CORR Insights®: People Have Mixed Reactions to Both Physiological and Psychological Explanations of Disproportionate Pain

Where Are We Now?

According to Cartesian dualism, our physical and mental worlds (our bodies and minds) exist as separate entities. Pain signals a damaged or diseased body part. But pain that exists in the absence of identifiable damage or disease, or pain that persists beyond the expected resolution timeline, is perceived by some as being indicative of a “faulty mind.” This dualistic paradigm has persisted in mainstream medicine for around 400 years and remains pervasive today among the general population, patient population, and clinicians [5]. The diagnosis of underlying damage or disease that can explain the pain experience is widely perceived as necessary to legitimize suffering as worthy of support from others (family, clinicians, workplaces, and welfare agencies) and to enter the linear diagnosis-treatment-cure pathway [4].

However, this dualistic paradigm can give rise to tensions, as Gonzalez and colleagues [6] eloquently illustrate in the latest issue of Clinical Orthopaedics and Related Research®. In their study, the authors present people experiencing persistent musculoskeletal pain with either a physiological explanation or a psychological explanation for their persistent pain and use qualitative research to understand how participants experience these explanations. The findings suggest that a physiological explanation fails to acknowledge the psychosocial impact of pain, which can be distressing for some people, while a psychological explanation can leave people feeling stigmatized as being “weak” and without a clear plan of action. These findings affirm some contemporary research in the area of pain, which is moving away from a simplistic model of dualism towards a biopsychosocial framework [7].

A biopsychosocial framework recognizes that the pain experience is influenced by more than just damaged or diseased body parts; it also is influenced by an individuals’ unique psychosocial context [7]. Importantly, this influence can be bidirectional—psychosocial factors can both cause persistent pain and result from persistent pain [1]. For example, the belief that pain is a sign of damage occurring to the body can (logically) lead people to avoid activities associated with the threat of pain for fear of causing further damage. Avoidance behaviors commonly include guarding and bracing to protect what people perceive to be “damaged” body parts, which can themselves be a source of nociception. Avoidance behaviors also include withdrawal from physical, social, or work activities. These can lead to physical deconditioning, poor general health, lack of sleep, anxiety, and distress—all of which serve to heighten the experience of pain. A heightened pain experience, in turn, reinforces fear and avoidance behavior in an ongoing vicious cycle [12].

People need an explanation for their pain to make decisions about it [8]. Rather than a physiological explanation or psychological explanation for persistent pain, contemporary pain physicians and surgeons can draw on biopsychosocial understandings to help people make sense of their unique pain experience.

Where Do We Need To Go?

We need to move beyond understanding pain based on a dualistic paradigm. The majority of patients seeking care for persistent musculoskeletal pain expect to be diagnosed with an underlying tissue problem that will be investigated, treated, and fixed. As Gonzalez and colleagues [6] point out, clinicians may fear that challenging these expectations will affect the patient-clinician relationship. However, as described above, leaving these expectations unchallenged can give rise to feelings of invalidation, fear and distress among patients if the pain experience does not follow the expected diagnosis-treatment-cure pathway within the expected timeline. We need to equip clinicians with the knowledge and skills they need to provide people with a biopsychosocial understanding of their pain experience that gives rise to helpful beliefs and coping responses.

As clinicians, we need to be aware of our existing biases that can reinforce misunderstandings among patients. For example, the inappropriate use of imaging for persistent musculoskeletal pain can be driven by clinicians’ fear of missing pathology, a desire to meet patient expectations, or to reassure patients that their conditions are not serious [9]. But imaging increases the risk that normal variants or age-appropriate findings (like rotator cuff tendinosis or degenerative meniscal tears) will be misinterpreted, causing patients to experience emotional distress and undergo more testing and invasive procedures [13], which may result in iatrogenic harm.

