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14 Articles in Volume 19, Issue #5
Agonism and Antagonism of the Muscles of the Shoulder Joint: An SEMG Approach
Analgesics of the Future: The Potential of IV Formulations for Post-Op Treatment of Pain
Blood Biomarkers Show Promise for Precision Pain Management
Can I Call Myself a “Pain Specialist?”
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 2)
Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap
How to Avoid Patient Alienation When Discussing Stress
Managing Phantom Limb Pain with Medication
Nerve Blocks Lead to Improved Quality of Life
Sacroiliac Joint Dysfunction: New Methods in Evaluation and Management
SCS Therapy in a Patient with Advanced Bilateral Kienbocks
Thoracic Epidural Abscess with Cord Compression Following a High-Frequency SCS Trial
What is the evidence to support clonidine as an adjuvant analgesic?
What’s In A Name? In This Case, That Which We Call Addiction Is Not Dependence

How to Avoid Patient Alienation When Discussing Stress

Anecdotal examples of how to start a conversation around stress with patients trying to manage chronic pain.
Pages 62-63

While there is a large body of evidence dedicated to elucidating the relationship between chronic stress and pain, stress is rarely discussed at the clinical level.1 For example, a patient complaining of low back pain (LBP) may also happen to mention that she is upset about receiving several customer complaints at work. The patient shares that she has become anxious, irritable, and has lost sleep as a result. Her partner is out of town on business and is not available for support. In addition, she has stopped performing her usual exercise routine.

Providers who incorporate the biopsychosocial model of pain into how they conceptualize their treatment2 are likely to recognize from this scenario that stress is a significant contributing factor to this patient’s LBP. However, providers often avoid talking about stress with their pain patients. Indeed, in my discussions with providers who offer psychotherapy, they have mentioned that they avoid this subject because they do not feel comfortable explaining the biological connections.

On the other hand, providers who do not offer psychotherapy have shared with me that they do not feel comfortable explaining the non-biological aspects of the biopsychosocial model to pain management. They have said, simply, that they fear their patient will “roll their eyes” or be offended because they think that their physician is describing their pain as “all in their head.”

However, stress is an important variable that may influence pain, and it needs to be discussed. The following tips may help clinicians direct the first conversation with a patient about the effects of stress on pain, and vice versa, without turning them off.

To aid in the conversation, clinicians should be educated on the stress-pain connection. (Source: 123RF)

Clearly Identify Their Pain

Many patients with chronic pain have, in the past, had their pain complaints dismissed by providers. An important way to start any discussion about stress, therefore, is to talk directly to the patient, bringing attention to their diagnosis and comorbid symptoms, and sharing what you know about their pain levels. You could say something along the lines of, “As you know, pain is very complex and has affected your body and life in many different ways.”

Then, discuss how their body has likely become sensitized and may be reacting more strongly to smaller signals of pain. Discuss with the patient that while some people think stress is only in the mind, the mind is, in fact, part of the brain and body, and this is where the pain is perceived.

Educate Patients and Yourself on the Stress-Pain Connection

Research has shown that pain may be treated by explaining to patients how and why they experience more pain via stress.3 Educate the patient that stress in their environment can turn into chemical and neurological signals in the body that may worsen an underlying medical condition. Discuss pain pathways and how pain is modulated in the brain and spinal cord—most patients wish to understand the details and it is appropriate to get scientific so long as you ensure that they understand what you are explaining.4 This type of transparency may also clear up any assumptions or questions the patient may have discovered online prior to the office visit.

Identify any personal factors the patient may have that may make them more vulnerable to the effects of stress on the body (eg, depression, trauma, or loss). Point out that stress is when something crucial happens that results in a noticeable change in the person; the patient should know that any event can become a stressor depending on the timing, variability, meaning, predictability, and controllability.5

For instance, a loud radio is not stressful if you can turn down the sound, but it can become stressful when the volume cannot be controlled. Another example would be thinking about going out to dinner, but the thought becomes stressful when a patient fears that their pain will increase from sitting down too long. Let the patient know that with chronic pain, a change in routine or interpersonal conflict can turn into physical changes that result in increased pain levels.

Learn more about the autonomic nervous system and the modulation of pain, and then translate this information into language that the patient can easily integrate and apply in their life. For example, be prepared to discuss several physical changes that happen when stress generates a fight or flight response, such as muscle tension or inflammation. Clinicians may also wish to discuss how this may worsen a patient’s pain in any muscles or nerves that are already affected by an existing illness or injury.

Lorimer Moseley, a professor of neuroscience and physiotherapy chair at the Sansom Institute for Health Research at the University of South Australia, has produced many online videos that provide excellent examples on how to explain pain (see, for example, “TEDxAdelaide, Lorimer Moseley, Why Things Hurt” on YouTube).

Take Note of Apparent Stress?

Ask your patient, “Does your pain make you stressed? Do you ever notice that stress makes your pain worse?” Let them know that this interaction can be both what they observe and what you observe, and provide feedback when necessary.

Perhaps you have noticed that a patient with face pain clenches their jaw when talking about a family conflict, stress related to work, or a recent loss, leading to pain and disability. You can ask the patient whether these are stressful situations and provide feedback on what you notice them doing when they discuss these issues. “I am noticing that when you talk about your job, your shoulders go up and you hold your breath.”

Refer Patients to Treat Their Stress

Familiarize yourself with a psychologically-oriented provider who can help the patient identify new strategies and skills to managing their stress, which could include such practices as self-regulation training, biofeedback, cognitive behavioral therapy (CBT), mindfulness meditation, or communication skills training.6 A psychotherapist may utilize treatments for stress, anxiety, catastrophic thinking, and stress triggers on the patient’s pain. By briefly discussing these treatments, you can explain their usefulness of with the patient and make a referral, increasing the potential for the patient to follow-through with the appropriate recommended treatment.

Conceptualizing chronic pain management via a pain-stress model is helpful for excellent patient-provider rapport, providing the patient with appropriate treatment or referral, avoiding focus on increasing medications, and most importantly, allowing the provider to discuss the emotional and stress-related components of pain.

Last updated on: August 5, 2019
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Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap
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