People Have Mixed Reactions to Both Physiological and Psychological Explanations of Disproportionate Pain

Abstract

Background

There are two general frameworks that conceptualize pain that is more intense or persistent than expected based on measurable pathologic findings: the psychological (unhelpful thoughts and emotions) and the physiological (purported nervous system dysfunction, such as central sensitization). Some clinicians believe people will be more receptive to a physiological conceptualization. Prior quantitative research demonstrated that carefully crafted psychological explanations are rated similarly to crafted physiological explanations, with relatively mixed reactions. This qualitative study was undertaken in parallel with that quantitative study to help develop effective communication and treatment strategies by identifying specific thoughts and feelings (themes) regarding the physiological and psychological conceptualizations of disproportionate pain that make people more or less comfortable considering comprehensive, biopsychosocial treatment approaches.

Question/purpose

What themes arise in patient thoughts and feelings regarding physiological and psychological conceptualizations of pain that is more intense or persistent than expected?

Methods

We sought to understand the experience of considering pain as a biopsychosocial experience (phenomenology approach) by studying the thoughts and feelings that arise as people seeking care for arm and back pain engage with physiological and psychological conceptualizations of pain that is more intense or persistent than one would expect based on the pathology. We recruited 29 patients presenting for upper extremity or back pain specialty care at one of two urban offices, intentionally recruiting people of various ages, genders, backgrounds, socioeconomic status, as well as type and duration of pain (purposive sampling). The 29 patients included 18 women and 11 men (16 married, 15 non-White, 20 with arm pain) with a median (interquartile range) age of 62 years (42 to 67). The interviews were conducted by a trained woman orthopaedic surgeon interviewer using a semistructured interview guide soliciting participants’ thoughts and feelings about a physiological explanation (nerves in the central nervous system stuck in the on position can make pain more intense) and a psychological explanation (unhelpful thoughts and feelings of distress can make pain more intense) for pain more intense or persistent than expected. The interviews were transcribed and themes were identified as the data were collected. Based on current experimental evidence, including what is known about the physiological effects of thoughts, feelings, and context (placebo/nocebo effects), we assumed an underlying physiological basis for pain that is variably experienced and expressed (mixed postpositive/interpretive approach). Themes were identified in the interview transcripts systematically by two coders and then discussed with the entire research team to arrive at consensus. We stopped enrolling patients when the authors agreed that additional themes did not arise in five consecutive interviews.

Results

The following themes and interpretations were derived from the analysis: Neither the physiological nor the psychological explanation for disproportionate pain (1) avoided the stigma associated with mental health, (2) was consistently understood, (3) provided a consistent sense of control, (4) consistently provided hope, and (5) represented the stress and emotion of disproportionate or persistent pain. The physiological explanation also generated mixed reactions regarding whether or not it: (1) was a useful point of conversation, (2) was reassuring or frightening, and (3) supported physiological or psychological treatments. The psychological explanation made some people feel worse.

Conclusion

People have mixed reactions to both physiological and psychological explanations of disproportionate pain. As such, without direction on content, communication might be most effective by focusing on relational aspects, such as emotional connection and trust.

Clinical Relevance

Although there is room to improve the content of strategies for explaining more pain than expected to patients, our findings extend the discoveries of others in highlighting the need for tailored relational communication strategies that prioritize feeling heard, validated, and accompanied.

Introduction

Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [17]. For a given degree or type of actual or potential tissue damage, there is notable variation in the intensity and duration of pain. There is substantial evidence that variation in pain intensity is mostly associated with mental and social health [10], much more so than variations in objectively measurable pathologic findings [12]. The factor that is most strongly and consistently associated with variation in pain intensity is unhelpful thoughts (misinterpretation of symptoms and cognitive errors), commonly measured as negative pain thoughts, catastrophic thinking, or kinesiophobia [6, 8]. There is evidence that these common unhelpful thoughts are reinforced by stress (insecurity of role or support) and distress (symptoms of worry and despair) [8].