Existing biases can also be reflected in the language clinicians use. These biases have been covered in previous columns on clinicians discourse regarding musculoskeletal pain [2, 10]. For example, the dominant impairment discourse (which likens the body to a machine that breaks down or ‘wears out’ over time) may inadvertently perpetuate fear, avoidance behavior, and reliance on clinicians to fix the broken body. Alternatively, the use of participatory discourse (which frames participation as the ultimate health outcome) shifts the focus toward what people can do to gain control over pain.

Musculoskeletal pain is common, and most people either have it or will develop it, so it’s widely covered in the media. This means that people will have formed specific beliefs about musculoskeletal pain that will influence how they respond, should they encounter a symptom in the future [5]. By educating the public, we may reduce stigmatization of the pain experience by raising awareness of its psychosocial impact. Additionally, a heightened understanding of pain may help prevent the onset of a patient’s persistent pain and disability. By recognizing certain risk factors like fear avoidance behavior early in the process, clinicians may change their patients’ expectations related to diagnosis and care.

How Do We Get There?

Clinicians may benefit from an understanding of health belief theory, such as the Common-Sense Model, when communicating with people about persistent pain. The Common-Sense Model [8] describes how people draw on a set of pre-existing beliefs to form a cognitive representation of a health symptom like pain. This representation is comprised of: (1) Identity beliefs (the label given to the symptom), (2) Cause beliefs (what caused the symptom), (3) Consequence beliefs (the consequences of the symptom), (4) Control beliefs (how much control one has over the symptom), and (5) Timeline beliefs (how long the symptom will last). The way people represent their symptom will influence what they do about it (problem-based coping) and their emotional responses (emotion-directed coping).

By adopting a Common-Sense Model approach to musculoskeletal pain [3, 8], clinicians can: (1) consider their own beliefs about the identity, causes, consequences, controllability, and timeline of musculoskeletal pain and how these biases impact on their decisions about care, (2) explore how patients make sense of their pain by encouraging them to describe their condition along these five key belief dimensions while listening for any gaps, confusions or misconceptions in the representation that need to be addressed, and (3) offer patients a diagnostic explanation that addresses each of the five belief dimensions (Table 1). This should include an explanation of the modifiable factors within an individual’s unique context that contribute to the pain experience and be combined with effective strategies to gain control over pain and its impact. Clinicians can facilitate a conversation with their patients by adopting participatory language [2] that focuses on what people can do to live active engaged lives with musculoskeletal pain rather than what they can’t do because of musculoskeletal pain.

Table 1.

A Common-Sense Model approach to communicating about musculoskeletal pain

Belief domain	Example question(s)	Example of diagnostic explanation
Identity	Have you received imaging/a diagnosis for your pain, and if so, what does this mean to you?	Changes on imaging scans are common among pain-free people. This means that other factors also play a role in the pain you are experiencing.
Cause	What do you think is the cause of your pain?	You may have the ability to control some of the things that are causing your pain. For example, you may wish to modify how or how much you move, you can work on strengthening or increasing flexibility, or getting more sleep.
Consequences	What do you think your pain is telling you? What do you do when you feel the symptoms?	It is really common for people experiencing pain to avoid certain activities. But being active is important because it can improve your strength, flexibility, sleep, and mood—all of which may help improve your pain. And most importantly, being active is safe.
Controllability	How much control do you feel you have over your pain? What do you think it will take to get control over your pain?	By building your confidence to move, you can gain control over your pain and the impact it has on your life.
Timeline	How long do you expect your pain will last? How do you see yourself in the future?	Let’s work together on a plan to address the factors that are within your control so you can keep doing the things you enjoy into the future.

Finally, future public health initiatives could potentially change the way musculoskeletal pain is understood in the broader community. Mass-media campaigns, for example, have effectively improved beliefs about low back pain among the general public in Australian, Canadian, Norwegian and Scottish settings [11]. Future campaigns should be underpinned by a contemporary biopsychosocial understanding of pain. They can adopt a Common-Sense Model approach to target public myths about the identity, cause, consequences, controllability, and timeline of musculoskeletal pain. Such campaigns should be codesigned with consumers to ensure they are credible, accessible, and meet community needs and preferences.