BRINGING SCIENCE TO TREATMENT

Rethinking pain: psychologically informed practice

Experiencing pain is a fundamental biopsychosocial phenomenon. However, practitioners typically treat pain in isolation with little emphasis on psychological influence. Carl Bescoby explores the psychological impact of pain and discusses how psychologically informed practice may offer benefits to managing the whole pain experience throughout rehabilitation.

Soccer Football – FA Cup Semi Final – Chelsea v Crystal Palace – Chelsea’s Mateo Kovacic reacts after sustaining an injury REUTERS/David Klein

Introduction

It is common for athletes to experience pain when injured, during rehabilitation, or return to sports (RTS). Pain is an inherent biopsychosocial phenomenon, but practitioners may neglect the psychological components of an athlete’s overall pain experience(1). While incorporating psychological approaches within practice may prove challenging for some practitioners, psychologically informed practice has gained popularity. Practitioners can encompass the principles to assess and manage athletes’ cognitions, emotions, behaviors, and physical functioning(2-4). Furthermore, more awareness of the psychological impact of pain and the potential benefits of psychologically informed practice could enhance practitioners’ pain management toolset when supporting athletes.

The psychological impact of pain

Identifying how individuals perceive and experience pain following an injury and throughout rehabilitation may offer useful insight for practitioners when supporting athletes’ RTS. In addition, gaining an awareness of the athlete’s cognitions, emotions, and behaviors; may help establish and integrate psychological principles into physical therapy to enhance outcomes(2-4). It is important to note that psychological processes are intertwined as a functioning system and cannot be segmented (see figure 1).

Figure 1. Cognitive triangle

Impact on thoughts and beliefs

Unhelpful thinking patterns about pain may reduce the ability to develop habit-forming behaviors that enhance injury recovery. Therefore, it is useful for practitioners to understand some common unhelpful thinking patterns, such as emotional reasoning, black and white thinking, ‘must’ and or ‘should’ statements, jumping to conclusions, over-generalizing, rejecting the positives, labeling, and catastrophizing. Pain catastrophizing refers to the magnification of the pain threat and rumination about the inability to cope(5). This may lead to pain-related fear and avoidance beliefs, inhibiting athletes from engaging in rehabilitation (see figure 2).

Impact on emotions and behaviors

Emotions are integral to the assessment and conceptualization of pain(5,6). Pain may prompt negative emotions such as irritation, hopelessness, anger, and anxiety. These emotions may also contribute to the amplification and poor adjustment to pain. While it is important to acknowledge the impact of pain on emotions and how emotions consequently impact pain, practitioners should be cautious not to dismiss an athlete’s pain as real. Furthermore, practitioners should not imply that this is a psychological failure or an overtly emotional problem. Instead, it is important to state how emotional processes are normal components of the human pain experience(6).

Conversely, negative, or challenging emotions may influence or change behavior in the same way as thoughts and beliefs. Pain behavior can be either adaptive or maladaptive. Adaptive behavior may include avoiding painful movements to prevent further injury. In contrast, maladaptive behavior could consist of avoiding movement for too long or not resting enough, which may be due to the overriding negative emotions such as anxiety, irritation, or anger (see figure 2). Therefore, in acknowledging the athletes’ pain-related emotions and behavior, practitioners may increase the awareness of how these interact and impact each other.

Figure 2: Fear-avoidance model(5)

The benefits of psychologically informed practice

Psychologically informed practice is not a new phenomenon. Yet, the benefits of delivering psychosocially oriented care may be wide-reaching and could be a tool to support athletes’ pain experiences throughout rehabilitation. Psychologically informed practice mainly involves cognitive-behavioral techniques (CBT), and more recently, this has encompassed acceptance-based therapies and techniques(5-7). As a result, there has been growing interest in interventions that enhance acceptance and emotional awareness to promote a mindful engagement with thoughts, emotions, and physical sensations. Furthermore, practitioners utilizing CBT have enhanced their therapeutic relationships, reduced athletes’ perceived threat of pain, reconceptualized and refigured athletes’ beliefs, reframed pain experiences, and improved overall self-efficacy during rehabilitation(7).

