When patients are in pain, they typically worry that activity will cause more harm than good. However, overly rigid activity restrictions are responsible for promoting chronic pain behaviors and interfering with the recovery process. Frequently, advice such as, "Let pain be your guide," is given, which only reinforces attitudes and beliefs that foster pain-avoidance behavior and deconditioning.
In contrast, the idea that "hurt doesn't necessarily equal harm," and that rest is bad for tissues, has not received as much attention. A stepped-care approach involving incrementally more structured and comprehensive patient education is required to influence patient belief systems and concerns about activity. The goal is to modify patient health behavior in the direct of reactivation.
Fear-Avoidance Beliefs and Chronic, Disabling Pain
Patients at the greatest risk of developing chronic pain often have poorly developed coping skills.1 They may tend to catastrophize their illness and feel there is nothing they can do. When patients fear pain or fear the worst possible outcome, they are less likely to resume activity or perform exercise.2 It is easy for them to become dependent on manipulation, massage, medication, and various physical therapy modalities. A key to getting patients to become active in their own rehabilitation programs is to shift them from being pain avoiders to pain managers.3-5
The goal with fearful patients is to increase their confidence in normal activities and/or exercises.6-7 In cases of severely painful or unstable acute injury, it may be appropriate to equate hurt and harm, but in less severe cases, or certainly in the subacute or recovery phase, this should not be the case. In fact, the target of treatment may be the stiffness caused by a patient overprotecting himself or herself during the acute phase. Muscles and joints, which lose their mobility while the patient restricts activities during acute pain, should be expected to cause discomfort, and remobilizing them may hurt, but certainly won't harm. It is useful to explain to patients that their pain is due to dysfunction, not tissue damage or pathology (e.g., a herniated disc or arthritis).8-9
| Step One: Brief educational approaches, including advice to gradually increase activity from a cognitive-behavioral (CB) perspective, for patients in the acute phase of a painful episode. |
It has been shown how valuable appropriate patient advice can be,10 in particular, when it is given in a biopsychosocial context, which reduces pain-related anxiety and encourages patients to gradually resume normal activities.11-15 Such advice focuses on the consequences of pain, such as activity limitations, rather than the pain itself.
Techniques for motivating patients to resume activity include:
Back-related worries and fears are perhaps the most important thing to identify in acute patients. Most patients recover, but those with significant worries require a unique approach to prevent disabling disuse atrophy. According to Balderson and Von Korff,18 simple, brief educational approaches are needed to address fear-avoidance beliefs and assure resumption of normal activities:
| Step Two: Offer a more structured approach, involving CB classes or sessions, addressing patients' worries and fears, teaching them simple, safe, and effective methods to reduce these apprehensions. Apply this to subacute patients at heightened risk of developing chronic pain (i.e., a high "yellow flags" score), or those in the chronic phase.1 |
According to Balderson and Von Korff,18 care may need to be "stepped up" for those patients who continue to have residual activity intolerances or have substantial fears and worries, as evidenced by a high "yellow flags" score. Such patients need a more structured intervention that involves CB classes and supervised "graded exposure" to feared activities, such as exercise. "Graded exposures" should be specific to the feared activity. Vlaeyen20 documented the value of this approach; Goubert21 confirmed this was necessary, because effects of exposures to one movement don't necessarily translate to other dissimilar movements.
Cognitive-Behavioral Therapy
This CB approach is introduced with an explanation of the fear-avoidance model using the patient's own symptoms, beliefs and behaviors to illustrate the vicious circle. Reassurance by itself is not sufficient to help patients overcome their fears.17 Self-reassurance is required, so individually tailored practice tasks are designed. Patients select the activity they want to work on; they are given education and reassurance regarding that activity, and together, clinician and patient explore what is feared about the activity. Healthy behaviors are reinforced while pain behaviors (i.e., sighing, grimacing) are not.6 Reinforcement includes such things as attention or praise.6 The specific reactivation goals the patient has helped to select are reviewed weekly. When progress is noted, it is important that it is not attributed to the clinician's intervention, but to the patient's efforts.17 Anderson suggested that supporting self-care of chronic illness through patient-entered approaches was more successful than physician-centered directive ones.22
Highly specialized programs, including rehabilitative exercises and psychologically oriented classes, have been developed. The classes involve education about the psychology and neurophysiology of pain, followed by quota-based "graded-exposures" to their own feared movements or activities. The desired outcome is that the patient develops a personalized coping program. The program includes six two-hour sessions with a clinical psychologist, accompanied by rehabilitation. The class size ranges from six to 10 people and covers the following summarized material:
Cognitive-behavioral class topics/skills:
The Problem-Solving Approach
According to Shaw, et al.,25,26 it is important to address a chronic patient's problem-solving style, which has been shown to be correlated with increased disability. This involves:
The Neurophysiologic Approach
It is essential to validate chronic patients' pain experience. Even if structural pathology or injury does not explain the patient's pain, the pain is still real. Modern neurophysiology helps us explain our patients' chronic pain. A simple metaphor for discomfort in deconditioned tissues is to compare persistant pain in underused tissues to gardening after the winter, or hiking for the first time in years. "Rusty" tissues are expected to be uncomfortable, but not hazardous, therefore, reactivation is safe - even if uncomfortable.
It is often difficult for chronic pain patients to understand that their spines are not damaged. One very simple explanation is that they have central sensitization. This is what causes phantom limb pain: It is the result of pain memory, not tissue damage. Basically, the nervous system has become habituated to pain - its threshold and tolerance has dropped, and now it responds to non-noxious stimuli as if it were injurious. The logical treatment is graded exposures to re-habituate those pathways. Janet Travell, White House physician to John F. Kennedy, said. "Tissues heal, but muscles learn. They readily develop habits of guarding that long outlast the source of the pain." When pain persists longer than it takes for an injury to heal (e.g., 8-12 weeks for a bone fracture), the pain threshold drops (allodynia) so that even non-noxious stimuli can elicit painful perceptions. Understanding this is essential to realizing that pain can be present that is not due to injured or damaged tissues, and thus, that hurt may not equal harm.
| Step Three: a comprehensive, multidisciplinary biopsychosocial approach involving the above CB model, with strategies that address return-to-work obstacles (employer, compensation system, etc.) as well as comorbid psychological illness, to be used for chronic cases if the above strategies fail. |
Marhold32 looked at the effects of CB therapy on the return to work (RTW) in those already on sick leave. This program involved six CB sessions plus six more on RTW issues. The one-year follow-up showed less days off work for those with short-term sick leave, but no improvement for those with long-term sick leave. Thus, it is better to prevent, rather than treat, chronic disability! Fortunately, only 10 percent of patients report ongoing work disability. Unfortunately, this group accounts for the majority of costs, and treatments are not as effective as for subacute or acute patients.
Summary
A report of findings that is patient-centered involves giving promising advice about how to return an individual to his or her chosen activities. Most patients prone to chronicity have significant fears and worries about their future capabilities. Such patients' concerns should be identified early on and addressed through reassuring reactivation advice. Ironically, treatments that create physician dependency and do not promote self-management skills undermine this goal.
References
Craig Liebenson, DC
Los Angeles, California
cldc@flash.net
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
