Cognitions 1: Understanding of pain and other beliefs, worries or concerns.

I don’t understand why I still have pain, maybe my back hasn’t healed properly or they’ve missed something

Paul’s view of his back pain

Cognitions  – examples of these include worries, beliefs, concerns, expectations and attributions.

Pain related beliefs represent a personal understanding of the pain experience as a whole (4). Negative beliefs predict greater pain intensity and disability(5)(6)(7)(8)(9). It can therefore be useful to identify what a patient believes about the nature of their pain, it’s cause(s), prognosis, treatment and likely consequences, why they believe that, with what level of conviction and whether these cognitions are more helpful/adaptive or more unhelpful/maladaptive.

  • That there is an underlying structural /pathoanatomical cause of pain
  • That hurt equates to harm
  • That pain is uncontrollable
  • That ‘passive’ treatments are the answer

When I do something I get more pain, so I worry that I could be causing myself more damage

Paul’s view

Hypervigilence, catastrophysing, fear and avoidance are all important components of the fear-avoidance model .

Worry refers to repetitive uncontrollable, negative thoughts, images, and emotions resulting from a proactive cognitive risk analysis made to avoid solve or anticipated potential threats and their potential consequences(10). Worry is common in people with pain, as pain represents an imminent threat to someone’s welfare.

Hypervigilence to pain is the excessive tendency to bodyscan for and selectively attend to pain/somatic sensations, to misinterpret sensations as threatening and narrow one’s attention in the presence of such sensations.

Pain catastrophysing is a negative cognitive response to pain or anticipated pain, characterized by a tendency to fixate on the pain stimulus, magnify its threat value, and adopt a helpless outlook regarding managing the pain (11). Catastrophic thinking is related to higher pain intensity, poorer psychological functioning and higher levels of physical disability. Threatening types of illness information can fuel catastrophic thoughts about pain (see (12)).

Post-traumatic stress disorder (PTSD) is an anxiety-related mental health disorder which comes after an event where a person is exposed to actual or threatened death, serious injury or sexual violence. The event could be something that has happened to the person, or something they saw.  Someone with PTSD often relives the traumatic event through nightmares and flashbacks, and may feel irritable and guilty. They tend to avoid potential triggers which leads to isolation and avoidance. 

So what might you do?

As part of your assessment and any physical examination, consider utilising teaching opportunities to reassure Paul about the structural integrity of his spine

Reassure Paul that hurt doesn’t necessarily mean harm

And that, with support it will be possible, over time, to start doing more of the things he values 

Help Paul arrive at an individualised, evidence-based neurophysiological understanding(18)(19)that weaves in any assessment/investigation findings, takes into account what other people have told Paul, Paul’s beliefs and which recognises the complex interplay between cognitions, emotions and behaviours. When doing so consider Pauls cultural background, his preferred method of learning and his level of heath literacy.

This film may help you do this:

 Check Paul’s understanding, to what extent he does or doesn’t relate to any explanations, whether they have reassured him and whether he changes his behaviour as a result.

If reassurance is successful, Paul may be more willing to change his behaviour, however reassurance may be complicated (21,22)(23), reducing pain-related fears may be difficult and it may not be as effective as we think (24,25). Reassurance is usually only temporary and is usually unhelpful for those with high levels of worry or anxiety.(24) It is also possible to change behaviour without being reassured first or at all and there may be occasions where attempts to reassure may be unhelpful and where there may be more therapeutic mileage in not reassuring someone, and in helping them to change behaviour, with anxiety, fear, confusion or uncertainty

Receiving a credible neurophysiological explanation of pain that Paul believes and relates to may have many benefits for Paul e.g. feeling understood, heard, cared for and supported. He may also feel reassured and change his behaviour.  However:

  1. generic information is not likely to be as effective as an individualised explanation, delivered using an interactive style which enables Paul to raise and resolve difficulties in understanding the material or in applying it to his symptoms, situations or problems.
  2. A neurophysiological explanation should only ever be part of treatment and is not THE treatment in and of itself. 
  3. It may also fail and unsuccessful explanations can be unhelpful.  
  4. Giving Paul an experience of something through which he learn for themselves(28)is likely to be more effective than conceptual learning. 
  5. Not everyone wants or would benefit from an explanation 
  6. it is possible for people to change their behaviour without having an explanation, first or at all.

It may be appropriate to refer Paul to a qualified practitioner who can assess him for PTSD.

Cognitions 2: Explore current management strategies

Painkillers are not essential, it is a choice to take them, and taking them is a behavioural response to pain. As well as reducing pain, they can sometimes help people to do more of the things they value, sometimes they don’t/no longer work, cause intolerable side effects or people just prefer not to take them. People can have unhelpful ideas about pain related medication and concerns or worries about taking them. Sometimes people can be chaotic in their use of mediation or misuse and abuse prescribed, non-prescribed or recreational drugs.

Provide evidence based information to address any unhelpful ideas, worries or concerns about medication, advise Paul about appropriate use of medication, taking account of his previous experiences and preferencesand support Paul to make any changes or facilitate him to see someone who can do the above.

Self–efficacy is ‘Confidence in one’s ability to perform a particular behaviour and in overcoming barriers to that behaviour’ (20,21). Self-efficacy is behaviour specific and can fluctuate. It is related to pain intensity, psychological wellbeing behaviour (e.g. exercise adherence) and adaptation to illness (22–24)

Develop Paul’s self-efficacy by supporting Paul to successfully perform relevant activities(25). If he has high self-efficacy then he is likely to invest more effort and persist longer, recover more quickly and maintain his commitment to his goal, than if he has low self-efficacy.

Cognitions 3: Ask about views about healthcare

Paul has been discharged by the orthopaedic surgeons and feels that health care professionals are not taking him seriously. He doesn’t feel they believe that he is in as much pain as he says he is and doesn’t think they really care or are trying to help.

Stigma, skepticism and invalidation of someone’s pain experience can adversely affect their pain, their psychological  well-being (self-esteem, depression) and their relationships with others, including health care providers.

Trust, rapport and empathy relate to patient outcomes, patient satisfaction and clinician experience.

Build a therapeutic relationship(trust, rapport, empathy) with Paul by:

  • Using open questions and reflective statements.
  • Acknowledging his previous experience.
  • Being curiousabout Paul’s pain experience, how it is impacting on him and how he is responding to it.

Paying attention to your verbal and non-verbal communication, try and communicate to Paul that you are listening, that you believe him, are taking him seriously and want to help.

Cognitions 4: Establish expectations for the future with regards to pain and functioning

It is important to establish the patient’s expectations and agree objectives for treatment as if there is a mismatch between the clinician and patient, the two may be talking and acting at cross purposes and the consultation or course of treatment is not likely to be successful in the eyes of the patient.(26).

Facilitate Paul’s acceptance that his pain is likely to persist at some level for the foreseeable future. One way of doing this would be to help Paul do a short and long-term cost/benefit analysis of what he has tried to date in order to reduce, control, change or get rid of pain and what further attempts are likely to achieve in terms of improvements in pain, functioning, quality of life and in terms of financial and non-financial costs

Acceptance of pain is associated with less disability and with better overall functioning in patients with chronic pain. (29)(30)(31)

Low perceived control of symptoms or repeated failed attempts to control things that cannot be controlled (e.g. symptoms in many people with persistent pain) is associated with poorer physical and psychological functioning (27). See the misdirected problem solving model (28)and the hexaflex of psychopathology (29)for more information.

Help Paul focus on control of his life direction, with pain, rather than on Pain control.