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Fear (of pain) is the 'mind-killer'

Social Context in the recovery process from MSK pain.

Unlike the litany against fear, as seen in the recent blockbuster 'Dune' fear of injury and subsequent pain is not so easily managed for many.

In a recent study on the psychological, social and contextual factors after a sport related knee injury, the authors looked at what is commonly know as the psychosocial aspects of recovery. Although specific to knees their conclusions can be generally applied to the population after occasional of sudden onset of MSK (musculoskeletal) pain or even after experiencing a period of chronic pain.

Fear and Frustration

In the context of the study, fear was identified as the most commonly reported barrier to recovery alongside frustration and anxiety. Taking this into the context of the general public I believe that these emotions are equally present and prevalent at the time of an onset of any type of physical pain. There is fear of the pain, fear of worse pain and fear that the pain will not go and they will be like this when they are old. This observation is, in part, based on comments I have heard from my own patients; ‘If I’m like this now, what am I going to be like when I’m older?”

There is also frustration; the frustration often of not knowing the cause. And there is anxiety, again related to the idea that something is damaged. What else could be the explanation for such pain?

If the individual is active there there is suspicion that the activity was the cause, or that continuing to do any activity is again going to cause or exacerbate the perceived damage. It is these sorts of negative emotions that the therapist needs to help the individual to identify and acknowledge since this is very important for recovery.

Active Involvement in the Recovery Process

Equally important for the recovery is the active involvement of the individual in the process. Many people want to understand the injury and start by wondering what they have done for the problem to have occurred. Not that this will help in their recovery but it is an indication of the lack of understanding of why they are in pain. Obviously if there has been trauma this is more straight forward but it is still worth the therapist explaining the healing process. Otherwise, apart from asking the question in the consultation, if the mechanism of injury is not obvious then it may not be worthwhile dwelling on it.

Coping strategies are very important in the recovery process and an absence of these can be associated with being unprepared for the metal demand of recovery. This can manifest in depressed feelings or even catastrophising the pain even more. The therapist should also help provide active coping strategies. These help to motivate the patient, help to develop resilient behaviour and also stick to the exercise programme provided.

Self-motivation is another important aspect in the recovery process. But expectations needs to be realistic otherwise frustration and loss of confidence both in the therapist and the process can occur. The initial expectations of recovery are focussed on the therapist but these can also be influenced by those in the person’s social context. If they are surrounded by people who mollycoddle them into being passive they are less driven to adhere to recovery programmes.

One important aspect from the very start of the process is goal setting. What is this pain preventing the individual from doing which was part of their normal life? Is this important to them? These goals drive the programme and the psyche of the patient to complete the programme. The goals have to be realistic and also real. That is to say the first aims should be pain relief so previous activities can be reintroduced. These can be anything from walking to the get the paper in the morning to being able to walk from the shops rather than drive. On occasion the patient may wish to go beyond and indicate a desire, for example, to get fit or lose weight, in order to prevent such an occurrence happening again. Goal setting can lead to positive rehab experiences and improved trust in the therapist.

This engagement between patient and therapist creates a positive association with self-care and health outcomes. Shared decision-making approaches lead to improved outcomes for recovery. It is essential to understand the the personal goals, values and definitions of success of the patient since they will influence recovery expectations. It is worth realising that the environmental factors surrounding the individual may be a stronger determinant of recovery that the treatment alone. Social context is almost everything.

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