Building a therapeutic relationship is a prerequisite to practitioner care. Because psychological processes influence both the pain experience and treatment outcome, integrating psychological principles into physical therapy would seem to have the potential to enhance outcomes. Therefore, the skills involved in establishing a good rapport and effective therapeutic relationships within a psychological context are extremely critical to effective treatment and support. This often includes using soft skills, such as empathic active listening, paraphrasing, requesting clarification, and effective summation.

Practitioners can also reduce the athlete’s perceived pain threat by utilizing psychologically informed practice. For example, clinicians can normalize somatic experiences by reinterpreting symptoms and shifting focus away from pain toward good sensations, feelings, and perceptions of the injury or rehabilitation. Furthermore, practitioners could utilize problem-solving skills to match rehabilitation activity demands to patient tolerance levels and abilities(8). These strategies may help reduce the perceived pain threat, which may decrease pain catastrophizing when athletes are rehabilitating and minimize the fear of reinjury.

Additionally, psychologically informed practice may also help athletes reconceptualize their beliefs about pain(8). Certain beliefs about pain may lead to avoidance or reduce self-efficacy when dealing with pain throughout rehabilitation. Practitioners may challenge pain-related beliefs by educating athletes and creating space to fact-check their thoughts and evaluate how these may influence their behavior. For example, practitioners can ask athletes to write down or discuss their pain-related thoughts; this may be a helpful way to increase awareness of their thought processes and beliefs. Asking athletes to log their thoughts may seem a bit of a stretch from physical therapy, but it could be beneficial in identifying thinking patterns and how these may influence behaviors that could negatively impact their rehabilitation goals.

Clinical recommendations

  1. Awareness of the psychological flags

Gaining an awareness of the psychological flags may help practitioners better interpret how their athletes may be experiencing, perceiving, and reacting to pain. Doing so may enhance the therapeutic relationship, connection, and understanding of the individual. Additionally, understanding how individuals think about and conceptualize their pain-related beliefs may present the opportunity to redefine or challenge them to enhance recovery. Moreover, understanding these thinking patterns and beliefs may enable awareness of how they impact behavior which is essential when considering adherence to rehabilitation programs. Finally, if athletes feel understood and supported, it may also enhance self-efficacy and confidence when they RTS.

  1. Enhance psychological flexibility

When considering psychologically informed practice and building fundamental cognitive-behavioral approaches such as acceptance and commitment therapy, a critical recommendation would be looking at ways to develop and enhance individuals’ psychological flexibility. Psychological flexibility is the capacity to be open with thoughts, feelings, and emotions (see figure 3)(9,10). Practitioners may achieve this by raising awareness of how athletes speak about their pain experiences and helping them develop openness, mindfulness, and directed action. This could enable athletes to purposefully pursue their goals and values, accepting the psychological discomfort of pain without engaging in avoidant behaviors that may increase their pain experience and impact their RTS.

Figure 3. Psychological flexibility triangle

  1. Consider psychological referral pathways

Increasing awareness of pain’s psychological flags throughout injury rehabilitation may enable practitioners to implement psychologically informed practice. However, it is also essential to also establish referral networks of psychologists and other mental health practitioners that may be able to support athletes psychologically with their pain experiences. Additionally, if an athlete’s needs extend beyond the competencies of the practitioner, a referral pathway to a psychologist may be a suitable option to support the rehabilitation process.

Conclusion

Athletes’ pain experience may offer unique challenges for practitioners looking to treat and support their ongoing physical needs. Gaining an awareness of the psychological impact of pain and how cognitions, beliefs, emotions, and behavior interact may help establish psychological principles to inform physical therapy. Furthermore, in highlighting the benefits of psychologically informed practice, practitioners may feel empowered to integrate some of these recommendations within their practice to enhance outcomes. Finally, psychologically informed practice can deliver psychosocially oriented care by integrating biopsychosocial interventions into patient management.

References

  1. J of Pain. 2014, 15 (3), 221-234.
  2. Br J Health Psych. 2022.
  3. Physical Therapy. 2018, 98, 398-407.
  4. Physiotherapy. 2012, 98: 110–6.
  5. Pain. 2010, 148, 120-127.
  6. J Clin Psychol. 2011, 67(9): 942–968
  7. Phys Ther. 2011, 91:700 –711.
  8. Physiotherapy. 2020, 106, 163–173.
  9. Behav Res Ther. 2006, 44: 1-25.
  10. ACT, The Guilford Press. 2012.
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