Musculoskeletal Pain Management: Shifting Focus from Fear to Empowerment

Background

Chronic musculoskeletal pain is now a leading cause of disability worldwide, and the burden of disability is projected to grow exponentially over the next 2 decades, placing unsustainable pressure on healthcare systems.

Once serious pathology has been excluded , a person’s experience of musculoskeletal pain is influenced by a variable interplay of multidimensional factors, including physical, anatomical, pathological, lifestyle, psychological, social, cultural, past, sensory, comorbid health, genetics, sex, and life stage. The dynamic interaction and relative contribution of each factor is variable, interrelated, and temporally fluctuating, making chronic pain a unique experience for each individual.

These interactions influence tissue sensitivity and continually shape a person’s interpretation of their pain experience.

Contemporary conceptualizations of pain emphasize its protective function . The meaning assigned to pain is potentially a powerful cognitive contributor to the need for protection and therefore influences both the pain itself and the person’s individual experience and response to pain.

For example, a recent trial randomly assigned patients to receive threatening and non-threatening information from MRI reports. Compared with those who received non-threatening information, patients randomly assigned to threatening information were more likely to perceive a need for interventions that carry greater risk and lower benefit, such as opioids, injections, and surgery, while also reporting worse pain intensity, disability, cognitions, mental health and self-efficacy. This highlights how both threatening and safety messages can influence a person’s experience of pain and their trajectory through the healthcare system.

The meaning of pain also influences emotional (i.e., pain-related fear) and behavioral (i.e., protection and avoidance) responses. Pain-related fear can therefore be defined as a cognitive and emotional response to an appraisal that the body is in danger and needs protection.

Pain-related fear, psychological distress, and self-efficacy have been shown to mediate the relationship between pain and disability. High levels of pain-related fear predict greater disability and worse outcomes in people with chronic musculoskeletal pain. Pain-related fear is modifiable, and focusing on protective (e.g., slow and cautious execution of tasks) and avoidance (e.g., not performing a task) behaviors may be an opportunity to reduce disability and the burden of chronic musculoskeletal pain.

There is now compelling evidence that the treatment of chronic musculoskeletal pain must integrate biological, psychological, and social perspectives. However, there is a lack of clear instructions for clinicians, particularly physiotherapists, on how to implement psychology-based approaches in practice.

The document aims to provide physical therapists with a clinical framework that describes how Cognitive Functional Therapy (CFT) can be implemented through the lens of the common sense model to promote safety learning in people with musculoskeletal pain. CFT is an exposure-based physical therapy-led approach that was developed to reduce disability in people with chronic musculoskeletal pain. Because chronic musculoskeletal pain in different regions of the body shares common biopsychosocial risk profiles for pain and disability, we consider this framework to be applicable to a variety of musculoskeletal pain conditions.

To illustrate the usefulness of this framework, we present a case study in which CFT is used to guide a person with disabling back pain and significant pain-related fear on a journey toward recovery. Recovery is defined here as a person developing control over pain, confident engagement in valued activities, and quality of life.

Learning from fear

Social beliefs about the body and pain

In Western society, people of all ages, both in pain and without pain in geographically diverse settings, often hold unhelpful beliefs about the body and pain. The body is often perceived as fragile and vulnerable to damage, and the experience of pain is interpreted as threatening and often understood as a sign of structural damage. As such, there is a perception that the part of the body that hurts always needs to be protected and “fixed.”

There are examples of this in people who suffer from back, knee and hip pain. Our own clinical studies have shown that people with and without back pain, as well as physical therapists who treat people with back pain, show implicit (non-conscious) bias about back vulnerability, even when they explicitly report otherwise. . This suggests that, as a society, we are biased toward information that supports fearful beliefs about the body and pain.

Lived experience of fear related to pain

A body of qualitative work exploring the lives of people living with chronic pain and high fear provides compelling evidence that pain-related fear can be understood as a common sense response to a threatening pain experience described as severe, uncontrollable. and unpredictable.

For example, when a person believes that performing a painful activity will hurt and/or cause damage to their body, avoiding or modifying that activity is common sense. Although avoidance may reduce fear or pain in the short term, it also prevents the person from having positive learning experiences that would refute the person’s expectations and beliefs. Failed attempts to control the experience of pain and its impact can reinforce fear learning and lead to greater long-term disability.

Qualitative and experimental data highlighted several factors that may reinforce fear and pain-related behaviors, including diagnostic uncertainty, threatening radiology reports along with negative advice (explicit or implicit) received from physicians during healthcare encounters, advice contradictory views of different medical and social beliefs about the structural vulnerability of the body.