Another theory, commonly referred to as central sensitization, posits that the neuropathology of the central nervous system (in which neurons are caught in an overexcited state) can increase the intensity of pain for a given nociception [22]. This theory converges with the theory that accounts for variation in pain intensity based on variation in unhelpful thoughts and feelings, to the extent that reorientation of misinterpretations and alleviation of distress are believed to alleviate the proposed neuropathology [3, 4, 13]. Some proponents of the concept of central sensitization envision future biomedical treatments that can alter neuropathology [22], but many advocates see this as a safe way to interest people in treatments in the biopsychosocial realm, such as cognitive behavioral therapy and its variants [1].

Patients are not always open to considering unhelpful thoughts and emotions as opportunities for improved health, even when effective treatments are readily available. Specialist clinicians might therefore avoid a discussion of well-recognized mental health opportunities because they are concerned that attempts to address unhelpful thoughts and emotions might be offensive and consequently harm the patient-clinician relationship. There is agreement that to improve the health of people with illnesses characterized by more pain than expected for a given pathologic condition or nociception, we need more effective communication strategies to increase the appeal of comprehensive treatment approaches. A prior quantitative study presented people seeking musculoskeletal specialty care with several crafted explanations of the physiological and psychological explanations of more pain than expected for a given pathophysiology and found that the best psychological explanations were rated similarly to the best physiological explanations, and both generated mixed reactions [9]. This qualitative study was undertaken in parallel with that quantitative study to identify specific thoughts and feelings (themes) regarding the physiological and psychological conceptualizations associated with more or less comfort considering more comprehensive, biopsychosocial treatment approach. A more thorough and detailed understanding of more helpful and less helpful communication strategies has the potential to facilitate integration of mental health care into musculoskeletal care.

We therefore asked: What themes arise in patient thoughts and feelings regarding physiological and psychological explanations of pain that is more intense or persistent than expected?

Patients and Methods

Qualitative Approach and Research Paradigm

We sought to understand the experience of considering pain as a biopsychosocial experience (phenomenology approach) by studying the thoughts and feelings (themes) that arise as people seeking care for arm and back pain engage with physiological and psychological explanations of pain that is more intense or persistent than one would expect based on the pathology. Based on current experimental evidence, including what is known about the physiological effects of thoughts, feelings, and context (placebo/nocebo effects) [5, 7, 11], we assumed an underlying physiological basis for pain that is variably experienced and expressed (mixed postpositive/interpretive approach).

Researcher Characteristics and Reflexivity

The research team consists of two orthopaedic surgeons—one of whom favors the psychological conceptualization of disproportionate pain (DR), and the other a neutral visiting researcher who is a physiological medicine and rehabilitation physician who favors the physiological conceptualization (MQ)—and two neutral medical student researchers (SR, DD). The interviews were performed by the neutral orthopaedic surgeon doing research fellowship (no clinical duties) who was trained in qualitative research techniques and interviewing by a qualitative research expert in our institution. The draft coding was done by the two medical students, who were overseen and finalized by the practicing orthopaedic surgeon and physiological medicine and rehabilitation physician with differing favored conceptualizations.

Context

People seeking musculoskeletal care for arm or low back pain were recruited from the practices of two authors (DR, MQ) in one office and another nonauthor, spine surgeon colleague in a separate office in a large urban area. A physician assistant, nurse practitioner, or a chiropractor were often the primary or only clinician to see the patient. The study was described to some patients before their visit with the clinician and some after. All interviews occurred after the visit with the clinician.

Sampling Strategy

Adult English-speaking patients with no cognitive impairments who presented for upper extremity or back pain specialty care at one of two urban offices were considered. We enrolled on days when the interviewer was available and there was adequate space in the office to use rooms for the interviews. We made an effort to enroll people of various ages, genders, backgrounds, symptom duration, and socioeconomic status (purposive sampling). Among the 29 patients included were 18 women and 11 men (16 married, 15 non-White, 20 with arm pain) with a median (interquartile range) age of 62 years (42 to 67 years). We identified themes as the data were collected. We stopped enrolling patients when five consecutive interviews resulted in no new themes.

Ethical Issues Pertaining to Human Subjects

The protocol was approved by our institutional review board. The Consolidated Criteria for Reporting Qualitative Research standards [19] and the Standard for Reporting Qualitative Research were followed [14]. Agreement to participate in the interview after a verbal and written description of the study represented informed consent. There was no compensation.

