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11/1/2023 Newsletter

Musculoskeletal (MSK) pain is a multidimensional condition that involves interaction between structure, physical, psychological, social, lifestyle and comorbid factors. And our beliefs significantly impact our pain. For example, clinical guidelines for treatment suggest that we address unhelpful beliefs that people have. However, many healthcare professionals hold unhelpful beliefs about pain and our bodies, and others feel like they lack the skills needed to address these issues with patients, or that it is outside their scope of practice.


Beliefs are a tricky subject because many clinicians find it difficult to have hard conversations with patients about their beliefs. Despite the original paper by George Engel being over 40+ years old at this point many clinicians do not understand the biopsychosocial model and how this is relevant in MSK treatment.


Especially given the multifaceted nature of pain, giving a diagnosis becomes muddy. This is because of the lack of reliability and validity of special tests and many joints being transitioned to sub classification or syndromes.


Many clinicians also have outdated and negative beliefs about the body that are now lacking a strong evidence base as further research emerges about pain. Biomechanical information still matters but not as much as we used to think.


But what is a belief? This is according to the Oxford dictionary “something one accepts as true, or real, a firmly held opinion”. And beliefs may not always seem rational because they can persist even when presented with facts. Many individuals will hold onto a diagnostic label they might have been given years later despite many MSK diagnosis being temporary. Further, this is hard because imaging findings are often present without someone having symptoms with these changes and those who are in pain can find that hard to believe because of their experiences. Further, someone can believe things that are contradicting, like they need to be stronger while also thinking exercise is harmful.


Beliefs can be broken up into explicit and implicit. Explicit are those that we are directly told or are consciously more aware of. Implicit beliefs are things we may not be aware of that we are doing or might be more automatic or socially held beliefs.


Many times people who seek care use more of a common sense model to influence their behavior and actions because they might not be well informed on healthcare or anatomy like clinicians. Even clinicians can fall into a trap of using more “common sense” as a fallacy like believing nociception (excessive stretching, or irritating sensations, aka signals sent by tissues and peripheral nerves) always equates to pain, tissue damage is the reason for pain, or all biomechanical reasoning.


The common sense model suggests that when we experience symptoms we want to make rational sense and thus form beliefs using our liver experience. We use representations of our symptoms to try to identify the why, what is it, consequences of pain, what we can do to control it , and how long it might last. We often form beliefs based on prior experience with similar symptoms and what happened when we last had those. Beliefs relate to the identity, cause, consequence, controllability and timeline of musculoskeletal pain


1) the identity of the pain (“a slipped disc”),

2) the causes of the pain ( “lifting with a rounded back ”)

3) the consequences of the pain (“physical incapacity”)

4) how controllable the pain is (“activity avoidance”)

5) how long the pain will last (“here to stay”).

This is why recommendations for more active approaches and being more bias towards active approaches is likely more beneficial long term. If someone “gets better” with dependency on manual, massage gun etc, in theory then a persons belief could now be that they need those things if this happens again versus having agency that exercise and self directed movements are more beneficial.


If the prior behavior is useful or not this can also trigger an emotional response which can further reinforce associations in our nervous system. And without a cognitive representation to guide us, responses may be based more on emotional behavior.


However, these reactions and responses are not static; they can change over time but often require further information to be represented or lived experience changes. Ie having a friend who got better with an exercise program versus surgery, or showing someone through movement pain can be changed after planting seeds with education.


Beliefs are related to many aspects of our identity and constantly being updated. Our experiences can reinforce specific beliefs we have about certain ideas while making us more likely to have the belief that other information is not true. Ie pain doesn’t equal damage and we can recover in this case.


Many of our beliefs about pain can be influenced from early ages from care givers and parents. Many people across cultures and geographic regions also have the beliefs that the body is like a machine and that pain is a sign the body needs to rest, and heal what has been damaged. This belief is deep seated in our society going back to 1644 with Decartes. We grow up believing that the alarm system protects us from real threats and must mean damage. Versus that pain can occur without nociception and without damage. And the ideas Decartes founded are especially unhelpful when pain persists beyond tissue healing times.


“the desire among clinicians to diagnose a tissue problem and fear of missing pathology contribute to the inappropriate use of imaging.”


However misinterpreted results can lead to excessive and unneeded care, catastrophic thoughts by people seeking care, leading to fear of activity, and lower expectations of recovery which negatively influences prognosis.


“clinicians who endorse ‘biomedical’ pain beliefs are more likely to engage in care that is inconsistent with guideline recommendations”


Human bodies are crazy and with movement we can adapt to so many activities and situations.


