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12/1/2023 Newsletter

In this part of the newsletter series we will get into what is a person centered interview? And aspects we can look at in clinical practices when someone is in pain.

A person centered interview is where we

focus on the person in front of us and give them the floor to fully discuss and explore their story and the beliefs and emotions behind that story. Many people forget that pain is not just a physical perception but by definition also includes emotional aspects.

Through the paper cited they give a list of questions and each area the question covers that we could ask people about. I find that it’s useful to look over the questions and if you aren’t already asking similar things, find a way to integrate these types of things into your history and in a way that feels more natural to you.

It’s one thing to have examples and pre-set questions, it’s another to make it flow well for yourself. You can’t be another person and I found it best to be genuine and ask things in a way that best fits your communication style and or personality.

In the article they show a fear avoidance model of pain. There are five dimensions that generally occur within that cycle and that we can ask about to get to better know the person's situation. These include: interpretation, identity, cause,consequences, representation (control/cure-ability or timeline). We then can look at behavioral and emotional responses.

Remember unhelpful beliefs can increase the risk for persistent pain, and can impact future pain, and risk for future pain and disability. Negative emotional responses can further perpetuate pain as well, especially due to the cascade of the fear of pain and how it impacts our ability to engage in things we enjoy and who we are. This can then increase feelings of anxiety, depression, and insomnia. This further reinforces beliefs there is a missed pathology, and when one cannot be found many are told its psychogenic or in their heads. Many are then not listened to or believed, this then increases fear and reinforces past actions, and often in seeking new cures they receive conflicting information which is confusing.

This is where the interview comes in and we ask them to put us in their shoes to understand how the symptoms have impacted them, their work, social and home lives. It might be useful to aks them what they think is causing the problem, if they've gotten a diagnosis and what this means to them, as well as about diagnostic tests. Going further we can discuss with them what might happen if they do things they have been avoiding, if they feel they have control over what is happening, and how confident they are in doing things they previously enjoyed. Do they know what causes flare ups, and can they do anything about it? This can be daunting and difficult conversation to have with patients. Especially as many can lose hope and may not understand how long this might last, or see themselves returning to prior activities, they might also not be forthcoming with this information. We might want to ask what they do when they have pain and if they avoid or pace activities and what they think would take to control this.

The behavioral response someone has to their pain often can help us to understand their beliefs and what they have previously learned or not learned about their body and pain. Appraise how they behave with pain and if it has worked for them before, and what their goals are. As many times what they do are not in alignment with their goals. It then is important to explicitly discuss the emotions they have because of the pain, like how does it impact their ability to do things they enjoy, if they fear they are causing damage, and how they think others see them.

Looking at behavioral responses can help uncover, coping responses to pain, engagement or avoidance of activity, feared, protected, avoided, or painful movements, lifestyle behaviors like sleep and activity level, and barriers to change of lifestyle, Goals and expectations.

Most common persons understanding of pain is based on the Descartes model of pain. Pain must equal damage in a lot of perspectives. This can also help us to understand if they have any current coping strategies in place to handle their pain and how it is currently impacting them. Does this make them avoid valued activities that contribute to their identity and sense of self for example.

We can often also identify aggravating and alleviating factors to help with decision making in protecting someone or exposing them to more activities. Because some patients are over protective or guarded and need to be more exposed to activity in a graded way. Some people have very pro-nociceptive patterns that can respond well to more specific interventions such as directed manual therapy or directional preference to help short term with pain alleviation and return to more normal activities. But pain modulation is a beast in itself to cover at a later date.

However even if we are able to modulate symptoms with exercise or manual interventions it would still be important to address beliefs, coping mechanisms, and emotional response because MSK pain has high recurrence rates.

Developing a better foundation of understanding in regards to their symptoms can help prevent secondary disability related to their beliefs and representation of symptoms. We can also better set expectations and timelines for prognosis/recovery and make gradual changes to lifestyle behaviors and habits which have a large impact on overall health than interventions. Especially long term.

Also never forget to screen for red flags and make sure you are the appropriate person to be treating someone. First do no harm, missing red flags would be a big deal. Also this is a good time to screen for anxiety and depression which are ever present with pain, especially chronic pain. It is a chicken and the egg relationship and they feed each other and can impact someone's recovery and long term prognosis. Especially useful are questionnaires as we often are not good at picking up psychological issues just when talking with someone directly.

With emotional responses after screening red flags we can look at loss of valued activities and responses to pain and past treatment. We also should look at fears like “movement causes damage” or pain and functional loss overall psychological well-being social context and support.

Make sure to summarize someone's history and narrative to allow space for corrections and clarification. Also the history might not be fully revealing for their experiences and behaviors, and until someone is confronted with the feared or painful activity they might not be noticed.