For some, threatening social contexts , such as abusive relationships, bullying, stressful life events, and negative healthcare encounters, promote a salient learning experience and may also play a role in facilitating fear learning. .

Pain-related fear, protection, and avoidance of movement

A large proportion of people with chronic back pain believe that incorrect movement could have serious negative consequences for their back. This belief potentially increases the expectation of pain, the experience of pain, and fear, shaping people’s behavior toward activity avoidance, protective muscle defense, and restricted movement.

It has been proposed (but not yet empirically established) that overprotective motor responses may be pro-nociceptive , leading to abnormal stress on sensitized spinal structures and, in turn, increased pain intensity and persistence. Other studies highlight the role of cognitions and emotions as potential mechanisms that may underlie the coexistence of pain and fear and modulate a person’s experience of pain.

Generalization of fear, protection and avoidance

The inability to distinguish what is safe from what is dangerous has been proposed as a central mechanism in the generalization of protective responses that lead to disability.

This can cause pain to be triggered by functionally different stimuli, meaning people are more likely to disengage from a wider range of movements and activities. For example, when the original painful trigger is associated with bending and lifting, this can lead to generalization of fear, avoidance, and pain to similar (e.g., vacuuming, putting on shoes) and different movements. (e.g., walking, washing dishes) and occupations.

This generalization of fear and avoidance reduces opportunities to challenge and refute a person’s feared expectations, reinforcing fear as a driver of unhelpful behavior and perpetuating disability . This perceived lack of sustained safety may play a role in maintaining pain-related fear.

Fear avoidance models in musculoskeletal pain

The fear avoidance model

A prevailing model that explains the pathway to disability associated with chronic musculoskeletal pain is the fear-avoidance model . The model describes how a threatening pain experience can lead to an unhelpful cycle of catastrophic thinking, pain-related fear, avoidance of movement and activity, and subsequent disability and depressed mood, which in turn increases the experience. from pain. Although the fear avoidance model proposes that return to normal activity in the absence of catastrophic events leads to recovery, the path to recovery is less researched and understood.

The common sense model and learning from fear

Sensemaking is the process by which an individual makes sense of their pain and what it means now and in the future. Insights from qualitative research suggest that “sense-making” processes , beyond pain catastrophizing, play a role in learning pain-related fear and disability. Sensemaking is at the heart of the common sense model.

Bunzli et al proposed the usefulness of the common sense model as a framework to help health professionals understand the sense-making processes involved in the fear-avoidance cycle and how these processes can be targeted to facilitate fear reduction in People with chronic musculoskeletal pain disorders.

The model describes a dynamic process that constitutes a person’s "cognitive representation" of their pain condition, which is formed by memory structures of their own normal functioning, past pain experiences, treatments, lifestyle, and social activities. This is updated based on new information that is heard (e.g., media, family, encounters with health professionals), observed (e.g., vicarious experience of friends, family, co-workers). ) and felt (e.g., bodily sensations, perceived pain).

Once a person experiences pain, it helps them understand pain based on 4 dimensions:

1. Identity (What is this pain?)
2. Cause (What caused this pain?)
3. Consequences (What are the consequences of having this pain?)
4. Timeline (How long will this pain last?)

The way a person makes sense of their pain will influence how they respond to it from a behavioral and emotional perspective.

The dynamic process that includes a person’s understanding and behavioral and emotional responses is defined here as “schema learning” .

For example, when a person with back pain believes that "flexion of the spine will cause pain" , the action taken is to avoid and protect against flexion, and therefore the intended outcome is that pain is avoided. If this occurs, there appears to be coherence between the prediction and the outcome even though the coherence actually relates to an opposing prediction and its outcome. However, the original cognitive representation (that bending will cause pain) is reinforced by inference and the behavior is maintained (i.e., the experience does not promote learning).

If the prediction becomes "avoiding flexion prevents pain" but this does not occur (i.e., pain is experienced despite avoiding flexion), there is inconsistency between the prediction and the outcome and learning occurs sensitively toward the notion. that cognitive representation is not working and things are even worse than they first seemed.

A person’s inability to predict what makes their pain worse and lack of control over their pain experience results in an inability to understand pain , which is in turn self-perpetuating, distressing and disabling, and reinforcing learning. of fear (fear learning scheme).

Safety training

Extinction research highlights the importance of learning a new safety experience as the primary mechanism underlying fear reduction.