Data Collection Methods

All interviews were semistructured (Appendix 1; http://links.lww.com/CORR/A747), conducted in the patient’s clinic room after their visit, and administered by a woman orthopaedic surgeon (AG) doing a research fellowship, trained in qualitative interviewing by an experienced qualitative researcher. Interviews were conducted between April 2019 and July 2019. Patients completed a REDCap (Vanderbilt University) survey on a tablet to record demographics including age, gender, ethnicity, highest education level, income, insurance status, marital status, employment, and musculoskeletal region involved. We achieved good diversity in all of these parameters (Table 1).

Table 1.

Characteristics of the patients interviewed

Variable	Value (n = 29)
Age, years	62 (43-67)
PSEQ-2	9 (6-12)
Pain intensity	5 (4-8)
% Women	62 (18)
% Married or dating	55 (16)
% Employed	55 (16)
% White	52 (15)
Insurance type
Medicare	0 (0)
Medicaid	21 (6)
Private	28 (8)
Uninsured	3 (1)
Workers compensation	3 (1)
Other	45 (13)
Education level
No high school diploma	7 (2)
High school diploma	28 (8)
Some college	21 (6)
Bachelor’s degree	14 (4)
Graduate or professional degree	31 (9)
Musculoskeletal region involved
Hand, wrist, or elbow	52 (15)
Shoulder	17 (5)
Back	28 (8)

Data presented as median (interquartile range) or % (n); PSEQ-2 = 2 question version of the Pain Self-Efficacy Questionnaire. Score range from 0 to 12 with high scores representing greater accommodation of pain; pain intensity was rated on an 11-point ordinal scale between 0, no pain, and 10, the worst possible pain.

Data Processing

Interviews were digitally audio recorded on a recorder not connected to the internet. The interviewer completed a debrief summary after the qualitative interview, during which the quality of the data was assessed, emerging themes were discerned, and modifications to the interview strategy were considered. Interviews were transcribed by one of the medical student researchers (DD) and coded after approximately each five interviews and audio recordings were deleted. All files were stored with an identification number only on secure, encrypted, password protected servers.

Data Analysis

The interview transcripts were analyzed using the phenomenological, mixed postpositive/interpretive approach described above. Two coders (SR, DR) coded each transcript and discussed discrepancies until a consensus was reached. Themes corresponded quite easily with subject descriptions. We grouped subthemes based on perceived relationships to an overarching theme, but also in an attempt to capture nuances specific to the physiological and psychological explanations. Themes were imported to an Excel (Microsoft) file for organization.

Techniques to Enhance Trustworthiness

To enhance trustworthiness and credibility of data analysis, we started with initial theme identification and organization by a neutral medical student (SR), followed by oversight from the author who favors the psychological framework (DR), then reviewed and revised by the author who favors the physiological framework (MQ) with ongoing discussion until we reached consensus. As a final step, a communication scholar colleague (acknowledged, not an author) with experience in qualitative research further revised the language and the themes with final discussion and consensus by the entire research team.

Results

Neither the Physiological nor the Psychological Explanation Avoids the Stigma Associated with Mental Health

Some clinicians hope that using physiological explanations and conceptualizations will avoid the stigma associated with mental health, but both physiological and psychological conceptualizations encountered this difficulty (Table 2). In reaction to the physiological conceptualization one person said “… but it’s all in your head, essentially what that says” (Participant 18, man, 71 years). And in reaction to the psychological conceptualization, the same person said: “There’s no acknowledgement that the patient’s actually feeling physical pain” (Participant 18, man, 71 years). The physiological concept was sometimes interpreted as “… you’re overreacting” (Participant 14, woman, 66 years) and the psychological concept as “… it puts into question my ability to cope …” (Participant 17, woman 55 years). Both concepts felt dismissive and uncaring to some people: “… it’s almost like the doctor is saying, ‘not my problem’” (Participant 18, man, 71 years) for the physiological explanation and “I would feel they are just pushing me out the door” (Participant 9, woman, 65 years) for the psychological explanation. Both concepts made some people feel blamed for their problem: “I’m bringing the pain more to myself and getting excited about it” (Participant 12, woman, 66 years) for the physiological explanation and “… saying you are making it worse by the way you’re acting” (Participant 14, woman, 66 years) for the psychological explanation.

Table 2.