There are some key areas to working on exposing patients to activities. These include: Targeting, questioning, exposure, reflecting, exposure with control, appraisal, and repeated exposure in a new way.

Targeting means using the history to aid you in finding avoided activities or movements that would aid someone in getting back to their normal function or goals. This is also where questionnaires are helpful like OSPRO YF and the patient specific functional scale.

Question if they have any explicit beliefs about that activity or movement and why.

Expose them to that activity to monitor their implicit behaviors and emotions when actually facing that threat.

Reflecting to find out if they even know they are doing some behaviors. The person might not, or may consider the change in how they are moving to be just known facts. Like “lifting with your legs”

Exposing with control this may mean helping them relax or breathe more in control while doing this or evenly distributing weight through their limbs. Trying to violate the expected outcome if they move that way.

Appraises reflect on what happened. Even if they had pain is it coming down, can they still move, are baselines from the objective exam the same or no worse?

Repeat exposure in a new way using new strategies that you review to help them perform that activity to violate expectations further and work on development of new “cause effect” appearing relationships with movement.

Using movement we can often change peoples beliefs more than with our words. If there are discrepancies between attitudes, beliefs, and emotions when performing a movement they fear or have been avoiding it gives them a new lived experience that is a positive association with movement. Further reflection helps more with learning as we often learn most from events after the fact.

How do we develop a new representation for someone? How do we change beliefs, behaviors and emotions? Well it is not by educating them and lecturing someone to death. As much as “pain science” has become popular, it is not an intervention that changes pain. But having a conversation with someone can impact their beliefs, emotional responses, and behavior. We cannot unlearn things that we know, we can however learn new information that can change how we appraise things.

With education we can influence and plant seeds about what is possible and change someone's outlook. However we do need to reinforce this education with movement and action to lead to meaningful changes. Most research on “pain education” is showing that it is not useful at changing someone's pain. But it can change their fear avoidance, beliefs and attitudes. With improvements in range of motion and scores on FABQ and the Tampa scale of kinesiophobia following educational conversations.

For best learning it is useful to make it conversational and to use simple non technical language. Which means you may need to spend a lot of time to understand pain at a very detailed level so you can think of analogies and metaphors that relate to the impairments the specific person in front of you has. Also do not dismiss their symptoms, experiences, or even imaging findings. Yes they may not be alone in their pain, and many people without pain may have the same findings but do not immediately say that doesnt matter. Remember nociceptive inputs are the main drivers of pain and chronic changes in joints do contribute to nociception that in most circumstances out bodies can adjust to and tune out. But if your cup is full you may not be able to adjust. Think allostatic loading.

Behavior change is hard, and it takes a lot of practice and failure as a clinician to get better at it and to make sure we can appropriately tailor information to that specific person in front of us. But it is most helpful to use their subjective information, and their lived experience to shape their understanding.

How do we improve generalization to support behavior change? Generalization refers to the ability for someone to go home and use the tools successfully without us. It is our job to give them tools and strategies to help their self efficacy for long term improvement and to manage future recurrence. MSK issues have very high recurrence rates within 1-3 years. But successful management could possibly improve someone's ability to cope and allow for natural history, regression to the mean, and other reasons why people get better in time to do its thing. Not intervention that we use regularly can actually significantly influence tissue healing times and our bodies naturally will heal tissue.

Supporting and encouraging positive health habits and behaviors is also a good strategy but has to be focused and targeted about how it can help and impact their symptoms. This is a tough area because often without enough support or the right conversations changes to health habits are often met with resistance. We need clear and concise education, non judgmental conversations, and handouts using things like apps etc to make this process easier. Behavior change is extremely hard and is a good area to dive into quantitative literature about. Charlotte Albury has a lot of good papers that discuss specifically weight loss and smoking cessation. I first heard her talk about this on the Words Matter Podcast with Oliver Thompson in his Qualitative research series.

Also encouragement to use activity logs/diaries, telling friends and family about this and new learned “tools”, writing down when they will practice these techniques, etc can be very helpful in the development of new habits. Also immediate integration can help form new representations and use their own lived experiences to shape their beliefs, emotions, and behaviors. Words are wind when it comes to behavioral change. Use their goals and sometimes set goals for between sessions, like implementing new strategies, reading or watching videos, to encourage conversation and progression at the next session.

Sometimes its also useful to use inertia as our friend. If we are seeing progress it is ok to not always change something or add more. Sometimes more practice with new skills or tools can be more important than adding more to someone's plate.

This part 2 of 3 in this newsletter series. Hopefully you are enjoying this so far

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

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