. She and her children suffered no immediate injuries. The next day the patient noticed pains in her chest and abdomen that would jump from one place to another without a specific pattern. Her legs started to hurt as well, with pain jumping from leg to leg; she was afraid she damaged something in the car accident without realizing it. She went to the Emergency Department at her local hospital; radiographs taken there showed no evidence of injury or disease.
After two weeks of persistent pain, and a referral for physical therapy from her primary care physician, she met me. She was too afraid to drive, and she had stopped playing with her kids. She did not understand her pain, and felt that her healthcare providers did not understand it either. After a number of tests that all came back negative, I told her I saw no tissue damage that could be causing her pain. She asked a question that many others have since asked me: “If nothing is wrong, then why do I hurt?”
At first, I asked her to trust that even though we don’t know exactly what is wrong, it’s important to remain active. Her pain persisted, and she became more confused about it. Still, she gradually returned to her normal activities, and within three months she reported occasional pain, but that her symptoms no longer interfered with her daily life.
I regret having fed her fear that we had no idea about what was causing her pain, which implied that we didn’t know what would alleviate it. After thinking that the Emergency Department performed a cursory evaluation, I tried to find a clearer answer despite feeling that the symptoms didn’t fit any common pathoanatomical diagnoses. In hindsight, I believe that a more effective evaluation would have investigated her fear of activities, her ability to cope with pain, and her goals. I was so focused on identifying a physical diagnosis that I didn’t allow time for education or an exploration of the barriers she faced to improving her quality of life.
As I interviewed my new patient, she was adamant that her pain was caused by a pinched nerve. She had significantly limited her mobility and all spine movements for fear of making her pain worse. After reviewing her medical record, examining the patient, and discussing the case with the patient’s referring provider, I found no physical or radiographic evidence of neurological compromise. I concluded that I needed to help change her perception of her symptoms and experience; otherwise, we would not get anywhere.
I delved into what I thought was an effective explanation of her pain based on pain neuroscience. As I started to discuss the difference between tissue pathology and pain, common findings on imaging, and the reassuring results of her physical exam, the patient’s body language demonstrated that she was not interested in my explanation. I attempted to elicit her thoughts regarding the education and her pain experience, but she no longer wanted to talk or participate in physical therapy. She told me that she felt I was missing something and because of this, working with me would do more harm than good. From that moment forward, I was unable to regain trust with the patient and she did not return to the clinic.
In this case, when determining what intervention to provide, I automatically assumed what was best for my patient rather than involve her in the decision-making process. By not involving her in this process, my realization that she was not interested in discussing pain physiology came too late. This led to a lack of trust and a poor therapeutic alliance. I learned some crucial lessons with this interaction: a foundation of trust is essential and it is important to tailor interventions to an individual’s readiness for change. If I had fostered a collaborative environment with shared decision-making, it may have led to the development of a positive therapeutic alliance, which could have facilitated behavioral change.
A thorough chart review of my patient revealed multiple surgeries, comorbidities including anxiety and depression, and extensive pain management interventions. I envisioned an individual with central sensitization, an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity.11 I speculated that he had received a biomedical explanation for his pain and was searching for answers to “fix it.” Consequently, I knew that I would need to focus my treatment on pain education and the role of the nervous system in persistent pain. The patient’s subjective and objective assessment confirmed my suspicions of central sensitization.
I asked the patient if anyone had ever talked to him about how we experience pain. When he said “no” and was willing to discuss pain, I remember thinking, “Oh, I got this. This is going to be great!” When I finished my typical pain education, he just looked at me and stated, “OK, but I have arthritis, so there is something wrong with me. I have real pain.”
The error that I made in this case was jumping to conclusions too quickly, providing too narrow of an explanation for this patient’s pain, and failing to acknowledge the patient’s underlying concerns about osteoarthritis. This led to decreased trust and buy-in from the patient. In my explanation of his pain I should have acknowledged his osteoarthritis, explained how it can cause nociceptive pain, but also how it related to his current central sensitization symptoms in order to give him a more thorough and personal explanation of his pain. This case reminded me of the importance of understanding the patient’s perspective and acknowledging it to lead to improved therapeutic alliance and a more successful outcome for the patient.
These patient stories reflect the complexity of pain and some pitfalls in clinical decision-making. Persistent pain is a condition with many potential contributing factors; its multifaceted nature can intimidate individuals experiencing it as well as their healthcare providers.12 Providers across multiple disciplines express concern about patients’ motivation, attention-seeking behavior, and the existence of actual pain.4-5,13 However, it is important to consider that these individuals are just like all patients we see. They have limitations in their daily lives and our job is to help them achieve their goals.
While all individuals have a combination of biological, psychological, and social factors impacting their pain experience, the extent to which each of these factors plays a role is unique to each person.14 For some, the biological factors will play a larger role; for others, the psychological factors will dominate.
Physical therapists are often viewed as healthcare providers who address biological factors, but we are in an excellent position to address certain psychosocial factors as well.14-15 Lack of familiarity can lead to discomfort when addressing psychosocial factors, but we can use our skills to identify modifiable impairments, and through shared decision-making, we can develop a plan of care to improve overall health and quality of life. Despite the complexity, we can make a significant impact in the lives of individuals with persistent pain. As Joshua J. Marine writes, “Challenges are what make life interesting and overcoming them is what makes life meaningful.”16 Marine’s words illustrate for us why we value working with individuals who have persistent pain, despite the challenges along the way.