CORR Insights®: Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series

Where Are We Now?

A science-based International Association for the Study of Pain commentary highlights the benefits of physical activity for combatting pain: “Large population studies show that individuals who are more physically active have a lower risk for development of chronic pain. It is also well recognized that exercise is an effective clinical treatment to reduce pain and improve function in a variety of pain conditions. On the other hand, a sedentary lifestyle enhances the risk for development of chronic pain” [11].

The value of physical activity for combatting pain reveals the importance of the “pain self-efficacy” concept that is the focus of the study by Schultz et al. [15] published in this issue of Clinical Orthopaedics and Related Research®. The authors define pain self-efficacy as, “the belief in one’s ability to carry out desired activities in the presence of pain.”

The findings of others have demonstrated that this concept has value. Weak pain self-efficacy was more predictive of pain becoming chronic than 16 other psychological or social variables that had previously been found to be predictive [9]. Weak pain self-efficacy was predictive of low levels of physical exercise, while pain itself was not [10]. Weak pain self-efficacy predicts long-term disability and is a better predictor than pain intensity or duration (which were not found to be reliably predictive) [6]. Weak presurgery pain self-efficacy predicted poor postsurgery functioning [17].

Like the authors of many previous projects, Schultz et al. [15] studied questionnaire data of relevance to pain self-efficacy rather than directly studying the extent to which participants engage in physical activity. Such questionnaire data are obviously an indirect attempt to determine the extent to which activity is maintained in spite of pain, while actual activity would be the direct source of health benefits [11]. The Pain Self-Efficacy Questionnaire that was used in the study by Schultz et al. has been extensively scientifically validated [14]. Results from that questionnaire that indicate weak pain self-efficacy have been found to be predictive of disability, dysfunctional coping strategies, noncompliance with healthcare, elevated demonstration of pain behaviors, compromised work status, elevated consumption of medication, elevated disruption of normal activity as reported by patients’ significant others, and poor treatment outcomes [14]. Given such validation, there is reason to hope that questionnaire data can truly reflect actual physical activity, and consequently, the extent to which a patient will obtain the health benefits of activity [12].

In light of this hope, projects such as that by Schultz et al. [15] utilize questionnaire data as an outcome measure (instead of directly assessing physical activity) when testing the effect of some intervention. The results from such projects have generally been less than convincing [13]. A 2020 systematic review of 60 randomized controlled trials produced conclusions that none of the strategies were reliably followed by improvement in pain self-efficacy that lasted longer than 12 months [13]. Similar to the projects listed in that review, the Schultz et al. [15] intervention failed to reliably change questionnaire results.

Where Do We Need To Go?

Based on these discoveries, surgeons should consider going beyond discussing questionnaire responses with patients. They should consider emphasizing to patients the value of maintaining or resuming a normal level of physical activity in spite of pain, emphasizing the self-defeating nature of withdrawing from physical activity, and setting and monitoring tangible activity goals as part of the treatment plan.

Most importantly, we need more work that focuses on strategies for ensuring that patients actually engage in physical activity in spite of pain [8]. This would be a more direct application of the knowledge that has been gained from research on pain self-efficacy (more direct than reliance on questionnaire data could be).

Future projects that rely on questionnaire data should consider including validity checks. Items from the Pain Self-Efficacy Questionnaire [14] are offered as examples of how data can be compromised by invalid responding: Individuals who are seeking pain medication for recreation or diversion might falsely claim that they cannot cope without such medication, individuals who are seeking disability compensation might falsely claim that they cannot work, and those who do not want to be perceived as weak might falsely claim that their pain does not compromise their engagement in hobbies.

How Do We Get There?

An example of a more direct approach, which can be emulated, is provided by projects that have focused on one of the many concepts that have been labeled “complex regional pain syndrome.” A focus on that concept is especially informative because inactivity is not only a risk factor for pain in such cases but also for observable physical changes [3, 7].

An example of strategies for such cases [8] calls for all involved parties (patient, clinicians, and family) to ignore the pain in favor of an emphasis on the patient engaging in normal activities. Physical therapists provide training for patients with regard to that emphasis, and family members are recruited to encourage such activity pervasively. Consequently, this is a much more direct strategy (much more direct than questionnaire data could be).

Generally successful outcomes have been documented [2, 5, 7, 8, 16] even when participants were limited to cases in which the presentation of complex regional pain syndrome had persisted for at least 9 months (with a mean of 55 months), with participants averaging more than three previous failed treatment plans [7, 8]. Researchers reported that “even patients who were considering amputation improved markedly” [7].

To encourage the creation of more healthcare programs and scientific projects that focus directly on maintaining and enhancing physical activity, efforts should be directed toward educating researchers, clinicians, and the general population about the value of activity as a response to pain. CORR® is contributing to such efforts by requesting this commentary. All publishers of scientific and healthcare information about pain should similarly find ways to emphasize the value of physical activity.

Clinicians probably will be the primary source of relevant information for patients. The importance of such education being provided for clinicians, so it can be passed on to patients, is highlighted by the benefit that was demonstrated when physical therapists were focused on helping patients ignore pain and engage in normal physical activity [8] versus the harmful effects that have been identified for physical therapy that lacks such focus [4].

Future projects that use pain self-efficacy questionnaires as an outcome measure should focus on designing interventions that have a stronger connection to actual activity. Such projects should also enhance the meaningfulness of their data by utilizing validity checks and excluding cases that involve invalid responding. The Minnesota Multiphasic Personality Inventory provides a model of methodology for identifying invalid responding [1].

Read This Next

• This study highlights the harmful effects of inactivity, the value of activity, and the iatrogenic nature of healthcare for chronic pain that fails to emphasize activity [8].

• In this guide, Ben-Porath and Sellbom [1] provide a model for designing questionnaires in a manner that includes validity checks so that cases that involve invalid responding can be identified and excluded from scientific research.