Neither the physiological nor the psychological explanation of disproportionate pain avoids the stigma associated with mental health

Subtheme	Patient	Physiological explanation	Patient	Psychological explanation
Offensive: Sounds like “the pain is not real”	9	“It’s in my head, that I’m really not, that I’m not suffering from the pain I came here for.”	28	“Well, I might feel like they were telling me I was crazy, like the pain is in your mind.”
	18	“... good to know that it's not degenerative or caused by some injury ... but it's all in your head, essentially what that says.”	18	“There’s no acknowledgement that the patient is actually feeling physical pain.”
Stigma: Implies that the individual is weak, broken, or responsible for the pain	14	“By saying you’re overreacting? By saying the brain and then you’re overreacting? Oh no. I don’t like either one of them, to be honest.”	10	“If I heard that, my thought would be [it’s as if they think] I have a mental illness”
			2	“I don’t let emotion bring me pain and you know I may get anxious or get anxieties but that doesn't bring me pain.”
			17	“I think the interpretation ... it puts into question my ability to cope … that I can’t handle things.”
Feeling blamed	12	“I'm bringing on the pain more to myself and getting excited about it.”	8	“If somebody tells me my mind is a storyteller [it seems as though they are telling me that] I am making a big thing out of [nothing], and [I am responsible for] my pain. That’s how I feel.”
			10	“The [mind as a storyteller explanation] to me is judgmental, this [central sensitization explanation] just seems specific, to the point, open and that’s what I prefer out of a medical professional.”
			14	“… saying you are making it worse by the way you’re acting. That just makes my blood pressure boil.”
Dismissive, uncaring, or confrontational	18	“... that this is all the doctor said, this is fairly cold. I would expect … the doctor [to have] some empathy for the patient and is mostly concerned with the patient's welfare.”	9	“... I would be a bit argumentative with that because ... I would feel they are just pushing me out the door. Instead of actually examining me and giving me an explanation based on what I have shared with them.”
	18	“I mean, it’s almost like the doctor is saying, ‘not my problem.’”	15	“I think it’s dismissive because it tells you that … I think, especially if you are a woman, it tells you that it may be all in your mind in a way and so it is dismissive.”
			24	“I don’t think you have the right to tell me how I should feel emotionally about my pain because I am the one living with it every single day.”

Neither the Physiological nor the Psychological Explanation Are Consistently Understood

Neither the single-paragraph physiological nor psychological explanations were consistently understood (Table 3). The physiological explanation can seem concrete and tangible (“… you can draw nerves …” [Participant 27, woman, 67 years] or “… [the nerve is] stuck in the on position …” [Participant 8, man, 71 years]), but it can also represent jargon (special words used by one group that are difficult for others to understand; “… you [are] talking in, like, a doctor language” [Participant 25, woman, 35 years]).

Table 3.

Neither the physiological nor the psychological explanation are consistently easily understood

Subtheme	Patient	Physiological explanation	Patient	Psychological explanation
Understandable, resonates, or believable	27	“People can visualize nerves. You can draw a brain, you can draw nerves, you can draw [signaling] stuck on. You can talk about pain signaling, I think, better with this than you can with [the mind-body explanation].”	18	“[It] seemed to acknowledge that there is real pain and that it might be aggravated by the stories we tell ourselves … It’s a more human approach than the more biological approach of that other way.”
	8	“They are stuck in the on position. They are exciting and signaling the brain and goes down through the body. You explain it very well.”	25	“I think your mind can make your physical pain worse just because [you are] emotionally upset. [What I am saying is that] emotional pain equates to more physical pain.”
Hard to understand	12	“In the first place, I didn’t know the brain had nerves, so how would I even think about it?”	7	“At the first visit, I didn't know what was going on and trying to figure it out … but now after he explained it a little more to me, I understand it a little more.”
	25	“It’s difficult because you [are] talking in, like, a doctor language.”
Resonates: personal experience	2	“You know the response you have for hot and cold and for reactions ... and automatically I raise my hand and catch it and I didn't even look at. It’s my body’s response to some sense that I'm not even totally aware of.”	14	“I agree with it, you know, you get scared, you start thinking about it, and yes the pain gets worse. It does happen, it’s true!”
Resonates: experience with others	14	“I would believe that because of the fact that my mother-in-law has ... And what they have told us is that … the nerve comes here and it hits something.”	2	“She [my sister] lived with me for a year and a half ... She was dwelling in all these fighting thoughts and they made her emotional pain so much stronger.”
	15	“My wife had to see a doctor last week because her nerves are over reactive and cause more pain than what they should to the point that it becomes more chronic than acute.”	9	“I have a sister who had been sick for the last couple of months and she was actually making herself sick, so there is some truth to this last statement here.”
			15	“I said my wife’s stress level goes up and her pain levels goes up because of this.”

