Resilience Despite Pain
Wellness is bigger than the absence of illness. One of my problems with the healthcare industry is that the predominance of the biomedical model leads us to treat pathology rather than actually promoting and reinforcing health.
I mean, do we even deserve the term “healthcare” anymore?
Here’s where it gets worse: Under a purely biomedical approach, when find pathology, we make assumptions about the relationship between pathoanatomy and symptoms. Then we start patients on a path of trying to eliminate pain in the face of scary radiographics and MRIs. Patients then interpret their condition as higher risk for pain; they might think that it will only get worse. Sometimes providers even feed into this and actually tell the patients that they will get worse. I’ve heard the stories, just as you have.
We need a different approach for pain.
Theories of Resilience
We need to focus more on resilience, not just risk.
Goubert & Trompetter (2017) wrote a perspective titled, “Toward a science and practice of resilience in the face pain,” which is the focus of this Physio Weekly. The authors present convincing evidence that positive outcomes are just as important, if not more important than negative outcomes. Physios can learn from this, as we are just as likely as other providers to look for what’s going wrong instead of what’s going right.
There are three perspectives that provide some direction for how we can foster resilience with patients. They are the psychological flexibility model, broaden-and-build theory, and self-determination theory.
The psychological flexibility model assumes that negative experiences like fear and pain are not pathological in nature by themselves. Of course these things can get in the way of our goals.
As this model suggests, our best path toward recovery involves accepting things as they are, yet disengaging from negative thoughts and feelings. Instead, we can determine what goals are important to our values, and then figure out how to meet those goals despite our problems.
If you use the Patient Specific Functional Scale, then you’re probably inclined to think this way already. But this also shifts how I think about our interventions. Should we try to chase pain away, using the kitchen sink if necessary, or should we pursue the patient’s goals in life despite pain?
This is the approach of Acceptance and Commitment Therapy (ACT) and one way to use these concepts is to use a values-based goal setting sheet so that you and your patients can work together to determine the higher objective — and then how to get there.
Strength Training and Self Mobilizations
Barbara Frederickson and colleagues developed the Broaden-and-build theory which emphasizes the role of positive emotions and thoughts in growth. If you’re more positive, then you are more likely to be active and to pursue your goals. Of course, those in pain are frustrated, but the Broaden-and-build theory suggests that we can induce positive affect in others. How can we do that?
A recent trial for knee osteoarthritis shows how we can use positive psychology interventions to decrease negativity — and even decrease pain. One easy exercise to use from the protocol is the “3 good things” exercise. For this, write down three good things that happen each day, and include explanations for why they were successful.
The Self-determination Theory suggests that humans have basic psychological needs for autonomy, competence, and relatedness. We want to feel free to choose what they want to do; we want to feel good at what we do; and we want to feel connected to one another. Physios have the opportunity to help patients to meet these needs in ways that almost no other healthcare providers can. We spend enough time with patients to develop real intimacy, and we can reinforce patients enough so that they feel successful.
I’ve wondered about how we can grant patients autonomy in treatment — whether it’s choosing how to exercise or even choosing interventions. How does this fit into high value care when the patient wishes to receive a modality that may be “low value”? Should patients decide when they follow up, rather than a prescriptive twice per week for six weeks?
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