Fear reduction is related to people’s ability to form new safety memories that compete with old fear memories, thereby regulating their emotional and behavioral response to the source of their fear.

This concept is based on inhibitory learning theory from the field of anxiety management, which proposes a shift from models that use cognitive restructuring and fear habituation (i.e., exposure until fear is reduced) as an index. of corrective learning, towards the development of safe models of associations (i.e., new safety experience). Inhibitory learning strategies have been proposed to maximize the learning of new secure memories.

Common Sense Model and Safety Learning

The common sense model may also help clinicians understand the sense-making processes involved in safety learning in people with chronic musculoskeletal pain. Consider the same person with back pain who is fearful, cautious, and avoids lumbar flexion. If they are assured that “spinal flexion is safe” and they experience that flexion of the back in a graduated, relaxed manner does not produce an increase in back pain (or even a reduction in pain), there is an inconsistency between the prediction and the result; Subsequently, learning occurs .

The violation of expectations is at the heart of inhibitory learning (or safety learning), which means that new safe memories develop (e.g., "flexing your spine is safe") and compete with the fear memory. original (e.g., "flexing the spine causes pain").

The development of a strategy that effectively controls the experience of pain combined with an explanation that helps a person make sense of their pain challenges the original fear schema that is sensibly updated toward an experience that is considered safe (safety learning schema). ). Repetition of a safety experience integrated into a person’s life is believed to reduce pain-related fear, disability, and distress.

Using CFT to implement security learning

We propose a framework that considers the person’s journey toward pain and disability, but focuses on the process of change in which safety learning can lead to recovery. This framework allows clinicians to capture the patient’s story, identify goals for recovery, and help patients gain new understanding through an alternative experience of safety.

The process of experiential learning and understanding described in this framework aims to equip patients with effective strategies to independently manage pain and prevent flares in pain intensity and/or manage the impact of pain on their lives and emotional responses. To pain. This framework supports best practice recommendations, providing clinicians with a clear roadmap for how to implement exposure to promote change clinically.

Not all pain patients are afraid. Recognize that avoidance can also occur as a common sense response to an unhelpful representation of pain based on what they have been told or experienced; We propose that our framework may also be useful in patients who report low levels of fear.

The therapeutic relationship

For patients with pain, using a communication style that is open, non-judgmental, reflective, and provides validation of the person’s emotions, beliefs, and experiences is critical to safe learning. This style of communication decreases arousal, facilitates disclosure, and encourages problem solving.

Communication practices that foster a strong, trusting therapeutic alliance create an environment of lower distress that sets the stage for safety learning and behavior change. Using a screening questionnaire before the interview provides the clinician with insight into the person’s pain and disability levels, cognitions, and emotions, providing the opportunity to specifically explore their concerns within the interview ( Fig. 1 provides examples of detection tools).

Clinicians are encouraged to use the common sense model to explore pain representation and patient emotions and behavioral responses to pain. Patients can be asked to reflect on the experiences that led them to understand pain and how this affects their behavior. Understanding the person’s feared, avoided, and pain-inducing activities that are aligned with their goals provides clear targets for exposure. This approach encourages greater collaboration in clinical encounters.

Exposure

Behavioral exposure specifically targets pain-related fear and avoidance by gradually exposing the person to feared or avoided tasks while challenging unhelpful cognitions and disconfirming threat expectations (i.e., performing the task without expected catastrophic outcome to occur).

Traditionally, exposure therapy focuses on erroneous damage beliefs (e.g., “lifting will damage my disc”) rather than the pain itself.

However, the basis of avoidance and the cognitive representation of pain vary between people (i.e., fear of harm, fear of pain, fear of the consequences of feeling pain, or a common sense response to what they have been told). or experienced). For patients who avoid lifting because they fear increased pain and its consequences, exposure to repeated lifting when it leads to increased pain and distress may inadvertently reinforce fear learning.

In contrast, exposure with control is a process of behavior change that explicitly targets the experience of pain itself (when possible), using pain as a hypothesis to test during behavioral experiments (e.g. ., "lifting will increase my pain"). Behavioral experiments during exposure provide an experience in which learned associations between threatening tasks and increased pain or harm can be corrected (i.e., new “safety” associations are formed). This strategy is derived from the premise that the mismatch between expectation and experience is useful for new learning.

