CORR Insights®: Do Unhelpful Thoughts or Confidence in Problem Solving Have Stronger Associations with Musculoskeletal Illness?

Where Are We Now?

Over the past decade we have accumulated a large body of research evidence showing that psychosocial factors (cognitions, behaviors, emotions, and social contexts) play a pivotal role in how people experience orthopaedic injury or illness, including their self-reported levels of pain, disability, and satisfaction with medical care [1]. In light of this, orthopaedic surgeons, psychologists, physical therapists, and social workers are forming interdisciplinary collaborations [5] to determine the best ways to convert this evidence into actionable strategies to support the development and implementation of comprehensive, biopsychosocial models of care in orthopaedic settings [4]. Identifying the level and type of psychosocial support each patient needs to optimize their own recovery or adjustment to orthopaedic illness is no small feat; it requires careful assessment, which can be challenging to implement within the current framework and culture of orthopaedic practices. Many psychosocial measures exist, and several have already shown associations with pain and disability among patients with orthopaedic injury or illness.

Rossano and colleagues conducted an interesting cross-sectional study [3] published in this month’s Clinical Orthopaedics and Related Research®. The team aimed to determine whether two measures assessing confidence in problem solving ability and past and current ability to achieve goals provide meaningful information about an individual’s level of capability (physical function) and pain over well-established measures of cognitive and emotional factors (like worst-case and negative pain thoughts and symptoms of depression and anxiety, respectively). The authors [3] found that negative thoughts about pain have the strongest associations with pain intensity and capability. They concluded that negative thoughts are most important for identifying individuals who need additional support. They also suggested that negative thoughts are the most efficient opportunities for targeted reorientation to promote recovery or adaptation. The authors argue that orthopaedic surgeons should focus on measuring and addressing unhelpful thoughts rather than optimism, self-efficacy, problem solving, or resiliency about pain. They recommend that future work focus on developing brief questions that capture unhelpful thinking without burdening patients and then prioritize communication strategies, relationship building, and motivational interviews to help patients reframe these unhelpful cognitions.

Where Do We Need To Go?

As a psychologist working with orthopaedic surgeons for almost two decades, I appreciate the need for quick and efficient ways to screen and address psychosocial factors within orthopaedic practices. Qualitative work with orthopaedic surgeons clearly shows that orthopaedic culture values efficiency [4], and current payment models reinforce this mindset [2]. At the same time, if psychosocial factors explain more variance in pain and disability than physical factors, wouldn’t it be important to prioritize addressing them with the same, or dare I say, more attention than physical factors? Is the goal of efficiency actually limiting our opportunity to fully support our orthopaedic patients? Is the physical exam (often painful) required as part of the orthopaedic visit less burdensome than completing a set of psychosocial measures? Why are we surprised that it is challenging to engage patients with musculoskeletal injuries with psychosocial care when orthopaedists generally brush off psychosocial factors and overfocus on the physical ones?

Psychosocial factors are complex, and orthopaedic surgeons should not reduce them only to unhelpful thoughts. Reframing one’s thoughts about pain is also not something that is appropriate for all our patients, particularly those who have complex socioeconomic situations who need a higher level of support to sort through those challenges, or those who carry a mistrust of medical systems. Within the larger field of chronic pain, it is well established that positive psychology, acceptance, commitment, and mindfulness-based interventions are just as effective as more traditional cognitive behavioral therapies, and different individuals benefit from different approaches A one-size-fits-all approach to individuals’ complex and unique responses to orthopaedic illness is limiting. Most patients with arthritis with whom I have worked benefitted more from skills and conversations around aging and mortality than reframing their negative pain thoughts. And in my experience, patients whose jobs cause them to have to depend on their bodies to make a living or support their families are unlikely to respond to reassurance that pain does not mean damage in a similar way to someone with more resources.

I believe that improving quality of care for patients with musculoskeletal injury or illness requires a shift in the culture of orthopaedic practices from efficiency and productivity toward a true value-based healthcare [2] model with strong emphasis on comprehensive assessment and interdisciplinary collaboration.

How Do We Get There?

Change is difficult for patients and for providers alike. We need to acknowledge and balance the initial challenges with the long-term opportunities that change brings about. Comprehensive care models, in which psychosocial and physical factors are treated with equal attention, exist for other medical illnesses and can act as blueprints for both orthopaedic practices and payors. Within cancer centers, for example, a patient receives assessment of psychosocial needs and tailored psychosocial skills interventions alongside the medical evaluation, diagnoses, and treatment. A similar model can be built in orthopaedic practices, and expectations can be set at the get go for both patients and orthopaedic providers. Patients can be educated on why and how psychosocial questionnaires can inform and improve medical care, and orthopaedic surgeons and psychologists can work together to determine best approaches to care consistent with the type of patient and individual needs and circumstances. Some patients may respond to education and thought reframing skills that a surgeon can demonstrate during the medical visit. Others may require support around managing aging, difficult life circumstances, and serious mental health concerns through various levels of care and therapy orientations. Success will depend on buy-in from the chiefs of orthopaedic practices alongside openness to true interdisciplinary collaboration and relationship building strategies among providers and patients [4]. The musculoskeletal injury that brings a patient into one’s practice can become an opportunity and catalyst to learning skills with benefits that extend to the entire lifespans of our patients, and potentially their families and society as a whole.