The psychological explanation is recognizable as part of the human experience (“… emotional pain equates to more physiological pain.” [Participant 25, woman, 35 years]), but people may be expecting pain to be entirely due to pathology (“... I didn’t know what was going on and trying to figure it out …” [Participant 7, woman, 62 years]), and the unexpectedness of the importance of thoughts, feelings, and circumstances may hinder comprehensive care, at least initially (“… but now … I understand it a little more.” [Participant 7, woman, 62 years]). Both explanations resonated with personal experience or experience with other people in their lives (Table 3).

Neither the Physiological nor the Psychological Explanation Provide a Consistent Sense of Control

The physiological explanation provided some participants a sense of control (“… I can explain it … and that is kind of reassuring” [Participant 17, woman, 55 years]) (Table 4) and felt to some as if it leads to a solution (“… there are a number of techniques that might be useful to work on this” [Participant 18, man, 71 years]) (Table 4). To others, the physiological explanation felt aimless (“… I want to know what’s wrong, and how I’m going to get better” [Participant 14, woman, 66 years]) (Table 4) and did not provide a sense of control (“… so how do you get rid of that pain?” [Participant 9, woman, 65 years]) (Table 4).

Table 4.

Neither the physiological nor the psychological explanation provide a consistent sense of control

Subtheme	Patient	Physiological explanation	Patient	Psychological explanation
Sense of control	24	“Well, because this is more of an explanation about how my body works that might impact the injury that I have as opposed to the first one, which is more about my emotional feelings and how that’s impacting it. Although part of that may be true, this is more of a, more something I can hold on to, tangibly.”	7	“I just need to clear my mind of a lot of stuff … so that I won't be stressed out and getting sick … I don’t know how I’m gonna do that, but I’ll try. I never thought about the mind having anything to do with pain… but I guess it does.”
	17	“If I do have more pain than usual or I have pain in spots where I didn’t usually have it, I can explain it with that, and that is kind of reassuring.”	11	“I feel better because this is a way of making the best medicine for myself …”
Lack of control	9	“The pain is always on, so how do you get rid of that pain?”	10	“The [mind-body explanation] is just saying well, it’s emotional pain that can come from something else and that’s not giving me anything.”
Leads to a solution	18	“There are a number of techniques that might be useful to work on this.”	22	“[As you were saying] if your mind is full and you talk to a doctor, you open your heart and [say] everything you want to say, this [will] help you to feel better [rather than to] keep everything in your mind, [which], is not good.”
			20	“I think it’s a good reminder to a lot of people that physical pain is not the only thing going on … I think a lot of people don't even realize that there is a stress and emotional component of the pain. … If you can calm the emotional, mental aspect of it and try to alleviate some of that stress maybe you can hope that you do not put your body in as much physical pain.”
Does not lead to a solution	14	“I know that everything goes to the brain with the nerves and all that but I want you to tell me why it’s doing it and how we are going to fix it. I want to know what's wrong and how am I going to get better.”	24	“I want to hear an explanation about what I can do to make it better.”
	28	“…well then what’s the solution to get it turned off, so that I don’t feel pain?”	10	“It feels very philosophical.”

For some participants, the psychological explanation also provided a sense of control (“I just need to clear my mind …” [Participant 7, woman, 62 years] and “… this is a way of making the best medicine for myself” [Participant 11, man, 62 years]) (Table 4) and leads to a solution (“… If you can calm the emotional, mental aspect … maybe you can hope that you do not put your body in as much physiological pain.” [Participant 20, woman, 38 years]) (Table 4). Others felt the psychological approach had a lack of control (“… that’s not giving me anything” [Participant 10, woman, 38 years] (Table 4) and offered no solution (“I want to hear an explanation of what I can do to make it better” [Participant 24, man, 62 years]) (Table 4).