While for some patients the goal is to experience less pain while performing tasks, for others, it may be to engage in feared and avoided tasks without harm. In this process, sympathetic responses and safety-seeking behaviors that occur during the performance of painful, feared, or avoided functional tasks are explicitly directed and controlled to create a discrepancy between the patient’s expected and actual pain responses (i.e. , the patient’s prior expectation: "I expect my pain to get worse with repeated flexion”; behavioral experiment: patient experience “When I relax, breathe, and bend my back without protecting it, my pain does not get worse, in fact it reduces"). This includes promoting body relaxation before exposure, reducing protective behaviors, facilitating body awareness, for example, lifting objects in a relaxed manner, and modifying the way the person physically performs the task without responses . unhelpful protective measures (i.e., holding your breath, bracing, avoiding spinal flexion) can result in a positive experience that promotes safety learning.

A recent case series demonstrated that people in whom improvements in pain were related to changes in movement adopted new behavior considered "less protective" (i.e., greater range and speed of movement and more back muscles). relaxed). In another case series, people with high pain-related fear re-engaged in previously feared and avoided activities after undergoing a 12-week CFT intervention. Exposure that promotes “control” of emotional and behavioral responses to pain provides a potential pathway for a person to return to valued activities without escalation of pain and associated distress.

Safety learning is consolidated by asking patients to reflect on what they learned about the nonoccurrence of the feared event, the discrepancies between what was predicted and what occurred, and the degree of “surprise” of the exposure practice. The experience and this reflection process question the person’s implicit and explicit beliefs. This process is repeated to reinforce the new experience, and the exposition progresses to further disprove the unhelpful beliefs. New learned strategies are immediately integrated into daily activities to develop self-efficacy and promote generalization across contexts and activities.

When pain control cannot be achieved during this process, the focus shifts away from pain and toward lack of protection and reassurance that the activity is safe while the process of graded exposure to functional and objective goals takes place. of personally relevant lifestyle. In these cases, the journey towards life is the experiment itself.

Exposure can be very challenging for the patient, as well as for the doctor who needs to support the patient throughout the journey. To guide their patient to engage in painful, feared, and/or avoided movements and activities, clinicians must be certain that they have adequately assessed the specific, underlying pathology and will not "harm" the patient in this process.

They must also be skilled at managing potential emotional responses, because exposure can provoke strong emotional responses, anxiety, and sometimes panic in a patient. The clinician’s own pain awareness and movement/activity beliefs , as well as specific training, appear to be important when implementing this approach. This reflects an exposure training process for both the physician and the patient.

Make sense of the pain

The process of making sense of pain is reflective and uses a person’s own story combined with their experiences during behavioral exposure to gain new understanding of their pain and develop self-efficacy to achieve their goals.

The common sense model can be used to explain this process. Qualitative and clinical data from people with disabling back pain undergoing CFT found that clinical improvement was attributed to a person’s ability to make sense of their pain experience in a non-threatening way and their ability to gain control over the experience. of pain and/or the effects of pain on your life. This was achieved by developing a new and coherent cognitive representation of pain that guides effective behavior.

Based on the common sense model, a coherent representation includes diagnostic certainty from a biopsychosocial perspective (identity) that can explain a person’s symptoms in a meaningful way (cause), replacing erroneous beliefs about pain and its harmful or disabling effects (consequences). ) and provides strategies to manage symptoms and emotions in a way that reengages them in life (timeline and control).

The development of a new cognitive representation is an interactive learning process that is achieved through reflection on the person’s own narrative, experience, self-reflection and education. This process refutes previously held unhelpful beliefs and allows a person to reconceptualize and understand their pain symptoms and emotional and behavioral responses to pain in a new way through a biopsychosocial lens, with the goal of gaining self-efficacy.

The journey to recovery

The experience of “safety” is key to the recovery of a protective and/or avoidant person. The path by which a person recovers is unique to each person. Although for some this process may occur in a few weeks, for others it may take longer (3 to 6 months). A study that investigated how changes in pain-related fear developed over the course of a 12-week CFT intervention demonstrated that changes in pain intensity, pain control ability, and pain-related fear were associated with changes in disability. The factors that changed, and the rate and pattern of change, differed for each person, highlighting individual variability in the change process.

A qualitative study found that people with chronic back pain who gained control over pain by modifying the way they move reported an ability to manage pain and flare-ups on their own while engaging in valued goals. Among those who failed to control their pain, some reported worse outcomes at follow-up, while others reported that accepting the unpredictability and uncontrollability of pain or adopting a new, more positive mindset about the causes and consequences of pain allowed them to control their worrying and participate in valuable activities. This suggests the likelihood of multiple individual pathways to reduce chronic pain-related disability in people with pain-related fear.