It’s crazy how with movement you could even adapt to form new joints. For example, in the case of the drawings done by the Sergent Surgeon to the King in England Sir Astley Cooper. He worked in London from the late 1700’s to 1830. There are many examples of this in engravings that he took during cadaver dissection where new joints were formed in people who could not get medical care who had traumatic injuries or dislocations.


Human bodies are strong but our beliefs and then use of our body because of our beliefs will heavily impact the stress we put on our body to then cause it to adapt differently.


Beliefs like that the body is a machine often cause disuse, increased disability, and worse overall health. Our inability to cope with symptoms and a change in our idea of who we are as a person can also significantly increase the levels of anxiety and depression someone has as well as insomnia which negatively impacts recovery as well. Many of these beliefs also occur due to a protective and self preserving response to pain, and potential psychological inflexibility. Psychological flexibility is our ability to stay present in the moment when presented with stress, adversity or troublesome thoughts and continue to act in a way that is in line with the type of person we want to be (Hayes et al 2022).


Certain behaviors like avoidance of recreational activities and work seem to make sense when we are in pain, but are also predictive of worse outcomes and increase in stress due to financial issues.


“For example avoidance of occupational activities affects job security and future financial security, causing emotional distress which further serves to heighten the pain experience.”


Further problems also arise when the biomedical model fails to find “a pain generator” because many people suffering can then be marginalized by lack of provider support and unhelpful beliefs held by clinicians.


Providing education, addressing beliefs, and giving treatment poses significant challenges with the time constraints on clinicians. Due to this automatic responses to associate pain with tissue damage and protecting and unloading people are clinicians' responses. As clinicians we need to reflect on our beliefs and experiences with pain.


“To understand the sufferer, one must understand the narrative, for it is through the story that the patient's suffering is accessed. This means both hearing the illness story and listening for the suffering narrative therein.”


Patient centered communication is key. Communication needs to be collaborative, incorporating patients' perspective to engage in dialogue to gain insights they might not find alone, body language like eye contact, expressive touch, body positioning, and good integration of documentation can enhance engagement. As well as we need to educate on resilience of our bodies


While our aim should never be to attempt to talk people out of pain, the language we use, and education we give can impact the effects of exercise on pain, and influence someone’s long term participation in activities.


One study published in 2020 looked at how what clinicians say impacts exercise induced hypoalgesia. The study measure pressure pain threshold on multiple locations using pressure algometers and blood pressure cuffs. They used three phrasing so had three groups.


1. group was told in prior studies they found after exercises it took more pressure to produce pain we don’t know if this is true yet with this exercise but expect it to be the case


2. Group was told we want to do this exercise and then reassess your pressure tolerance


3. Group was told these types of exercises can induce soreness, this exercise hasn’t been investigated yet but we expect you might be sore after.


They found in order that while not statistically significant difference was found between group 1 and 2 there might be a clinically significant difference in exercise induced analgesic effects. Negative information given to the third group causes hyper sensitivity to pressure measurements.


Also the Darlowl et al study the enduring impact of what clinicians say to patients suggests that our language can have a long standing impact on their participation in many activities of daily life like recreational activity, working, IADLs and ADLS.


This is part 1 of a 3 part series in the newsletter breaking down how we approach pain as clinicians, and reflecting on ways we can be better and question not only patients beliefs but our own.



Caneiro JP, Bunzli S, O'Sullivan P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther. 2021;25(1):17-29. doi:10.1016/j.bjpt.2020.06.003


Hayes SC, Ciarrochi J, Hofmann SG, Chin F, Sahdra B. Evolving an idionomic approach to processes of change: Towards a unified personalized science of human improvement. Behav Res Ther. 2022 Sep;156:104155. doi: 10.1016/j.brat.2022.104155. Epub 2022 Jul 3. PMID: 35863243.


Peter Stilwell, Anne Hudon, Keith Meldrum, M. Gabrielle Pagé, Timothy H. Wideman,

What is Pain-Related Suffering? Conceptual Critiques, Key Attributes, and Outstanding Questions, The Journal of Pain, Volume 23, Issue 5, 2022, Pages 729-738, ISSN 1526-5900, https://doi.org/10.1016/j.jpain.2021.11.005.


Vaegter HB, Thinggaard P, Madsen CH, Hasenbring M, Thorlund JB. Power of Words: Influence of Preexercise Information on Hypoalgesia after Exercise-Randomized Controlled Trial. Med Sci Sports Exerc. 2020;52(11):2373-2379. doi:10.1249/MSS.0000000000002396


Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-534. doi:10.1370/afm.1518


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