Neither the Physiological nor the Psychological Explanation Consistently Provide Hope

Neither the physiological, nor the psychological explanation consistently provided hope (Table 5). For the physiological, some participants felt that “I would expect the kind of explanation that offered some kind of hope. This does not offer anything” (Participant 18, man, 71 years). And for the psychological, some felt that: “… that kind of makes it sound like the situation is never going to improve” (Participant 20, woman, 38 years).

Table 5.

Other negative themes common to both the physiological and psychological explanations

Subtheme	Patient	Physiological explanation	Patient	Psychological explanation
Lack of hope	12	“My pain is always gonna be there.”	20	“I don’t know if I [would] use despair, that kind of makes it sound like the situation is never going to improve. So maybe a little bit more optimistic terminology …”
	18	“... this is very curt ... I would expect the kind of explanation that offered some kind of hope, this does not offer anything.”
It does not represent the stress and emotion of having pain	14	“... I think they call it the suicide disease … because they say the pain is so bad you just want to die ... if that’s all they were gonna say about it, I would probably be very frustrated.”	17	“... that pain can actually affect the mood, and your energy level and you’re, you know, being anxious and so I do not believe that the mind is always the driving force here. It could be very well the opposite …”
Aligns with “despair comes after pain”	29	“… [with the central sensitization explanation] you’re just working on your nerves, and that will get you out of your despair.”

Neither the Physiological nor the Psychological Represent the Stress and Emotion of Disproportionate or Persistent Pain

Some people felt both the physiological explanation (“… the pain is so bad you just want to die ... if that’s all they were gonna say about it I would probably be very frustrated” [Participant 14, woman, 66 years]) and the psychological explanation (“… I do not believe that the mind is always the driving force here, it could be very well the opposite …” [Participant 17, woman 66 years]) did not acknowledge the stress and emotion of persistent pain (Table 5). One person felt the physiological explanation was more understanding: “… you’re working on your nerves, and that will get you out of your despair” (Participant 29, woman, 88 years).

Other Mixed Reactions People Have to the Physiological Explanation

There were a few areas of inconsistent reaction specific to the physiological explanation that suggest it does not appeal to everyone (Table 6). For instance, some people felt it was a conversation starter because it was specific (“It opens up more dialogue … because this one seems like it’s very specific” [Participant 10, man, 27 years]), whereas others felt it was empty due to its lack of specificity (“I would expect more of an explanation of what’s going on with my elbow …” and “… the diagnosis part of it is missing” [Both quotes, Participant 24, man, 60 years]). The physiological explanation was also both reassuring (“It’s good to know …” [Participant 18, man, 71 years]) and frightening (“It makes me feel really scared” [Participant 8, man, 71 years]). Finally, some people felt an aversion to how a physiological explanation seemed to lead to medication or surgery (“… we have to do surgery or something …” or “… I have to prescribe this, but … I don’t want medication” [Both quotes, Participant 12, woman, 61 years]), whereas others thought it made mental health care more appealing (“… I’d try to deal with it through therapy or counselling” [Participant 15, man, 62 years]).

Table 6.

Other mixed reactions people have to the physiological explanation

Subtheme	Patient	Reaction
Opens up dialogue (conversation starter)	10	“It opens up more dialogue ... because this one seems like it’s very specific.”
Seems unrelated to the problem	24	“I would expect more of an explanation about what’s going on with my elbow, what I am doing or not doing to make it better, and what the prognosis might be for recovery period.”
Not specific enough	24	“I mean this can be part of it, but the diagnosis part of it is missing.”
Reassuring	18	“It's good to know that the pain isn’t being caused by some physical injury that needs to heal.”
Frightening	8	“It makes me feel really scared. Well, they need somebody to help them, a professional, right away. Especially if it lasts for a while or a long time.”
Seems to lead to a medication or surgery	12	“… maybe I'll get them excited, and say we have to do surgery or something... that is kind of scary.”
	12	“... if you were to say well, I have to prescribe this, but … I don’t want medication.”
Makes mental healthcare more appealing	15	“If you received an explanation [central sensitization] ... then you would want to get the stress out of the way ... I’d try to deal with it through therapy or counseling.”