Booster sessions may be necessary for when/if the pain becomes uncontrollable, distressing and/or disabling. During pain flares, the old cognitive representation can strongly resurface , often reactivating unhelpful behavioral and emotional responses. In the study by Caneiro et al, all participants experienced pain flares of varying intensity and duration that provided opportunities to reinforce safety learning. It is important to provide patients with an individualized management plan for pain flares with the potential for re-engagement in care.

The following clinical case illustrates the processes of learning fear and disability, and learning safety as a roadmap to recovery.

Case study

Patient history

A 45-year-old woman had a 23-year history of back pain (nonspecific). Mother of 2 children, she is married and works part time from home. She has seen several health professionals including general practitioners, chiropractors, massage therapists, physiotherapists, spine surgeons and pain doctors. She manages her pain with rest, hot compresses, massage, light stretching, nonsteroidal anti-inflammatories, gabapentin, various spinal injections, and opioids (including oxycodone for many years). Her goals are to be able to participate in her family’s activities and be healthier, fitter and stronger. Key factors contributing to this patient’s presentation are unhelpful beliefs about harm, high pain-related fear (of pain/flares and damage), high pain catastrophizing, cautious movement and avoidance behavior, poor sleep, avoidance of activities.

Table 1 describes this patient’s cognitive representation of her pain and her behavioral and emotional responses to pain before and after a CFT intervention (key elements of the intervention are described in the table). Supplementary Table 1 describes how Integrate inhibitory learning strategies into the management of musculoskeletal pain conditions using the case of the patient in this paper as an example.

Challenges and implications for clinical practice

Despite the promotion and awareness of a biopsychosocial approach to pain, a biomedical model often underpins current education and practice. Health system models can limit access to best practices, where health financing frequently provides reimbursement for imaging, medications, and surgery (when not indicated by guidelines), but not for physical and psychological interventions focused on health. person.

The biomedical model of care provides a fertile context for learning fear, which can lead a person to believe that their body is fragile and damaged and in need of protection.

The beliefs of both physicians and patients that pain is associated with harm (in the absence of trauma or indicators of severe/specific pathology), that scans identify the source of pain, and that symptoms occur as a consequence of structural abnormalities and biomechanics are generalized .

This commonly leads to the view that focusing on structure or body "abnormalities" will fix the pain, which in turn often leads to over-medicalization, unnecessary and potentially useless testing, and limited effectiveness of interventions. for most chronic musculoskeletal pain.

They suggest threatening advice to patients such as “let the pain guide you,” “your pain is due to wear and tear,” “if it hurts, avoid it,” “engage your core when you move,” and “lift with your back straight.” The vulnerability of the body is reinforced through an unhelpful cognitive representation that can lead to or reinforce avoidance/protective behaviors. In this way, physical therapists have the ability to influence patients to learn about fear or safety.

Changing the way we communicate about the body and pain to people with and without pain is necessary to reduce fear learning, promote safety messages , and minimize or prevent the impact of pain on people’s lives. To promote safety learning, it is imperative to widely disseminate messages in society that instill positive perceptions about the body and pain, that build confidence in the body in its ability to heal and adapt, and that encourage the adoption of healthy behaviors, including movement and physical activity, as safe and useful.

Having a unified narrative between family, friends, caregivers, co-workers, and counselors is essential because they play an important role in a person’s recovery process. Conversely, conflicting advice, unhelpful caregivers, social stress, mental health, and comorbidities can be obstacles to recovery. This highlights the importance of co-care and communication with community services to support a person’s path to recovery.

Clinical pathways that align with evidence and clinical practice guidelines are optimal, but are not always followed. To facilitate safety learning in pain patients who are fearful and/or avoidant, clinicians require excellent communication skills that are reflective, validating, and empowering. Clinicians must also be specifically trained and counseled to achieve competency to perform controlled exposure, and changes to the physical therapy curriculum are needed to improve clinicians’ skills in understanding and delivering person-centered care. .

Evidence for the application of this framework

There is emerging evidence of the effectiveness of exposure-based interventions for people with chronic musculoskeletal pain, using the principles described in this document. Physiotherapists who were trained in this framework reported greater confidence and competence in managing the biopsychosocial dimensions of pain. A large trial is currently underway to evaluate the effectiveness of this approach versus usual care in people with chronic back pain. This framework is aligned with best practice recommendations for managing musculoskeletal pain regardless of body region. More research is needed to evaluate the effectiveness of this approach in other musculoskeletal pain conditions.