This post first appeared in The Physical Therapy Tribune on February 6, 2018.
When I was struggling with persistent pain, I saw many providers who confidently reassured me that I’d be fine, that I’d get better. The problem, however, was that even after completing their recommended treatment or exercise program, I was not fine. I did not get better. And not only did I not improve, but sometimes my symptoms got worse, often accompanied by an increasing sense of despair and hopelessness, which would further feed into the pain cycle.
Unfortunately, this experience is all too common among those who suffer from persistent pain. These individuals have often seen numerous clinicians, each of whom may have provided different, and often incomplete, explanations of their pain. The reasons for this are vast and multifactorial, and include our broken health care system, lack of understanding of modern pain science, confirmation bias, inadequate or inappropriate treatment, and the use of quackery, among others. But what I want to discuss in this post is the concept of reassurance. It is quite common, and often expected, for clinicians to reassure patients that they will improve over time with (and sometimes without) treatment. And no doubt, especially in acute care situations, a little reassurance can go a long way toward healing, especially for patients exhibiting fear and avoidance behaviors. Further, sometimes persistent pain patients also just need some reassurance that that pain doesn’t equal damage, and that it’s okay to move.
But is reassurance always helpful to those experiencing persistent pain? I’d argue that there can often be a fine line between helpful reassurance and overpromising. Given the complexities of pain and pain-related behaviors, it is not uncommon for pain to be/become persistent, even in the presence of a strong therapeutic alliance in which patients receive high-quality care from a skilled provider and take an active role in their own recovery. And if pain can persist/be persistent despite these desirable circumstances, what happens in the majority of persistent pain cases in which many factors complicate potential recovery? More pain.
But wait? Wasn’t the patient reassured that they’d “be fine”?
Oh, they weren’t fine? They didn’t “get better”?
What do you think goes through the mind of a patient with persistent pain when they are told they’d improve, but then don’t? I know what went through my mind, but also spoke to a few people I know who are currently experiencing persistent pain, and asked them whether they had been reassured about their pain and prognosis, and if they found that reassurance to be helpful. Several people responded, all with a consistent theme. In particular, the general consensus was that early on, the reassurance was welcome and gave them hope, but as time when on and treatment failures accumulated, they began to lose confidence in the ability of the medical community to help them.
This comment pretty much sums it up:
“At first, I did. It seemed to offer hope, and the first orthopedist I saw as well as a physical therapist said they were determined to find answers and find the source of the pain/issue. At about the 8 month mark, after many tests, x-rays, MRI’s and many, many PT visits, the reassurance seemed hollow.” – Vanessa M.
Although it’s not scientifically based, I think this comment illustrates how important it is to beware of how, as a clinician, your words influence those in your care. Reassurance is an important aspect of care, and sometimes that may be all someone needs to improve their outlook and condition. But it’s also prudent to keep in mind that, depending on the situation at hand, the type of reassurance you offer can also be viewed as false hope or even insincerity by patients struggling with persistent pain.
So, what should you do? I suggest offering gentle reassurance, without overpromising. Recovery from persistent pain is never a guarantee. But is it possible…and there is most likely a path forward for almost everyone. Your job as a clinician is to:
- Use your knowledge and expertise to help them learn to find their own way
- Help them set realistic goals and expectations.
- Offer them support and encouragement.
During my own recovery, the physical therapist who helped me the most spoke this powerful phrase:
“I don’t see anything that would preclude a full recovery”
Let’s break that down. He did not say that I’d “be fine”. He did not say that I’d be better in 6-8 weeks. He did not say that recovery would be easy. Rather, he told me that it was going to take hard work. He told me that it was going to take time and patience. He told me that I’d continue to have some bad days, but over time we’d expect to see more good days than bad days. He told me we would work through it together. He was optimistic. He gave me hope. But he never overpromised. And during some of those dark days that are inevitable while experiencing persistent pain, I would think of that statement. It helped drive me forward. It was, well…..reassuring.
Thanks for reading,