The Psychological Explanation Sometimes Makes a Person Feel Worse

We separated a theme that people sometimes felt worse when they heard the psychological explanation because one participant (Participant 29, woman, 88 years) said, “Well, I would, I’d say ‘well, gee, you made me feel worse.’” It could be argued that this can be grouped with lack of control, lack of hope, or inadequate representation of how demoralizing pain can be, but we felt it was worthwhile to separate this because we did not hear anything comparable for the physiological explanation. It seems like the physiological explanation can be frustrating, but that the psychological explanation, perhaps by encouraging people to examine the stress and distress they are experiencing, in addition to the other factors in common with the physiological explanation including social stigma, can make some people feel worse.

Discussion

Musculoskeletal specialists are increasingly aware of the potential benefits of addressing unhelpful thoughts and distress regarding symptoms, but they may resist discussing these issues with patients for fear of offending them. Some specialists advocate a physiological, physiological, biomedical explanation (such as “nerves stuck in the ‘on’ position”) in the hopes that this will be less likely to offend and more likely to help patients consider opportunities for improved mental health as good options for feeling better and being more capable. Other specialists find that many patients want to talk about their thoughts and feelings if it is done with compassion. Difficult discussions can be made easier through strategizing, training, and practice. Effective communication could help establish trust and get people interested in comprehensive treatment. One quantitative study found that crafted physiological explanations and crafted psychological explanations had similar, albeit mixed, patient appeal [9]. Our qualitative study was performed in parallel in the hopes that it might uncover important themes for improved communication strategies. We found that both physiological and psychological explanations encountered difficulties that by our interpretation seemed related to the social stigma associated with mental health as well as the cognitive, and to some degree cultural, biases that symptoms are due entirely to pathophysiology. Both explanations created mixed feelings. The combined quantitative and qualitative evidence suggests to us that effective clinician-patient communication regarding more pain than expected needs to address the relational aspects of communication (how you feel about the other person) and not focus solely on the content (the information being explicitly discussed) [2]. Specifically, techniques that demonstrate compassion and help build trust may take priority.

Limitations

The most important limitation of this work may be that we tested two specific written paragraphs about the physiological and psychological conceptualizations of disproportionate pain in simple terms. Other formats for conveying these theories (including a video or an interactive website) and other language or analogies might produce different themes. Our impression is that the themes would likely be the same with other modes of conveyance, although we might obtain different themes specific to the material presented. It is also possible that a more detailed physiological explanation may have been better received. The subjective aspects of qualitative research are important to bear in mind, including the influence of the biases of the interviewer and the people that identified and classified the themes. We feel that the balance of bias in the research team, and our academic curiosity, helped guard against favoring one type of explanation. And the themes arose from descriptive terms used by the participants that relatively unambiguous. People who are new to qualitative research might see 29 patients as an unscientifically small number and be concerned that important themes were missed. We reached theme saturation with 29 participants among a diverse population of patients seeking musculoskeletal specialty care for arm and back pain in a large urban city in the United States. Although it is possible that our findings apply best to these patients and this setting, we believe the concepts capture basic aspects of the human illness experience that are likely to be reproduced by others in other settings.

Discussion of Key Themes

The major themes identified and our interpretations and groupings suggest several specific opportunities that musculoskeletal specialists can use to practice more effectively. First off, the hope that a physiological explanation would avoid the stigma associated with mental health and potential offense was not fully realized. Although an explanation based on nerves landed with some people, many had the same aversive reaction as with an explanation that emphasized the importance of healthy thinking and alleviation of stress and distress. An analysis of 11 published systematic reviews (a metaethnography) of qualitative research conducted with people seeking care for persistent pain identified common themes, many of which reflect the psychosocial aspects of illness including loss of role, loss of identity, feeling like something is being missed, and difficulty giving up the search for a pathophysiological explanation [21]. Others reflect a feeling of othering and dehumanization such as the stigma associated with mental health, feeling blamed, and the need to be treated with dignity [21]. A physiological explanation gave some people an increased sense of personal credibility, whereas others still felt doubted and shamed. Similarly, a psychological explanation, which to some people felt compassionate and humanizing, others felt cast aside, othered, and blamed. We saw a separate theme of “does not represent the stress and emotion of disproportionate or persistent pain,” but one could argue that this is a key aspect of “needing to be treated with dignity” and folds in well here. The observation that themes identified in the metaethnography of “need for personal credibility” and “trying to keep up appearances” were inconsistently addressed with content that emphasized the physiological or content that emphasized the psychological, may suggest that content alone will be insufficient and that greater attention is needed regarding the relational aspects of communication. This seems to be in line with the closing sentence of the abstract of the metaethnography: “This knowledge demonstrates that treating a patient with a sense that they are worthy of care and hearing their story is not an adjunct to, but integral to health care.” [21].

