Have you ever feared uncertainty? Unpredictability? Difficulties? Of not being able to control your circumstances? The indefinite? What doesn't make sense? Have you even feared fear?
Has the anticipation of those feelings ever caused you to avoid circumstances that could potentially create them?
Welcome to the intersection of fear and pain. Especially chronic pain. An interminable, "will it ever go away", hopeless feeling often accompanies chronic pain. Which creates anxiety. And depression. And potentially surrender and sub-optimal behavior (for example, isolation). And fear. Which can make it all worse.
Those who were fearful due to “diagnostic uncertainty” ;
Those who “feared their pain symptoms were a sign of damage or impending damage” and experienced confusion as to how to fix the problem ;
Those who had consulted healthcare providers due to the loss of function their pain caused, but whose treatments had failed to restore full function.
“The overarching theme was a LBP [low back pain] experience that did not make sense. For all participants, the experience of LBP as unpredictable, uncontrollable and/or intense made it threatening to them." So, to summarize, something they could not control actually ended up controlling them - regardless of the cohort to which they belonged. That threat instilled fear. And that fear can “further feed the catastrophic appraisal of pain, avoidance activity, and disability.” Which can make it all worse.
Fear can be paralyzing. As President Franklin Delano Roosevelt said in his first inaugural address in 1933 ...
The only thing we have to fear is fear itself.
So, what's the solution?
In their words ... Clinicians should present an "acceptable, individualized, BioPsychoSocial understanding of [chronic non-specific low back pain] using unambiguous language." That should be matched by "linking pain-control strategies with functional goals."
In my words ... Empower the patient through education by removing (at least some of) the unknown. Don't dance around the subject - be clear ("unambiguous"), concise, and honest. Ensure they know they've been heard and that the strategy to address their pain is tailored to their unique situation "with functional goals." Help them accept the fact of their pain and understand that being pain-free may not be possible.
It comes down to real pain management (verb), not "pain management" (noun) that often includes drugs that over-sedate or procedures that need to be done repeatedly. There are cases where medications and/or procedures are necessary, but an over-reliance on them creates an imbalance. Because it's about not counting on something or somebody else to fix the problem, but on what the individual can do for themselves. Firmly establishing, in their mind and their actions, an acquisition of the locus of control.
Sounds good, but will that resolve the chronic pain? No, because by definition the pain is going to be there regardless, and in many cases the pain truly is debilitating. Can reducing the fear by turning the unknown into the known empower the patient to better manage it? Maybe. Can changing fear avoidance behavior (aka "guarding") open up new opportunities for physical activity that will actually help lessen the impact of the pain? Probably. Is this easy? It sounds like it is but it is absolutely not. For the person who has the pain or the person who is trying to help.
How all of this happens must be customized to each individual. There is no template or check-list, only guiding principles to choose the evidence based method(s) that work best for that person at that point in time that will likely need to be modified as their condition changes. Cognitive behavioral therapy (CBT) is an important treatment regimen to deal with these emotions that can actually turn into physiological obstacles. That's why the momentum towards accepting CBT in Work Comp and elsewhere is a very welcome trend (although appropriate reimbursement rates still need to be addressed – see “CBT and CPT”).
This is all “squishy” stuff, for certain. It gets really close to making psych a "compensable diagnosis." It deals with thoughts and feelings and emotions that are not as “tangible” as a compressed nerve or a torn ACL. But to think they don't have an impact, oftentimes disastrous, is no longer justifiable. If the goal is real pain management, removing fear from the equation needs to be part of the formula.
Mark Pew, Senior Vice President of PRIUM, has been focused since 2003 on the intersection of chronic pain and appropriate treatment. That ranges from the clinical and financial costs of opioids and benzos, to the corresponding epidemic of heroin use, to the evolution in medical cannabis. Educating is his job and passion. Contact Mark at firstname.lastname@example.org, on LinkedIn at markpew, or on Twitter @RxProfessor.
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