Another finding that might help musculoskeletal specialists is that neither the physiological nor the psychological explanations were consistent in being understood, in providing a sense of control, and in increasing hope. This seems to indicate that neither the physiological nor the psychological explanation adequately address the following themes identified in the metaethnography of qualitative studies: “quest for the diagnostic ‘holy grail’,” “my life is impoverished and confined,” “struggling against my body to be me,” and “deciding to end the quest for the holy grail is not easy.” [21]. Again, it may be that we expect that a clear explanation of a compelling rationale will address these expressed needs by providing understanding, control, and hope, but what may be more important is making people feel worthy, heard, and cared for, and not insisting on a specific content or conceptualization. This might be conceptualized as “meeting people where they are” and “letting things develop over time.” It may not be the explanations themselves that are easy or difficult to understand, but rather how these explanations interact with the person’s inner narrative. The explanations either clash or resonate with that narrative and any psychological discordance may, at least initially, be expressed as difficulty understanding. It might be worthwhile to study how people understand the physiological and psychological conceptualizations of disproportionate pain over time, rather than at a single exposure point in time.

We did encounter a theme people may already associate with the psychological explanation “it made me feel worse,” but musculoskeletal specialists can also take note that some of the things we hope to accomplish with a physiological explanation generated mixed reactions. For instance, some people thought the physiological explanation was a useful point of discussion and others did not, suggesting that some people felt it represented treatment with dignity and easing the decision to end the diagnostic quest and others did not. And some people felt the physiological explanation was reassuring whereas others regarded it as frightening, which we interpret as either alleviating or reinforcing all of the themes identified in the metaethnography [21]. Finally, the hope that a physiological explanation might increase the appeal of psychological treatments was also inconsistent, suggesting that it may sometimes but not always be the approach that will help people with “giving up the diagnostic quest” and working on accommodation.

As we look to increase the relational content of our communication in musculoskeletal specialty care, we can be heartened by the finding that a video based on the findings of qualitative research regarding painful illness garnered positive comments in two important themes: (1) It has given voice to our suffering, and (2) it makes me feel that I am not alone [20]. This points to strategies that prioritize connecting over convincing; relation over content.

Another important strategy for musculoskeletal specialists comes from a study of how diagnostic imaging and its interpretation reinforced a misconception of damage in the context of age-related or idiopathic changes [15]. This left people feeling a lack of control and that the strategies being used were ineffective. Substituting the language of damage (such as the word “tear,” which is all too pervasive in musculoskeletal medicine) with language that normalizes the changes and reinforces effective accommodation can achieve the relational goals of helping people feel heard, legitimizing concerns, and demonstrating compassion. Although perhaps disappointing at first, over time, this normalization of imaging may decrease the disappointment that is often associated with an inaccurate frame of reference such as broken/needs to be fixed rather than aged/often can be accommodated [15].

Conclusion

This qualitative analysis of physiological and psychological explanations of more pain than expected for a given pathology, combined with a prior quantitative analysis [9], demonstrate that a physiological explanation may not eliminate negative reactions related to the social stigma associated with mental health. Similar to other qualitative research regarding pain [15, 16, 21], common themes emerged with respect to physiological as well as psychological explanations of pain regarding social stigma, legitimacy, being heard and understood, and having a sense of direction towards improved health. Although there is room to improve the content of strategies for explaining more pain than expected to patients, our findings extend the discoveries of others [15-18, 20-21] in highlighting the priority of tailored, relational communication strategies that prioritizes feeling heard, legitimized, and accompanied. For the clinician, giving a person in pain the impression that you listened and heard what they said may be more important than how pain is explained. If we prioritize making patients feel heard, we may improve our ability to treat them. Future studies might address the ability of effective relational communication to attenuate the offense often associated with explanations of disproportionate pain, whether that content emphasizes pain’s physiological or psychological aspects.